"There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy."

Challenge your beliefs.

• Notice if the pain increased during a period of stress.
• Look for the evidence that the pain is inconsistent. For example, it isn't as strong or maybe it isn't there at all when you are relaxed, enjoying an activity, or otherwise distracted.
• If the pain fluctuates with your state of mind, you are likely experiencing an incorrect pain signal from something benign, like a sense of stretch. 
• Choose to redefine it as it really is. Remind yourself that the related movement is safe. 
• Consider asking the pain about what it wants you to know. Acknowledge the response in the way that works best for you such as a journal or internal conversation. Use the awareness of the issue to make appropriate changes in your life or frame of mind. 
• Breathe. Exhale through pursed lips longer than you inhale. Keep going. Allow your nervous system to relax.

Move regularly.

• Strengthen your core, hips, and shoulders.
• Stretch tight muscles to improve flexibility.
• Take regular movement breaks.

Improve your posture 

• Use ergonomic positioning, including furniture alternatives or modifications.
• Support your progress with postural trainers (do not rely on them alone to make the improvements for you).

Manage the pain in the moment.

• Apply heat to fascial/muscle pain and ice to nerve pain. A combination of both may be necessary.
• Use foam rollers, tennis balls, a TheraCane, and/or massage devices to work out tight and tender areas.
• Use an over-the-counter pain relieving medication or cream.

Manage your risks.

• Use fall prevention aids, such as grab bars, non-slip bathroom surfaces, canes and walkers, stair rails, good lighting, and similar.
• Manage, manage, manage all inflammatory conditions you may have, including hormonal imbalances, diabetes, and borderline diabetes. If appropriate, eat an anti-inflammatory diet such as the Mediterranean or DASH diets.
• Make relaxation/mindfulness a regular practice to support lower levels of stress-related neurotransmitters.
• Manage your energy so you are not overextending yourself and increasing stress-related neurotransmitters.
• Get restful sleep. It is important for integrating all experiences into their appropriate memory banks in the brain, including the traumatic experiences. It also allows you brain to engage in needed repair processes.
• Manage your mood and relationships to support lower levels of stress-related neurotransmitters.

Get help from a clinician when you need it.

• See an appropriate clinician who can provide pain reprocessing therapy, myofascial release, trigger point release, therapeutic exercises, injections, prescription medication and other interventions based on your needs when your self-management efforts are not working.
• Remember, there can be side-effects to medications so it is best to pair them with other pain management methods to reduce the amount you need.
• Remember, too, that injections and surgeries are invasive procedures. Regular practice of non-invasive methods that help you reduce your risk of needing these.

Gentle, tolerable, regular movement has been found to be beneficial in reducing all pain types. 

• Explore online and community-based resources for gentle movement options. Not every option has to be an 'exercise' class. Social groups that get together to do something that happens to be physical such as birding, geocaching, volunteering, and more are great options.
• Pain BC, Self-Management BC, and the book Living a Healthy Life with Chronic Pain have links and/or pictures of exercise programs that you might find beneficial.

General movement recommendations (see your provider for any instruction specific to you):

• Generally, pain can increase 1-2 points from your baseline pain self-rating scale where 10 = the highest pain and 0 = no pain.
• Pain increases should not last for 24 hours or more.
• If either of the two recommendations, above, are exceeded, reduce something such as fewer repetitions, smaller movements, shorter durations, etc. 

Tip

• When starting out, it is often best to aim for a sense of effort but not pain as many people tend to be more guarded at the outset which tends to correlate with increased nociplastic pain and general inflammation. As confidence and comfort with movement improves, nociplastic pain tends to recede and tolerance improves.

Lots of people tell me that they do not need to use a tool. "I'm not there yet." I understand. More often than not, I want people to be physically engaged in their lives. However, people often need to re-build their tolerance to physical activity. This is best done in a paced manner. Therefore, I prefer people learn to 'spend their energy bucks' wisely. 

Additionally, some people, such as those with chronic fatigue syndrome, may actually need to be more restful rather than trying to physically push themselves. Tools are helpful in remaining occupationally engaged without over-exerting yourself. 

Still not sure? Think about this. Tools can have the equivalent effect of wearing cleats when it is icy. Sure, you may be able to take the trash out without slipping and falling on the ice, but you spend a lot of energy and increase you attention, possibly even your state of worry, while you take the trash out. If you're wearing cleats, you (your nervous system) calms down and your stability improves.

Below is a list of tools that can be helpful. Use the terms below to do an internet search to see what they look like. If you are using Google for the internet search, you will see a row of options at the top of your search results. One is "images." Clicking on this will allow you to see pictures of the options. If one looks like it could be useful, you can follow the links to the website for the item. Also, under the Safety, Tools, and Tips header is a document called "Tools & Tips" which has pictures of many of these items. 

• Pain: postural training devices that encompass both upper and lower back (thoracolumbar devices), lumbar support wrap devices, appropriate and cushioned foot wear, anti-fatigue matts when standing, etc. 

• Mobility: bilateral walking poles, canes, walkers, mobility scooters, lightweight and foldable power wheelchairs, standard transport/manual/power wheelchairs, etc.

• Bathing: non-slip stickers for bottom of tub/shower and/or floor, handheld showerhead, tub bench and/or shower chair, grab bars, transfer poles, washing mitts, soap-on-a-rope, pump dispensers, long-handled sponge, floor-based toe/foot scrubber, long-handled shampooer, preparation strategies, etc.

• Dressing: sock aid, dressing stick, reacher/grabber, button hook, zipper pull, dressing strategies, etc.

• Toileting: bedside commode over toilet, bilateral toilet rails, elevated toilet seats, transfer poles, bidets, bidet attachments, portable bidets, toilet paper wands, inspection mirrors, wet wipes, etc.

• Grooming: modified nail clippers, modified toothbrush/denture cleaners, pump dispensers, mounted holders for blow dryers, long-handled brushes and combs, built-up handles/grip aides, etc. 

• Seating/Bed transfers: furniture risers, bed canes, bed rails, transfer poles, traction on floor such as stuck-down stair treads or tub stickers, power lift recliners, etc.

• Seating surfaces: use of pillows to support good posture while allowing for tissue relaxation, seat cushions with coccyx cut-outs, lumbar supports, thoracolumbar supports, etc. 

• Meals: modified utensils, modified cups, modified plates, modified cutting boards, modified sharp knives, use of microwave over oven, use of paced and supported meal prep for the week, freezing meals and microwaving them, Meals on Wheels, etc. 

• Vehicles: entry and exit strategies, car cane device, window hand hold strap (pros and cons), slip sheet/plastic, covering slip sheet with towel for perspiration control, step-sides (static and power), carrying devices for wheelchairs, etc. 

Here is an excellent resource to delve into this topic more deeply. It includes information on sleep and pain, changing sleep cycles, sleep and aging, and sleep and chronic fatigue.

• https://www.healthlinkbc.ca/illnesses-conditions/fatigue-and-sleep 

Terms to Know: 

• Sleep hygiene. This simply pertains to good sleep-supporting habits, not actual cleanliness. 
• Circadian rhythm. This is simply the body’s 24-hour biological clock which helps to regulate physiological functions. These functions can have an impact on mood, stress tolerance, and pain when dysregulated.

The following tips can be beneficial. Each person is different so if one approach does not work for you, try another. Sometimes sleep is impacted by a variety of factors and combinations of adjustments need to be trialed.

Train the brain:

> Use the bedroom for sleeping and intimacy only so the brain begins to recognize it as the place for sleep to occur. Limit long naps in other areas of the home to aid in this learning.

> Go to sleep and awaken at consistent times daily to aid in facilitating and maintaining the circadian rhythm and training the brain to this rhythm.

> If not falling asleep within 20 minutes of lying down, get up and leave the bedroom until sleepiness occurs. Then return to bed. This aids in training the brain.

Use sensory inputs:

> Sleep in a cool room. It is ok to use blankets for body warmth but keep the air cool.

> Sleep in a dark room. Light can stimulate the brain to be wakeful.

• Place technological devices, such as cell phones and tablets, outside of the room if possible. If not, cover them or turn them upside-down so that the light from the screen is not emitted into the room.

> Sleep in a quiet room. 

• If electronic devices are present in the room, change their settings so they ‘sleep’ when you do which will stop incoming alerts for a period of time. If there is a concern that an important alert could be missed, consider reducing the volume, changing to a vibration, or changing the alert tone to something less intrusive. 
• If it is necessary to go to sleep with a device on, such as listening to a podcast or tv show, consider setting a timer on the device so it turns off automatically after you are asleep.

> Considering adding the sounds and smells of nature.

• Many people sleep more restfully when camping. Consider adding a water fountain, plants with pleasant odors, and a small fan to create gentle air circulation in your room. The fan should ideally be aimed so it circulates plant and water smells. It does not have to be aimed directly at the client. 
• Consider favored settings, such as forests or beaches, when deciding on natural features for the room. 

Behaviours when awake:

> Stop eating with enough time to digest food out of the stomach before lying down to sleep.

• This reduces reflux. Reducing reflux can reduce sinus congestion. 
• If it is necessary to eat later, consider a soluble fiber supplement such as Fiber 4 or psyllium (found in Metamucil and other supplements) to add a sense of fullness without eating too much and to help bind stomach contents to reduce reflux.

> Stop caffeine earlier.

• Tolerance for caffeine can change as one ages making it more likely it will contribute to wakefulness if consumed later in the day. 
• Consider caffeine free alternatives. 

> Be occupationally engaged during waking hours.

• This strengthens the cues to the brain that the client is awake versus asleep/sleepy which supports a healthy circadian rhythm.
• Occupations that involve physical activity/exercise can enhance this effect.
• Physical activity/exercise can help muscles relax at night because they have used stored energy. 

First of all, dietitians are awesome. Get to know one.

Inflammatory Pain:

This type of pain is recognized by the World Health Organization but not as widely recognized elsewhere. It has also been associated with nociplastic pain. It occurs from a normal response to expected inflammation that occurs from an injury or illness. It also occurs as a sensitized/hypersensitive response to inflammation. 

Inflammation in the context of diet: 

> Chronic systemic inflammation can result in increased and widespread pain.

> Systemic inflammation is often associated with the biomarker A1c which, when elevated, is typically seen in people with diabetes and/or heart disease. 

> Diabetes and heart disease can be managed, in part, by diet. This can reduce A1c which reduces the systemic inflammation which can reduce the pain. 

> Anti-inflammatory diets that are clinically recommended are: Mediterranean and DASH diets. 

• All people are different and may have different dietary needs. A dietitian can help guide a person in making appropriate dietary choices for their needs.

Is weight important?: 

One pound of weight loss has been found to reduce 4 pounds of force from the knees. Losing weight, if appropriate, can reduce joint stress and related pain so, yes, it can be important for nociceptive and neuroplastic pain types where injured, weight-bearing tissue is being compressed.

However, weight loss can prompt people to ‘diet.’ They may try the latest fad diet or feel confused by information in social media. Additionally, the mere idea of these social pressures can increase anxiety, depression and overall stress which, in turn, can increase nociplastic pain and prompt a person to seek comfort food. 

It is unfortunate that the idea of weight is so psychologically inflammatory in and of itself. If weight loss is important to you in your pain management/health management journey and if it is likely to trigger these unhelpful responses/behaviors, consider enlisting the support of a dietitian to help support and coach you through your journey. An occupational therapist can also help and support you in implementing dietary recommendations, but specific dietary instructions for your health needs should come from your GP/NP and/or dietitian.

A note: Dietitians can help you identify health-supporting dietary options even if you do not have a lot of money to spend or time to prepare meals. They are also willing to adjust recommendations as you go along to find options that work best for you. I know it can be difficult and personal to talk about eating habits you feel are embarrassing or not reflective of your ideal. A dietitian, though, should provide you with a safe space to open up. Go back. Talk to them again. They can support you.

If your GP/NP does not have any dietary concerns for you and you are unable to enlist the aid of a dietitian, then - in general - it is okay to 'play with your food' to see what works for you. Here are some basics.

> It is important to eat enough calories, and consume protein, carbohydrates, and fats. 

• Ideally these come from health-supporting food sources and are proportioned such that they meet dietary guidelines. 

> It is important to make dietary changes at a tolerable pace.

• Consider changing one undesirable food habit at a time. Find an alternative to the item that is tasty and healthy. Have it on hand to choose it over the less desirable choice. If possible, remove the less desirable choice to avoid the temptation. 
• The ‘diet’ that is best is the health-supporting one that a client is able to maintain over time, not a ‘quick fix.’ 
• Clients may return to old familiar food preferences. This is ok. Enjoy the experience. Return to the health-supporting choices as possible afterwards. Leave demeaning self-judgment behind. 

Gas, bloating, and irritable bowel syndrome (IBS): 

Normal aging can cause slower gastrointestinal motility thereby slowing digestion and giving food more time in the gut which can increase a sense of pressure, feeling backed-up, and possibly contributing to reflux. 

If you are eating the amount of food you 'used to eat’ when younger, you may benefit from some adjustments. Again, consider the aid of a dietitian. 

Pain medications, especially opiates, can slow GI motility more, often quite a lot. It can cause constipation and sometimes in some people fecal blockages. 

Fascial tissue, which has almost as many sensory nerves as skin, is interconnected through the abdomen and can be stretched from gas/bloating/abdominal distension from slowed motility and an overfull bowel. This can create pull through low and mid back fascia tissue and can contribute to increased abdominal and back pain.

IBS has not had an identified cause.* The pain from IBS has been attributed to a sensitivity of nerve endings within the bowel that occurs when IBS symptoms are triggered. Removing certain foods that contain short-chained carbohydrates called FODMAPS from the diet has been found to be helpful in reducing IBS symptoms. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols. 

*There is emerging research showing that more than 80% of people who have been diagnosed with IBS test positively for a condition called SIBO (small intestine bacterial overgrowth). When the SIBO is successfully treated, the IBS symptoms resolve. SIBO does require a test to diagnose. It is a breath test over a three-hour timeframe, typically. Treatment is usually done with a combination of tactics which generally includes at least one, possibly two antibiotics. 

General Tips: 

• Gas-X, Beano, and other over-the-counter gas relievers can be very helpful in reducing gas pressure and related pain. You may benefit from the ‘ultra-strength’ version of these and you may also benefit from taking the amount allowable per day. 
• Eliminating FODMAP foods can be done without limiting required calories or major food groups (protein, carbohydrates, fats). Not everyone will need to eliminate every FODMAP food to have it help them. It is typically recommended to try removing all to see if there is a benefit and then add one in at a time to see if it is tolerated. 
• Again, a dietitian can guide you through FODMAP trials and ensure your nutrition remains health-supporting. 

Here are excellent resources to learn more:

> Canada's Food Guide: 

• https://food-guide.canada.ca/en/ 

> US Dietary Guidelines for Americans: 

• dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf

> Dietitians of Canada Mediterranean Diet Toolkit, A Guide to Healthy Eating:

• https://www.dietitians.ca/DietitiansOfCanada/media/Documents/Mediterranean%20Diet%20Toolkit/Mediterranean-Diet-Toolkit-A-Guide-to-Healthy-Eating-(handout).pdf 

> Heart & Stroke Foundation Information on the DASH Diet (DASH = Dietary Approaches to Stop Hypertension): 

• https://www.heartandstroke.ca/healthy-living/healthy-eating/dash-diet 

> Canadian Digestive Foundation, Understanding the Low FODMAP Diet: 

• https://cdhf.ca/en/understanding-the-fodmap-diet/