Sometimes, DON'T "listen to your body"

In response to my previous post about observing pain I had quite a few interesting responses from my colleagues. My brother, also an occupational therapist, asked, "Observe, what for?"

Observe, then choose how you want to respond to it. The response to pain that is the best for your well-being may not necessarily be what your body automatically wants you to do.

Typically when people respond to pain, it's a reactive kind of response, i.e. when a Taekwondo athlete injures the top of his / her foot while fighting in a tournament by accidentally kicking their opponent in the elbow (a very common injury by the way), what would be the instinctive response?

The instinctive response is to take the injured foot off the ground and put the weight on your uninjured foot. The immediate response is to let the injured foot rest.

However, what if I told you that the best response is actually to put your body weight on the injured foot instead? Press on it, and keep pressing as the match goes on. That's the only way you could use it to support your uninjured foot (which should be used for kicking, since I don't think you would still want to use your injured one for kicking - at least for the time being).

Something important to be aware of particularly if you're in the ring with an opponent who's aiming to kick you in the head at any given point in time and you've got a match to continue with.

That's an example very specific to Taekwondo. Now let's look at another example closer to the day to day experience of a person living with chronic pain.

Last year in December, I had an impinged nerve in my spine. I immediately texted my good friend Dr Dansen Wong from Bangsar Chiropractic to set up an appointment when I realised something was not right, only to find out that he had gone on holiday so I had to wait a few days for him to get back.

I already had tons of appointments lined up - my typical work day either involves working on the computer (doing my writing work, development work, promotion work), working on the mobile phone (communicating with clients), or actually driving around to see clients, to events, etc. The pain was really really bad (I'm Malaysian, we avoid going to doctors for every tiny little thing that's not right with us ... So no way I would contact Dansen for an appointment unless I really needed it, and I know I did!) but I couldn't afford to let it get in the way of my work so I had to be my own occupational therapist - come up with some adaptations (see my makeshift standing-sitting work station below) so I could make my way through the day, keep doing what I needed to go etc.

When I finally got round to seeing Dansen, I was in pretty serious pain, BUT the pain could have gotten worse if I had done what (Malaysian - not sure if people in other cultures react the same way) people instinctively do, which is:

(1) drop everything until they manage to get that appointment in order for the chiropractor (or some other health worker who does manual manipulation) to see to them.

OR

(2) take painkillers then just ignore and go on as usual (or just go plugging on even when in pain until they can't stand it anymore).

By OBSERVING AND ACKNOWLEDGING pain OBJECTIVELY first, then only looking at what CHOICES are available, it allows us the time and mental space to think about what actions to take next in order to deal with the pain. Sometimes the best choices to preserve your well-being are not necessarily what you might expect. I'll write a blog post reviewing the lifestyle modifications I did for my nerve impingement episode another time (actually, this entire blog is about the CHOICES that are available), but hey - I was *so grateful* to get my spine sorted. Thanks Dansen!

Occupational therapy may not be able to "cure" a person from chronic pain, but it can sure help in terms of preventing deterioration and also encouraging a faster recovery (when you're not continuously damaging your body - that gives it time to rest and heal, right?)

Note: Dansen discharged me after only two sessions, the earlier expectation was that I would need about four sessions to get the impingement properly fixed. No repeat injuries since. :)

Meals while living with chronic pain. Part 3 - shopping solutions

Follow up from my previous posts about meals while living with chronic pain now I'm going to talk about food preparation.

Food preparation can be rather difficult for people living with chronic pain because it's something that takes time and energy - which can really exhaust a person with chronic pain and make the pain worse. All the way from shopping for the kind of groceries needed to sustain a healthy lifestyle, to preparing the ingredients, to cooking the meals themselves can be a real challenge if one is living with chronic pain. This post will focus mainly on shopping, whereas my next post on preparing meals will have some pretty nifty tips for easy and healthy food for people living with pain. :)

Why is shopping important? I find that with clients who come to me for weight management (my main clinical area of practice, before I started developing skills in pain / sleep / mental health management, because I found that people with weight issues usually needed help in these areas as well) not eating healthy is generally a shopping problem. The problem was that "healthy food" was regarded as something inconvenient, inaccessible, and sometimes expensive (particularly for those working in the more posh areas of KL city). It's a shopping problem, and also a meal planning problem (as what one eats for meals tends to be linked to what one manages to buy) hence I've actually dedicated an entire post to shopping solutions. :P

1. Online Shopping

We are very fortunate that we are living in the age of online shopping where it's so accessible if you're living within the Klang Valley. You don't even have to leave your house to get groceries, which is really great if you want to save on time and energy. ;)

The most well-known option is probably Tesco Online Delivery http://eshop.tesco.com.my/

(Note: I've never used it and I don't endorse it - however, my friend is on the back of their truck and seems like she likes it enough to be their poster girl!)

Another option if you're looking specifically for fruits and juices, is owned by my friend Cynthia Wong. I would recommend you contact her directly via her Facebook page.

https://www.facebook.com/pages/Fresh-Choice-Cynful-Pleasure/283927535151234

For other online grocery shopping options, do check out this cool link with all the research properly done:

http://leapingpost.com/2013/09/07/online-grocery-shopping-delivery-malaysia/

2. Group Buys

Group buys are very convenient and also a great way to maintain a bit of a social life (also a concern for many people living siwht chronic pain.) Basically the idea of a group buy means a bunch of people from a specific location (i.e. same office or close by housing area) getting together to buy specific items directly from a supplier (typically fruits, vegetables, other fresh produce). This is a strategy which can allow purchases to be 20-30% cheaper than what's available at the local supermarket, and because the main buyers would typically be living close to a certain area, if you happen to find a group by near to you then that would really save you plenty of travelling time!

Group Buys kind of started from my all time favourite health discussion resource Raw Food Today group (of which I'm an admin) - there are still occasional group buys these days, but there was a time when they were really hot and I think the trend picked up from there.

There are plenty of group-buy groups on Facebook (just search for "group buy"). However, there are some that I have personally used and where I know the people, like PJ Fresh Seafood And Fruits Group Buy run by my long-time real-life friend Michelle Woo, and a relatively new one called Health Food Group Buy run by my FB friend Michelle Mak who owns www.gohealthy.my

If you do plan to start your own group buy with neighbours or friends and family (just have someone assigned to pick up groceries each week, as an example to start with - and sometimes you just have to let yourself be surprised and make do what's available), here are some great places people would normally go to get their fresh produce at very reasonable prices (thanks to my wonderful clients who keep me updated with info like this!)

• Pasar Borong Selayang
• Pasar Pudu
• Pasar Chow Kit

If you want tips on how to do your own group buys, am sure the admins of the groups above would be willing to give you some ideas (especially Michelle Woo who is already very experienced with group buying and would probably be able to educate you very well on the subject!)

For previous posts on this topic:

Part 1 of meals while living with chronic pain, why meals are important - http://painmalaysia.blogspot.com/2015/01/meals-while-living-with-chronic-pain.html

Part 2 of meals while living with chronic pain, what to eat and how it helps you  - http://painmalaysia.blogspot.com/2015/01/meals-while-living-with-chronic-pain_9.html

Not part of the series but still helpful and relevant: Supplements for pain management

Your 5 minute breaks for a pain-free lifestyle

I first mention the Tomato Technique in my earlier blog post about eye pain.

 In a nutshell, the Tomato Technique works like this:

Set a timer for 25 minutes, work through those 25 minutes - focus, then make a "tick" on piece of paper and take a 5 minute break. When you have accumulated 4 "ticks", take a half hour break. 

However, what people may not realise as being important is what they would be doing during those 5 minute breaks. When I first started using the Tomato Technique, I used those 5 minute breaks to go on YouTube or Facebook. It was easy, it was convenient, and I really enjoy social networking sites (who doesn't eh?)

 Big mistake though. What I didn't realise was in order to be good for our eyes, those 5 minutes are best utilised away from the screen.

Yep, we gotta ****tear ourselves away from the screen****!

 Here are some examples of good 5 minute activities you can engage in during your break:

1. toilet break

Some of clients complain that because of the water regime they have to drink (3 litres a day - you'll need to drink this amount of water minimum in order to lose weight, I kid you not) they are going to the bathroom exceptionally often and they find it rather bothersome. Well, if you schedule in time to go to the bathroom during your 5 minute break (since you're going to have to take a break away from the screen anyways, why not to the bathroom?) then it won't seem like such a chore. Considering that you'll have four 5-minute breaks per Tomato Cyle, that's 4 breaks away from the screen = 4 opportunities to choose whether or not to go to the bathroom.

2. walking break

This one goes hand in hand with the bathroom break. My clients who want to lose weight typically need to accumulate 10,000 steps throughout the day on their pedometer. What better opportunity to accumulate those steps than with a bathroom break - you're going to have to walk away from the screen anyways, why not use the time to walk to the bathroom as well? Or crazy idea, how about a short walk to the pantry to have a drink of water?

3. water break

Tying into the second suggestion (walking break), my clients often say they have difficulty drinking 3 litres of water a day because they just totally forget about drinking water altogether. Or they ignore their thirst and keep going at their jobs because they feel it is absolutely necessary for them to get work done. How about IF it was absolutely necessary to get as much work done as possible within 25 minutes AND THEN it was absolutely necessary to be away from the screen for the next 5 minutes? Since one has to be away from the screen anyways, why not take the opportunity to re-hydrate (and accumulate more steps, and so your body has more fluids to flush out toxins in the next 25 minutes while you're working - very efficient no)?

4. snack break

Many of my clients are not eating enough and not eating well. Just like I mentioned in the water break segment, sometimes they are just so totally engrossed in their work that they forget about eating and drinking altogether, or they ignore the body's hunger and thirst signals. Continue to ignore these signals over the years, and one typically ends up with a very damaged body - prone to obesity and other related issues (chronic pain being one of them as well). 5 minute snack breaks are great opportunities to (1) accumulate steps as you walk to the pantry or wherever your food is stored (2) drink some water as you eat your snacks (one would typically feel thirsty while eating, wouldn't we?) and (3) keep the body nourished and good to go - which is what eating was originally for in the first place (!)

5. dancing break

Definitely a healthy activity, stress-buster, good to take your mind off work for a bit and lots of fun! Movement of any sort is ALWAYS good, especially if you're experiencing chronic pain of some sort. Put on some cheesy pop songs and just move - they'll do you plenty of good! Just bear in mind that you may need some earphones and privacy so you don't disturb others. ;)

You'll probably be able to work only 1-2 of each item into each break. That's fine. You have four 5 minute breaks in each Tomato Cycle, so there's plenty of opportunity to vary what you do in your breaks! You may want to consider putting away your phone during the breaks though (since the whole point of utilising this technique is to minimise eye pain, and phone screens like computer screens give your eyes strain too). You could use it as a treat during the longer 30 minute break though, that would make phone use even more rewarding, wouldn't it?

Note: different offices may have different rules so do keep that in mind when implementing these techniques. Alternately, get your HR to talk to an occupational therapist (feel free to send me an email or text if you're keen to get more info - contact details on top of every page) and see if we can come up with a strategy to ensure a healthier workplace for a healthier you. :D

Observing pain - an underrated skill to living in harmony with pain.

This is a response to a blog post from my colleague in New Zealand, Bronnie Thompson who has done much significant work in occupational therapy for chronic pain and whose blog has been an inspiration and helpful resource to clinicians and clients everywhere.

Clients who are familiar with my work will be aware that I use mindfulness as a tool. I don't really get anybody to do meditation of any sort (meditation, while being a tool that can facilitate mindfulness, should be used with care and taught only by experienced teachers. I would say that while I am significantly experienced with using mindfulness in therapy, I would not dare to venture to teach meditation. I will write a blog post about this later.)

In the recent meditation retreat I attended, there were a few sessions called “sittings of strong determination”. This was really interesting – we had to stay in our positions (and cross-legged meditation positions aren't the most comfortable ones) without moving our bodies at all (not our legs, not our eyes, not the position of our hands) for as long as we could, a full hour if possible. We were supposed to be aware of sensations, but observe them in a detached manner, not react to them. What was interesting was that there were actually many people who started the course with some form of chronic pain (typically it's the sort of circumstances where they would have already gone to the doctors and the doctors are not very sure what to do about the pain - not due to a misalignment somewhere or weak muscles or something like that, although I still maintain many people actually have very weak muscles and should work on strengthening those first), but by the last day (when they were allowed to talk and share their experiences) they related that they didn't feel the pain that was bugging them previously anymore. It took me 3 days to develop this skill of sitting through an entire hour without moving (although it was only introduced to the students on the 4th day).

Something I have realised from this experience (and also in my experiences working in pain management) is that skills to deal with pain are very subtle and need to be cultivated consistently before one needs it (just like after the meditation course we were encouraged to go back and continue deliberate practice of detached observation of our bodily sensations – and many things in life also need such deliberate cultivation, like working out and eating healthy for example, if you notice, this blog is really all about these subtle things).

Personally I am very good at dealing with pain and working through pain because of my background as a Taekwondo athlete and my coach’s policy was no painkillers because they could dull senses and affect safety performance. When in the ring fighting with an opponent in a dangerous combat sport (and typically having many rounds of fights to go) we really get plenty of hands on practice on observing but not reacting to pain. This was a skill that I realised served me very well later on in life. But then, after developing this skill, we also have to learn how to recognise when a pain needs to be addressed and when it needs to be worked through, but that’s another blog post altogether.

Meals while living with chronic pain. Part 2 - What to eat and how it helps you.

In Part 1 of this series, I talk about why emphasis on the kind of meals we have while living with chronic pain is important. Part 2 will cover what I recommend my occupational therapy clients eat and how eating like this would help you maintain optimal health even while you have chronic pain.

This is the Havard School of Public Health (HSPH) Healthy Eating Plate.

I am a big fan of the HSPH Healthy Eating Plate. I always show this to all my occupational therapy clients, regardless of what health conditions they may have. This Healthy Eating Plate is an excellent guideline to use for clients who want to lose and maintain weight, to regulate their blood pressure, blood cholesterol and blood sugar, to regulate their sleep (yes!) and also for clients who have chronic pain too.

So what does this Healthy Eating Plate have to do with recovering from pain?

1. It is full of antioxidants which have anti-inflammatory properties.

If you notice, half the plate is full of fruits and vegetables. Now everybody knows fruits and vegetables are good for your health because they are full of fibre and nutrients which your body would need to maintain optimal functioning. In my earlier post I talked about how taking foods that are inflammatory can actually aggravate your pain. So anti-inflammatory foods, reduce inflammation and reduce pain, good right?

Also, take note that the portion of vegetables is double that of fruits. Fruit to vegetable ratio should ideally be 1:2 at every meal. Why? This is because of the sugars that fruits contain, and we want less sugar for less inflammation, right?

2. Healthy oils - you can refer to my post about omega 3, it's anti-inflammatory properties and how it has helped my clients reduce pain for further details.

3. Proteins

Your cells are made out of protein, so taking enough protein is an absolutely necessary part to aid recovery and for your body to be able to rebuild the damage done to them. If you notice, proteins are a quarter of your plate.

4. Whole grains

Yes, whole grains, not white grains, not refined grains. Try to cut down on the mee hoon, the mee sua, the noodles, the biscuits and bread - I know Malaysians seem to think these are "healthy" substitutes for rice, but they are not. They are actually worse for your health than rice is, so yes - you can go back to eating rice with a clear conscience now. ;) They are more processed than rice is, and ideally we would want to eat things that are as close to their original form as possible. Grains are essentially sugars and as mentioned in Part 1, sugars trigger inflammation.

Also, do note that the composition of a typical Malaysian meal is typically 99% grain (fried rice, fried noodles, char kuey teow, nasi lemak, roti canai, etc) so I would suggest to take this seriously if you're living with chronic pain and start reviewing your eating habits!

In Part 3 of this series, we will talk about how to make eating healthily easier for people living with chronic pain.

Meals while living with chronic pain. Part 1: Why is this important??

When people talk about living with pain, rarely do they talk about the kind of food that one has to eat. Of course, if you're Malaysian, and you go to traditional treatments (i.e. Chinese medicine etc) then there is especial emphasis on certain herbs and soups to eat to help certain conditions, etc. But rarely do we spend much time talking about the composition of our every day eating. However, knowing what to eat to maintain our bodies in optimal condition is just as important as many other aspects of pain management that are typically covered by conventional treatment. In fact, it may help support a faster recovery too.

When do people living with pain need are not careful how they organise their meals:

1. they are at risk of putting on weight.

This is very common and I do see it happening in my occupational therapy clients. Besides reducing physical activity, our body goes into a fight or flight response while we are experiencing pain - this is equivalent to our body experiencing stress. This can cause cravings - or perhaps a more appropriate word, as they don't really feel like cravings sometimes, "increased attraction" to sugar-containing foods that could lead to weight gain.

2. They are at risk of causing further inflammation which leads to increased pain.

Sugar is a major cause of inflammation. It doesn't help that when our bodies are stressed, it leads us to be attracted to more sugar. Pain can be sign of inflammation (as mentioned in the post about nutrition, one of my clients has reduced pain when she takes salmon omega 3 which is anti-inflammatory) and while inflammation is a natural part of the healing process, it may not necessarily be a good idea to stimulate even more inflammation (and more pain!) than the body finds necessary.

3. They are at risk of leading to further diseases and health problems that could further weaken their already weakened physical state.

Chronic inflammation then leads to further complications. Did you know that the root cause of heart disease is actually inflammation rather than high cholesterol? Read this post on my stroke blog to find out how that happens. If you're already feeling that chronic pain is inconvenient to you, are you sure you want to complicate things further with more health problems and further hospital visits?

In Part 2 of this series, we would be talking about what to eat to maintain optimal health while living with chronic pain.

Update - other posts on this topic:

Part 2 of meals while living with chronic pain, what to eat and how it helps you  - http://painmalaysia.blogspot.com/2015/01/meals-while-living-with-chronic-pain_9.html

Part 3 of meals while living with chronic pain, shopping solutions - http://painmalaysia.blogspot.com/2015/01/meals-while-living-with-chronic-pain_20.html

Not part of the series but still helpful and relevant: Supplements for pain management

Compromised activity performance with pain Part 1 - understanding what leads to poor performance.

From my observations, people in pain tend to gradually cut down on their physical activity. As a result, they would also start to reduce the amount of everyday activities they do, as well as cut down on the quality of the activity. For instance, the hypothetical client in the activity log post, by the time she gets back from grocery shopping with a pain level of 9 - she would be rushing to get home as soon as possible. This could compromise the qualify of performance in the following activities: driving (to get home), and putting the groceries away, even getting from the vehicle to the house.

What leads to poor performance when in pain?

1. Fatigue and physical exhaustion

Pain can be very physically taxing and energy zapping, particularly if the client doesn't know how to manage their bodies in a certain manner. In the example of the hypothetical client above, fatigue and exhaustion can affect her in the following ways:

a) safety when driving - losing control of the car and putting herself and other road users in danger
b) at risk of dropping groceries when getting them from vehicle to house or when putting the groceries away
c) at risk of falling when moving groceries from vehicle to house or when putting them away

2. Frustration and clouded judgement

Frustration creeps up very easily when experiencing pain. Pain can easily distract on our focus from a task at hand, and if we are trying to perform the task while addressing the pain at the same time, this could easily result in:

a) missed turns
b) not noticing the movements of other vehicles around us
c) not noticing what's happening to the car (this actually happens to my clients - they didn't realise that the car had overheated or that the car was running low on fuel)

As a result they end up stranded in an emergency situation that is very difficult to deal with because of pain + physical exhaustion + frustration from the buildup of all the errors that could have possibly happened. This is very real and has happened to my clients before, resulting in falls and subsequently escalated pain that puts them in bed for a few days in order to be able to recover, resulting in what could be perceived as "wasted" time and "wasted" money (if treatment is involved - there would be money spent, and even if treatment is not involved, there would be missed opportunities for potential income. For some people, they would still have money flowing out of their pocket when they are not at work even if they don't make a deliberate effort to spend money - this is particularly true for self employed business owners who still have overheads in their business that would keep taking money out of their pocket while they are unable to work - rental, etc.)

I'll show you solutions which has worked very successfully for me (yes, I experience pain too - and am very fortunate that my occupational therapy skills have helped me deal with it) and my occupational therapy clients in another post. :)