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 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. :)

How to keep an activity / pain log

People with chronic pain may not realise that how they schedule their every day activities, including how they fit sleep and rest into the schedule, can influence the level of pain they are feeling in each day. I always get my occupational therapy clients to keep an activity / pain log to show me how they are currently planning their day (when in uncomfortable situations, planning can really go a long way - regardless if the discomfort is referring to health or even other parts of life like parenting and finances.)

Example of an activity log.

Time	Activity	Pain Level (0-10)
7.00am	Wake Up, climb out of bed to go into toilet, morning toilet activities	0
7.30am	Prepare breakfast for family, wake the kids	0
8.00am	Eat breakfast together with kids	0
8.30am	Drive kids to school	1 (pain slowly creeps up while driving)
9.00am	Shopping for groceries at market.	5 (still tolerable)
10.00am	Completed shopping, start the drive home	7
10.30am	Reached home completely exhausted, quickly sorts out groceries and urgently needs to rest	9

And the details of the rest of the day until my occupational therapy client goes to bed. This log provides the occupational therapist with lots of very valuable data, which the client and the therapist can use to come up with strategies to manage pain better.

Eye Pain When You're Staring at the Computer Screen? Here's what to do.

Today I want to call your attention to a very special kind of software that you can install on your computer to reduce eye pain. It's called f.lux.

https://justgetflux.com/

Yep, just get f.lux.

I came across this software when I was doing research for my occupational therapy GR:IN Lifestyle Modification sleep and rest management programme (yes, I also include sleep and rest management into my occupational therapy work, and sleep and rest play a very important part in pain management, just as much as pain can influence the quality of your sleep!)

Of course I installed it into my computer to try it out before recommending it to my clients. (I don't practice what I preach, I preach what I practice. So the saying goes!)

Initially, it was a bit hard for my eyes to get used to as my laptop screen seemed to become weirdly orange-ish but after a bit (within the first session) it was fine. Just took some time for my eyes to adjust I guess.

I like f.lux a lot. I don't really get that much eye pain when using my computer anymore.

Another handy method I am learning to use is the Pomodoro technique (or the tomato technique - which is easier to remember. You'll still find the Pomodoro technique if you google "tomato technique").

The gist of the Tomato Technique is, 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. This will also help reduce your eye strain (provided you leave your desk when you're on your 5 minute break - when I first started I used my 5 minute break to go on Facebook and watch YouTube videos. Big mistake I tell you, my eyes were dying!) Of course there are more sophisticated ways to using this Tomato Technique, but you can go find out more on their website.

I'll make a post about what cool health-supporting things you can do while on your 5 minute break. It will be fun! :D

The Best Supplements for Pain Management

One aspect of pain management that not many people look into is the nutritional aspect. I often tell my occupational therapy clients, you can go to the acupuncturist or the chiropractor as many times as you like, and they will put you back together nicely again, but if you keep going back to them too many times it could mean either one of two things:

1) the clinician who is treating you wants to make a profit from you and keep you coming back for a long time (much of healthcare in Malaysia is unregulated and private - this is fodder for another blog post and I won't talk much about it here).

2) you're undoing the clinician's work with certain every day habits, which result in increased risk of damaging your body. Every time the clinician fixes your body, and you go back to injure / cause more damage to it, that's why you have to go back to get it fixed again.

Many people are not aware of the 2nd reason. When they start to protest at Reason 1 and tell me that they have a very good clinician treating them, then it's most likely Reason 2, and that makes them an ideal candidate for occupational therapy.

Occupational therapists look at how your habits and routines in your every day life would affect your health and how your health affects these habits. That's why I work with people who develop health problems from work, and also whose health problems affect their work. (I get invited to speak to corporations about these workplace health issues and am also developing a programme to train HR to recognise health problems in staff early so that they can get their staff to seek help.)

Eating and nutrition is a very important habit too.

Here are some recommended supplements that my clients find to be helpful to them when managing pain. (Note, supplements are - and should be - intended to provide nutrients that may otherwise not be consumed in regular quantities. This means that the stuff I'm recommending is typically found in your every day food - however, our every day food tends to be very nutritionally deficient, and if you're experiencing chronic pain, chances are your body could use the extra nutrients to help it recover).

1. Salmon Omega 3

Whenever there's an injury (pain is an indication of injury) there is inflammation. Chronic inflammation occurs every where in the bodies of people these days, resulting in damage, injury and subsequently pain. Have you ever slammed the door on your finger and seen how big your finger swells? That's inflammation for you! My clients find that Omega 3 helps to reduce the inflammation and provide relief, even with such a small dose of one capsule a day! There are plenty of these supplements out in the market, so do beware to ensure your omega 3 comes from reliable sources though, as sea water fish can be prone to heavy metal toxins. And also, try to ensure that your supplement is Omega 3 and doesn't contain Omega 6. Omega 6 is inflammatory (causes swelling) whereas Omega 3 is anti-inflammatory (reduces swelling). You don't want more swelling to cause more pain!

2. B-Complex and Calcium-Magnesium

These two have a calming effect on the nerves (they help convert your tryptophan to serotonin that calms you down and can help you call asleep too!) I take them when I'm feeling stressed, and I take them when I get those really annoying flu aches - no more body-wrecking aches when I have flu anymore, and I can get enough sleep to recover (the role sleep plays in pain management - now that's for another post!) They are a great alternative to paracetamol, especially if you're a tad worried about the residues of drugs left in your body (the ones I use are from organic sources and have very good bioavailability - which means the body can absorb them very well without leaving residue in your gut!) I have used them with autistic kids as well (nutrition is very important to them as they have very unique guts - that's another post for another day now) and non-verbal kids who threw tantrums learn very quickly to ask their parents for these supplements when they notice the agitated feelings coming on. Yes, the effects are *that* significant!

The company I get my supplements from is a very reliable manufacturer with more than 80 years of experience in nutrition and supplementation production, they even have their own organic farms surrounded by forests to keep the air clean, and plenty of state-of-the-art farming practices. If you're keen to get more information on these supplements and get them for yourself, go here. Do note that supplements are just that - *supplements* supplementing your actual food and you're still supposed to eat real food in order for them to be able to work best for you. We'll talk about food and eating habits and how they aid recovery from pain in another post.

Update, other posts on related topics - series on meals while living with chronic pain:

Why focus on meals is important
http://painmalaysia.blogspot.com/2015/01/meals-while-living-with-chronic-pain.html

What you should expect to be in your meals

http://painmalaysia.blogspot.com/2015/01/meals-while-living-with-chronic-pain_9.html

Shopping Solutions (and why they are important)

http://painmalaysia.blogspot.com/2015/01/meals-while-living-with-chronic-pain_20.html

How this occupational therapist got into pain management.

Skills to deal with pain should be on every occupational therapists' personal "occupational therapy tool kit". However, based on my observation of occupational therapy in Malaysia, not enough emphasis is being given to learning about the condition of pain and how to address it in our occupational therapy work (there are many other things that I feel occupational therapy education in Malaysia doesn't really teach us to address in our work, but that's for another blog post).

As a Taekwondo athlete and coach (my life before qualifying as an occupational therapy practitioner), dealing with pain and injury was part and parcel of my work. I had to learn:

1) proper movement to prevent injury (important when you've got a last a few rounds of fighting)
2) how to address and care for acute injury (so you can move on to the next match)
3) how to recover properly from injury - caring for injuries in the long run (so that your sporting career can last longer)

So I was already equipped with skills to manage pain and injury even before being an occupational therapist. (Note: not all Taekwondo and sports coaches are trained as such though, and that's a topic for another blog post. If you're a Taekwondo or sports coach who is keen to pick up these skills, I am actually lecturing this topic for Taekwondo Malaysia, the national body - you can feel free to invite me to conduct a course for you and the instructors / coaches in your club / association).

The need for occupational therapists to have skills to deal with pain came rather unexpectedly through my work with clients suffering from obesity-related conditions that eventually led to the GR:IN Lifestyle Modification Approach. When I started working with these people, the idea was that they would mainly be coming to me for weight management. What I didn't really think of (although it would seem pretty obvious!) was that people who were overweight would also come with knee and back pains, and that people with nerve damage from diabetes and stroke would also develop pain, and at the same time they would also have various unhealthy habits that also lead to other sorts of pain (like carpal tunnel syndrome - especially if they have lead a rather sedentary, computer-using lifestyle). There's plenty of people suffering from pain out there (that's why massages are very popular!) but we overlook it too easily!

How chronic pain affects lives

Pain is often an underestimated health condition, and many people do not realise the kind of consequences that could result from not addressing the root cause of their pain. I have had occupational therapy clients who had to quit their jobs and are unable to take on employment, isolated at home because their pain renders them unable to drive and get about in their every day activities. And I can say that it doesn't necessarily have to be that way. If addressed at a much earlier stage, their current condition (unemployment, unable to leave the house, isolated from community) could have been easily prevented, but many people do not necessarily know where to get help, who to get help from, or realise that they need help even.

I have had friends with persistently recurring pain ignore my suggestions about certain lifestyle modifications that they might need to go through to prevent further deterioration. This despite the fact that I'm an occupational therapist and also developed the GR:IN Lifestyle Modification Approach (which I use for clients with chronic pain, weight issues, sleep issues and also for mental health). One of my friends only started to take her health more seriously when her pain had gotten to the point where she started to have episodes so serious that they rendered her bedridden and unable to do her work. Sometimes I see people who despite multiple hospital admissions, are still unable to persist in making the changes in their lifestyle (how to make changes that stick? This will be another topic altogether).

In my talks to the general public, people are generally astonished at the incredibly devastating effect chronic pain can have on our every day lives, but it is not something that happens overnight. Chronic pain is one of those things that creep up on you over time. Like I always tell my occupational therapy clients, your health is where it is today because of an accumulation of factors over a significant time period: 10, 20, 30 years even (for my clients with stroke, high blood pressure, diabetes etc - yes, I see these clients too, and they too suffer from chronic pain, which was what led to my involvement in occupational therapy pain practice), so it is quite unfair to your body to expect it to recover very quickly after implementing a few changes via undergoing occupational therapy for a week or two.

Occupational Therapy and Pain Management

What is occupational therapy and what has it got to do with pain management?

Occupational therapy is a healthcare profession, just like doctors, pharmacists, physiotherapists, dietitians, etc. Occupational therapists are not easily found in Malaysia - there are only about 1000 of us around the country, with more than 90% of occupational therapists practicing in the government system.

What makes occupational therapy different from other healthcare professions have a more lock-and-key, specific approach towards health. E.g. when we go to see a doctor for pain, doctors would typically prescribe a person pain medication; when people go to see a chiropractor for back pain management, the chiropractor would then adjust their back; when people go to see an acupuncturist for pain management, the acupuncturist would then target the specific parts of the body nervous system that are causing the pain with their acupuncture needles.

The common point between the practices of all the health professionals mentioned above (and other health professionals that treat pain) is that most of the time, they aim to reduce the pain. But what happens when the pain continues to come back again and again? For Malaysians with such persistent, repeating chronic pain, they feel like they have to continue to return to therapy consistently for the rest of their lives.

Occupational therapists do not necessarily work directly with the pain. Sometimes, occupational therapists may not necessarily aim to reduce the pain directly. However, occupational therapists can teach their clients strategies to reduce pain and more importantly, live in harmony with the pain. We are the ones who should be in control of our lives, not the pain. Occupational therapists would look at what are the other factors that could be influencing the pain and then work together with the clients to be able to work around them.