Practical Stress Management: Part 2

If there is one aspect of life that is often undervalued and under-appreciated it is sleep.  Our ability to sleep is essential to allow a full resolution of pain and restoration of our movement.  Our ability to sleep can be correlated to how our nervous system is being activated. We have 2 parts of our nervous system:  sympathetic and parasympathetic. You see, when we are experiencing pain our nervous system becomes sensitized and preferential to the sympathetic nervous system.  Now when this is the case you will see a rise in heart rate, blood pressure, respiration rate, and even anxiety. Sound familiar on those sleepless nights? You can loosely think of this activation of the sympathetic nervous system as if you drank a large cup of coffee or an energy drink right before bed.  Most people would not choose to partake in such behavior because they would be up all night. This is the exact case for many of those who have had or are currently in a pain-cycle however it isn’t perceived as such. People who are experiencing sleep disturbances or find it difficult to become comfortable at night, please realize that the solution is on the other side of the nervous system:  parasympathetic. There are numerous things we can control or change in the activities leading up to bed as well as with the sleep environment that will allow the parasympathetic nervous system to be tapped into.

According to the National Sleep Foundation, sleep hygiene is considered to be a variety of different practices and habits that are necessary to have good nighttime sleep quality and full daytime alertness.  Sounds great, but what does this have to do with resolving pain and improving movement? Well, consider sleep as the foundation of your health and stress management. By purposefully improving sleep hygiene you are taking a step in regaining control of your life.  Here’s how to do it:

1. Be regular and consistent with the time you get up.  

That’s right when you get up opposed to when you go to sleep.  The reason is that this will allow you to improve your sleep efficiency, the ratio of time in bed asleep opposed to in bed and awake.  The first couple of days may be rough and you may feel fatigue during the day, but this should be reflected on the back end of the day because you will feel tired sooner and be able to determine your ideal bedtime.  I guess you can say we are trying to reverse engineer your bed time.

2. Don’t oversleep.  

Many people live by the idea that they can go on little to no sleep during the week and make up for it on the weekend.  This is not the case. You cannot make up for your accumulated weekly sleep debt by sleeping in on the weekends or days off.  What you are actually doing is setting yourself up for increased grogginess and fatigue throughout the day, which in turn could increase tension and amplify your aches and pains.  

3. Create a positive psychological association with the bedroom.  

The purpose of a bedroom is two-fold:  sleep and sex. If you currently reading, watching television, drinking a cup of tea, etc. before bed, work to try to move these activities to somewhere outside of the bedroom and prior to being ready for sleep.  To perform these activities it requires an increase in alertness and attention, which are both associated with wakefulness and thus an increase in sympathetic activity.

4. Substance avoidance:   alcohol, nicotine, or caffeine.  

Alcohol is often regarded as the ideal nightcap beverage given that it is a depressant.  This is true that it is a depressant, but what is often missed is that alcohol causes us to fall asleep faster than we normally would thus miss out on a portion of our REM (radpid eye movement) cycle.  This is important because disruption of the REM cycle can alter the entire sleep-wake cycle and associated hormonal releases that help you both function and recover when injured.

With regards to nicotine and caffeine, they are both stimulants and will make it difficult to fall asleep.  Now if your thinking I drink a cup of coffee before bed every night and don’t have any changes in my ability to sleep.  I am here to tell you that this is likely due to you already being sympathetically driven and in need of a shift into more parasympathetic activity.  Take the caffeine away and see if you notice a difference.

5. Can’t sleep, GET UP.  

If you lay in bed unable to sleep for more than 20-30 minutes get up and perform some form of relaxation:  meditation, breathing exercises, etc. Once you feel tired again return to your bedroom and go to sleep. The goal here is to keep the positive association with your sleeping environment.  

6. Get rid of all your thoughts and worries.  

A lot of people ponder their to do list for the next day or revisit a stressful part of work day that happened this only achieves a rise in heart rate and blood pressure.  Take the 3-5 minutes before going to bed to let it all out in a journal so you can clear your mind before you sleep.

7. Create a sleeping environment.

Try to implement 1 or more of these sleep environment changes to optimizes your quality of sleep once you fall asleep.  

I hope these help you understand and appreciate the role of sleep in our ability to not only manage stress in our lives, but how it can facilitate an improvement in function.  In the next post we will visit the ever controversial topic of nutrition.

Stay Well, Stay Strong, 
Keaton

References:

1. Chouchou, F. and Desseilles, M. (2017). Heart rate variability: a tool to explore the sleeping brain?.

2. H. Craig Heller, P.  (2017.) https://www.thegreatcourses.com/.

3. Hartman, B.  (2017). All Gain, No Pain.

4. sleepfoundation.org.  (2017).  Sleep Hygiene.  [online] Available at:  https://sleepfoundation.org/sleep-topics/sleep-hygiene [Accessed 21 Oct. 2017].

Understanding the Airway Part 3: The Diaphragm

In Parts 1 and 2, we discussed the relationship between the airway and stress on the body and how the upper airway plays into that. In this article, we will discuss the prime mover of the respiratory system, the diaphragm. The diaphragm muscle is especially important, not just because it keeps us alive but also because we use it roughly 25,000 times per day. It then becomes important to know how it functions, and this requires an understanding of anatomy.  Here’s a few important facts about the anatomy of the diaphragm:

1. The right half of the diaphragm (hemi-diaphragm) is larger, thicker and stronger than the left.

2. The crura (“legs”) of the diaphragm attach to the bodies and disks of the 1st, 2nd, and 3rd lumbar vertebrae on the right and the 1st and 2nd on the left.

3. The medial ligaments of the diaphragm cross over the psoas, a muscle which has a hip flexor function.

4. The position of the right hemi-diaphragm over the liver assists in keeping the right side in its resting domed shape whereas the position of the left hemi-diaphragm under the pericardium assists in keeping the left side in its flattened descended active state.  

5. The arcuate ligaments of the diaphragm on the lumbar spine can act to “tighten” the back into an arched and loaded position.

6. During inhalation, the diaphragm descends into a “flattened” shape and during exhalation the diaphragm forms into a domed shape allowing airflow.  

A few things that we can learn about function of the diaphragm based off of these facts is that the diaphragm is a muscle with a stronger pull on the right.  This means as we breathe 25,000 times per day we may be cranking the spine to the right. The diaphragm is also an important muscle in regards to posture. If the abdominals, especially the internal obliques and transverse abdominus, become weak, the diaphragm may stay descended on both sides into a “flat” and shortened state resulting in potentially tight backs and hip flexors.  When this occurs the diaphragm will assume a more postural stabilizing role rather than its desired respiratory role. We may also notice rib flares, especially on the left due to the position and asymmetry of the diaphragm. This shortened state of the diaphragm makes it weaker as a respiratory muscle because it lacks a normal length tension relationship. Because of this we may end up using accessory muscles of the back and shoulders to inhale which may result in tight shoulders and necks.  Though this doesn’t sound like it should be a problem because you’re just breathing, but you’re doing it 25,000 times per day!

This strongly relates to stress.  The resulting decrease in intra-abdominal pressure results in a “hyper-inflated” state.  This can lower the CO2 in the body which increases the “fight or flight” response resulting in an increased breath rate at rest.  This can also restrict blood flow to the cerebral cortex of the brain, impair gastrointestinal blood flow, promote fatigue and weakness, increase sympathetic adrenal activity, increase anxiety, as well as make you more sensitive to light and sounds.  Like we discussed in Part 2 these are all strongly associated with mouth-breathing.

Now that we’ve seen what inefficient breathing looks like at rest, let’s look at optimal mechanical function of the diaphragm and how a physical therapist can help you out in this regard.  

Optimal mechanical function and power of the diaphragm occurs when the diaphragm is able to go in and out of its resting domed shape and flattened active state on both sides and even be able to alternate in the appropriate conditions.  The diaphragm is mechanically coupled with the abdominals and the rib cage and these all depend on each other for optimal function. This relationship is referred to as the “zone of apposition.” Abdominal disuse can result in flared ribs and a loss of a zone of apposition.  This may appear as “belly breathing.” There’s nothing wrong with belly breathing however if this is the preferred way of respiration, the result can be an elevated stress response and the development of pain syndromes. A physical therapist can help you to restore a zone of apposition by helping you to normalizing resting abdominal tone thereby increasing intra-abdominal pressure and allowing the diaphragm to rest in its domed shape.  In this shape, the diaphragm will function with the abdominal musclature in a piston-like movement allow us to avoid overextending and tightening up the lower back. In turn, this will end up relaxing accessory breathing muscles throughout the body: back, shoulders, and neck. Hence, how you breathe matters, especially since we do it 25,000 times per day!

As always, take care, and breathe easy!

Dave

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References

1. Postural Respiration: An Integrated Approach to Treatment of Patterned Thoraco-Abdominal Pathomechanics. 2000-2016.

2. Boynton B, Barnas G, Dadmun J, Fredberg J: Mechanical coupling of the rib cage, abdomen, and diaphragm through their area of apposition. J Appl Physiol 70:3,1991.

3. Cassart M, Pettiaux N, Gevenois PA, Paiva M, Estenne M. Effect of chronic hyperinflation on diaphragm length and surface area. Am J Respir Crit Care Med. 156:504-508, 1997.

4. Estenne M, Derom E, DeTroyer A. Neck and abdominal muscle activity in patients with severe thoracic scoliosis. Am J Respir Crit Care Med. 1998 Aug;158 (2):452-457.

5. Goldman M, Mead J: Mechanical interaction between the diaphragm and the rib cage. J Appl Physiol 35:2,1973.9.Hodges P, Gandevia S, Richardson C: Contractions of specific abdominal muscles in postural tasks are affected by respiratory maneuvers. J Appl Physiol 83:3, 1997.10.

6. Hruska RJ: Influences of dysfunctional respiratory mechanics on orofacial pain. Dent Clin North Am 41:2,1997.

The Sportsman: A Journey Together

Sports are the most captivating scenes in America.  We can all identify the iconic sportsmen of our childhood and we all know what it means when we hear, “I wanna be like-Mike”.  However, most of us fall short and recognize these sportsman as the lucky few who were blessed with God-given talent that reached super-stardom, effortlessly.  This is not true though, the journey of a sportsman is anything but effortless.  No journey is effortless.  And no journey occurs in isolation.    

In reflection of the sportsman journey, I see the journey of a patient.  The sportsman is usually part of a team who cohesively works together to achieve a common goal:  winning.  A team struggles as well as finds success as a singular unit.  Similarly a patient is part of the rehabilitation team striving to succeed at restoring functional capacity.  However there are often roadblocks that slow this process.  Identification of how the sports team and rehab team constructs are similar can allow us to begin to see where our roadblocks may be developing and how we can overcome them.

So here’s the breakdown:  coaches = physical therapists, players = patients, opposition = movement/behavioral dysfunction, and the officials = our pain.  Recognizing that not only are we a part of a team, but we carry a specific role is powerful.

Let’s dive into each of these to learn how to overcome our roadblocks.  

Distinguishment between the opposition and the official is essential.  Far too often we hang our hat on “It’s my pain’s fault.”  Why?  It’s always easier to blame someone or something else.  Just like in basketball, it is easier to say “the refs cost us the game.”  However we know this is not the case.  The officials are present to ensure we play be the rules and to alert us if we do anything wrong just like our pain does.  To not get the whistle blown on us again we have to change our behavior.  However, this can be incredibly difficult, but it’s not just you, even elite athletes have ordinary habits they struggle to overcome.  A recent sport psychology article identified three primary drivers of behavioral change in elite athletes:  credibility, reliability, and intimacy.  However the interesting part is that these three primary drivers are not about the elite athlete, but rather their coach.     

This is no different in physical therapy.  A patient and physical therapist must not only trust one another, but they have to trust the process.  This starts with effective communication from the physical therapist.  An explanation of a patient’s condition or procedure allows the credibility of the physical therapist to be highlighted.  Providing knowledge and resources alike ensures a person they are in good hands.  The outcome is often improved compliance in their behavioral modifications.  Knowledge can be the liberator needed by a patient to break them free of a movement dysfunction.

However sometimes more than one explanation is needed to help break a chronic movement/behavioral pattern.  Being a reliable and consistent resource is also critical.  Often a person leaves a session feeling good about their exercise program as well as her behavior changes, but return ill-confident in their performance.  Utilizing repeated exposures and reassuring a person can go along way.  And just because a person struggles doesn’t mean they are doing something wrong and need “more change”.  It is quite the contrary, at the point of struggle is the start of learning, so consistency in their performance becomes essential.  The physical therapist should highlight this notion and coach each person through their exercises as they learn how to regain control of their movement patterns.  

That being said though sometimes frustration sets in and hinders performance.  Early recognition of this by the physical therapist is important.  This reflects the intimacy of the relationship between a patient and physical therapist.  Being able to pick up on differences in mood, verbal language, and/or body language can mitigate the frustration roadblock and allow for a consistent restoration of their movement and resolution of symptoms.  

In the end, a physical therapist is in the coaches seat.  Their influence drives and guides the success of the players.  The role of the coach is to maintain focus on overcoming the opposition and not the officials.  To do so hangs on the three primary drivers of behavioral change:  credibility, reliability, and intimacy.  

Stay Well,

Keaton

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References:  

1. Butler DS, Moseley GL, Sunyata. Explain Pain 2nd Edn. Noigroup Publications; 2013.

2. Halson SL, Lastella M. Amazing Athletes With Ordinary Habits: Why Is Changing Behavior So Difficult?. Int J Sports Physiol Perform. 2017;12(10):1273-1274.