Why Everyone Should Get to Know Their Pelvic Floor

There is a common misconception that the pelvic floor is only relevant for women who have had kids. I’m here to tell you this is bonkers. Sure, having a child tends to lend to more obvious pelvic floor dysfunction, but there are many signs of impairment that aren’t recognized as coming from the pelvic floor. Also, why has it been deemed acceptable to completely neglect a part of the body until a baby is shoved out of it or cancer shows up in the prostate? We wouldn’t ignore a person’s right leg until it needed amputation right? And yes, males have pelvic floors too! There is definitely more talk about the pelvic floor within the perinatal population which is progress, but male pelvic health continues to be taboo leaving most men to suffer quietly not knowing there is any other option. I can’t bring up quiet suffering without also acknowledging the fact that those who don’t identify with the genitalia they were born with and those who have experienced physical and/or emotional abuse or trauma are even more likely to be silent. This can come from not knowing there is something that can be done, feeling uncomfortable or too ashamed to bring it up and/or not trusting that a medical professional will listen and actually hear them which is unfortunately a valid concern. Each one of these barriers to pelvic floor health can, should and will be a blog post of their own but my main purpose here is to just convince you that it’s time you introduced yourself to your pelvic floor if you haven’t already.

Why is the pelvic floor important?

The pelvic floor is a group of muscles that are responsible for poop and pee control, all sexual functions, lymphatic drainage, support of the organs that lie above it and stability of the spine, hips and pelvis. Do I need to say more? All of these functions are absolutely essential to our ability to be functional and happy people in the world.

Even further, the pelvic floor is our emotional holding place and our energetic center. Did I lose you with that one? I never thought these words would be a part of my western-based practice either but when you specialize in the pelvic floor they have to be. Again, I’ll save most of my words and RESEARCH to back it up for another blog but for now, just think about how the root chakra has been a part of many ancient practices that still hold true and effective in today’s modern world.

What are signs and symptoms of pelvic floor dysfunction?

The most obvious signs of dysfunction include: peeing yourself, pooping yourself, erectile dysfunction, pain with penetration, feeling like your organs are falling out of your vagina and/or butthole, and inability to sit because of tailbone pain.

The not so obvious signs include: peeing too frequently, always feeling like you have to pee, having to rush to the bathroom, difficulty initiating voiding, non-continuous urine stream, post-pee dribble, not feeling like you empty poop or pee all the way, waking up at night to pee, feeling like you have a urinary tract infection when you don’t, interstitial cystitis, overactive bladder, not being able to hold a fart in, not being able to discern whether its a fart or poop that is waiting to come out, having to bear down to get poop or pee out, pooping taking longer than 10 min, not pooping everyday, clinically diagnosed constipation, constipation-diarrhea yo-yo, irritable bowel syndrome, hemorrhoids, premature orgasm, inability to orgasm, decreased natural lubrication, decreased libido, enlarged prostate, fibroids, cysts, endometriosis, the feeling of pressure or heaviness, peeing/pooping/farting a little when you laugh/cough/sneeze/run/jump, poop getting stuck in a pocket, having to splint to poop (if you have to do this you will know what I mean), pain with pooping or peeing, painful menstrual cycles, perineal, testicular, scrotal, sacroiliac and pubic pain. Whew! Anyone else winded from that?

And the signs that you wouldn’t guess had anything to do with the pelvic floor include: abdominal pain, hernias, diastasis recti (abdominal separation), hypersensitive nervous system, PTSD, piriformis syndrome, sciatica, groin pain, hip pain, low back pain and get this…even knee, neck and shoulder pain! How can this be? It’s because the pelvic floor is the bottom of our core which stabilizes the spine. Without spinal stability, nothing works right. You can read more about this in my previous blog post, “Spinal Stability”.

What can be done to improve pelvic floor dysfunction?

SOOOOOO MUCH! As I mentioned right off the back, the pelvic floor is a series of muscles. As with all muscles of the body, their strength can be improved leading to more functional capacity and decreased symptoms. Sometimes this has to start with learning how to relax the pelvic floor (again, needs to be another blog…I have created quite the list for myself), sometimes it has to begin with posture and breath, and other times its pressure management, loading the system and introducing impact. It never ever ever ever, is just kegels. I will save that soap box for another day.

When the dysfunction is beyond what can be fixed through muscle strength, there are many surgeries to fix any ligamentous or tissue damage. This is the equivalent of when leg strengthening isn’t enough to return to soccer without an intact ACL. The surgery replaces the ACL but then rehabilitation after the surgery is a must. Same goes with any pelvic floor surgery (having a kid counts as such). The post-op rehabilitation is absolutely imperative to gaining proper function afterwards. Scar tissue doesn’t magically disappear and muscle strength doesn’t miraculously pop back.

Who can you talk to about your pelvic floor?

I encourage everyone to start using the words poop, pee, vagina, penis and sex in their day to day conversations. I think part of the problem here is that we aren’t comfortable saying or hearing, let alone discussing these things with anyone, especially doctors.

If you are experiencing any of the above signs or symptoms, don’t sit and wait for your doctor to bring up the topic. While it should be part of their routine screen, it’s often forgotten or breezed over. If your doctor asks you the questions, feel comfortable answering them honestly. It does nothing for you to lie and say no just because it’s an uncomfortable conversation. It doesn’t have to be!

When you do bring it up or answer honestly, don’t be surprised if your doctor goes straight to prescribing a medication or giving you a urologist or gynecologist referral. This is when you need to be your own advocate and ask for a pelvic physical therapy referral first. Pelvic physical therapy is a relatively new thing in America so it still isn’t the go to for most doctors. Heck, we are still trying to get some doctors to refer to physical therapy for back pain. It will definitely be some time before doctors routinely refer to PT for incontinence. So ask for it yourself. You wouldn’t sign up for a back surgery before trying to strengthen your core first nor would you choose to be addicted to narcotics for pain before trying to improve your musculoskeletal impairments. Same goes for the pelvic floor. Address the muscles first before signing up for bladder surgery or viagra.

Still unsure or uncomfortable?

I gotcha covered. Shoot me an email here. Let’s work through it.

Schedule a Free 30-minute Consult


The Pillars of Health

Most of us want to be healthy or know we should be. But what is health and how is it measured? When do we know that we have achieved it and how can we achieve something that we haven’t yet defined? We can’t. My aim is to briefly outline what I would consider the pillars of health. I am going to keep it simple here. In future posts, I will dive into each one of these pillars and their components with research to back it all up but I want to start with an overview of the big picture, of what it means to be healthy and what our bodies need in order to function at an optimal level for as long as we are on this earth.

HAPPINESS

Happiness: another vague term just like “health”. I always hate it when people define something with yet another word that needs a definition, but here I am doing it. I use the word “happiness” because there is a lot that goes into our mental well-being and it’s the best we have when it comes to summing it all up. Our mental state is foundational to our health. Feelings and thoughts drive our actions and results. Negative emotions are also absorbed in the physical body and manifest disease. For these reasons, I would argue that nothing matters more to our health than our level of happiness. It over-rides everything else we do or don’t do for our body.

So what is happiness? It’s the state of being happy, obviously. Ha! Sorry, couldn’t resist that one. In all seriousness, I believe there are many components to achieving the state of happiness. In my opinion, this includes proper stress management, permission to feel with a high level of emotional intelligence, positive self talk, unconditional self love, the feeling of purpose, deep social connection and support. Easy peasy right? Absolutely not. I don’t think we put enough time and effort into improving these areas. Nor do I think people realize how essential they are to our physical health. I could write a novel on each of these components and I eventually will but for now I am going to leave it at this: you can’t be physically healthy unless you are happy. Period.

FOOD

Food: a simple but not so simple thing. Everyone knows you are what you eat but there isn’t a lot of agreement on what that should be. Sure, we can all agree sugar intake should be limited but what about natural sweeteners? what about artificial ones? how much sugar is too much? and are carbs considered a sugar? The same confusion exists when considering meat, dairy, alcohol and carbohydrates. I have even witnessed debate around which vegetables and fruits are quote-on-quote “good or bad” for you.

Again, I could spend my whole life writing about food and I will write more in future posts but for now, I just want to highlight what I consider to be the most important principles to follow when it comes to what you eat. I think Michael Pollan sums it up nicely when he says “eat food, not too much, mostly plants”.

  1. Avoid processed food (this includes sugar, all-purpose flour, food with long shelf lives and most foods that have more than five ingredients especially containing ones you can’t pronounce)
  2. Limit alcohol
  3. Mostly vegetables (especially green ones)
  4. Include healthy fats (nuts, avocado, chia seeds, extra virgin olive oil, coconut)

EXERCISE

Exercise: finally one that is easy to define but not necessarily easy to consistently do. When it comes to what type, how much and how often, I would say that variety and consistency are key. It’s important to have both a strength and endurance component to your exercise as well as a form of recovery like stretching, yoga, hot tubs or bodywork. From there, it depends on what your goals are and what you enjoy doing. I think exercise is most effective when it is functional aka it looks a lot like what you want to accomplish in your day to day. But nothing is effective when it’s not consistent so it’s important that you choose forms of exercise that are enjoyable so you are motivated to do it and keep doing it.

SLEEP

Sleep: something so simple and yet so difficult. There are two components to sleep: quality and quantity. In order to attain the restful sleep that our body needs, you have to have both. There are many reasons that sleep can be disrupted (which I will write about in the future) but sleep also tends to be something we don’t prioritize. Often we feel there is too much to do and no time to sleep. Or we develop habits that we think are necessary to get everything done that interrupt our ability to get deep sleep like loading up on caffeine or working on the computer late into the night. The reality is that we would be far more effective in our day and feel better if our priority was sleep. Try sleeping 8 hours every night for one week. You will be amazed at how much of a game-changer sleep is.

ENVIRONMENT

The environment: the often forgotten and oh so covert component to health. I’m still wrapping my head around all of the things in our environment that we can’t see or aren’t aware of that have a profound impact on our physical health. Infections and parasites are the most obvious ones but then there are heavy metals, pesticides and plastics that we can’t see but are in our water, on our food and in most of the products that we use. It’s a scary rabbit hole to go down which is why I avoided for as long as I could but there are small changes you can make that go a long way like removing plastics from your kitchen, replacing your make-up and skin care products with ones that don’t contain metals or hormone disruptors and using cleaning supplies that are made from natural products instead of chemicals. Once again, there is a lot to talk about here and I will write more in future posts but for now, just start looking at what you use in your house and on your body. Items or products that you use everyday are worth replacing even if you only just opened the bottle. Your body will thank you.

Want to see the research?

I have none for this one but as I address each pillar in future posts, I will be sure to provide the evidence for everything I say or I will make it clear that it is my opinion 🙂

Are you interested in a specific pillar? Let me know which one you want me to dive deeper into by emailing me here.

Spinal Stability

The intricacies of spinal stability can get complicated but the big picture is pretty simple. It can be summed up in a few sentences: a stable spine is required for strength and proper function of our limbs or whole body for that matter. The spine is stabilized by two mechanisms: intra-abdominal pressure (IAP) and muscle activity. Contraction of the diaphragm produces intra-abdominal pressure. Muscles including the transversus abdominis, pelvic floor and multifidus control that pressure and are responsible for spinal stability in the absence of it. Breath coordinates the system.

The end.

Just kidding. Jenny write a short blog? Never.

Let’s break this down further. Stability is “the precise control of excessive joint motion while allowing for the generation of necessary torques for desired multi-joint movement” (C. Frank 2013). In normal talk, it is a lack of movement at one joint allowing for enough force production to create movement at another joint. Spinal stability aka stiffness, enables limb motion and strength. It can be likened to a tree trunk and its branches. A large, stiff and stable tree trunk can support branches that can sustain a heavy load whereas a Gumby-like, thin tree trunk would give way to the weight of even the smallest branch.

This comparison of the spine to a tree trunk should give insight into why spinal stability is absolutely essential to the function and strength of all joints and limbs. If the spine isn’t stable, the body struggles to find stability elsewhere leading to compensation and overuse of small muscles trying to do a really big job that shouldn’t be their responsibility. It also lends to excessive movement in the spine which can cause degenerative disc disease, arthritis, fractures, spondylolesthesis, stenosis, nerve compression and the list goes on. This would be the equivalent of a flimsy trunk breaking under the load of a heavy branch.

So how do we achieve spinal stability? There are two components: intra-abdominal pressure and muscle activity. Both have been proven to be effective in stabilizing the lumbar spine and the preferred mechanism has been shown to be task, movement and posture dependent.

Let’s turn the spotlight on intra-abdominal pressure. I’m about to rattle off a whole bunch of contradictory research that will likely confuse most people so I’ll start with a few statements that are largely agreed upon. First, intra-abdominal pressure stabilizes the spine. Period. It’s a known fact. Next, contraction of the diaphragm which occurs on an inhale, increases intra-abdominal pressure. Another known fact. And lastly, contraction of the abdominals control and contribute to intra-abdominal pressure. Thats about where the clarity ends.

The mechanism by which intra-abdominal pressure stabilizes the spine is not clearly understood. The theory most supported in literature is that the increase in intra-abdominal pressure is accompanied by a co-contraction of the abdominals which provides spinal stiffness and stability. This implies that tension of the abdominals in a lengthened state (eccentric contraction) is essential to the mechanism. Within this body of research, some studies show that all abdominals are involved while the majority say it is mainly, if not solely, the transversus abdominis. Like I said, there isn’t a lot of agreement in the details.

Most research indicates that intra-abdominal pressure is the preferred strategy for activities that place a large extension moment on the spine such as lifting and jumping because the spine is able to stabilize without additional activation of the erector spinae. Intra-abdominal pressure may also be preferred with heavy loads but there is no consensus as to whether it unloads the spine or increases intra-discal pressure. Some theorize that the intra-abdominal pressure unloads the spine by directly pressing upwards on the rib cage via the diaphragm as well as indirectly by generating an extensor moment on the lumbar spine that decreases back extensor muscle activity. Others have shown that there is an increase in intra-discal pressure during a Valsalva maneuver with no reduction in erector spinae activity making the unloading effect of intra-abdominal pressure controversial.

At the end of the day, I think it’s safe to conclude that the unloading and stabilizing effect of intra-abdominal pressure and the muscles responsible for generating it are posture and task specific. But really big picture, we know intra-abdominal pressure stabilizes the spine and we know the diaphragm and the transversus abdominis are involved in producing it. I hope I didn’t lose too many of you with all of that.

Let’s move on to muscle activity and it’s role in stabilizing the spine. On an exhale, the diaphragm relaxes, reducing intra-abdominal pressure. A shortening contraction of the core muscles replaces the absence of intra-abdominal pressure with tension that increases spinal stiffness and creates stability of the spine. However, there isn’t a lot of agreement regarding which muscles do this.

Most studies refer to the transversus abdominis, multifidis and pelvic floor as the core musculature. Some say that transversus abdominis is solely responsible but other studies show that all muscles of the trunk increase spinal stiffness and can be involved. Research supporting the later demonstrates that muscle activation is position, task and movement specific making the most important stabilizer transient to the task. Regardless of which muscles are doing the work, coordination and proportional tension of the muscles are required to provide effective spinal stability.

Both intra-abdominal pressure and muscle activity have been shown to increase stiffness of the spine in isolation but in function, they always go together. I believe this fact, combined with everything being task, posture and movement specific, explains why the details of spinal stability cannot be agreed upon within research.

So how do I apply all of this to my patient care? No matter where the pain is, I always assess spinal stability. If impaired, it is prioritized in addition to addressing impairments directly at or surrounding the location of pain. This includes posture and breathing patterns since spinal stability is directly tied to both. When it comes to my progression of spinal stabilization exercises, I start with static postures in spinal neutral to re-coordinate the system through breath and conscious muscle recruitment. At first postures are gravity eliminated (aka lying down) and gradually progressed to positions against gravity (aka sitting, kneeling and standing). Once coordinated and able to stabilize against gravity, I progress to loading the system with weight and/or limb movement on a stable spine. This is when we are training the muscles of the core to work while both lengthening and shortening, keeping tension throughout the whole breath cycle. From there I progress patients into loaded multi-joint movements while maintaining neutral spine. The last step is training out of spinal neutral because let’s face it, life doesn’t happen in neutral so it’s important that we are strong in all positions of the spine. And then voila! You have achieved spinal stability! Sounds easy peasy right? Definitely not. Which is probably why I have a job. But it is totally doable. It just takes a lot of work and an understanding of your why which I have hopefully helped with a little bit today.

What to see the research?

  • Frank, C., Kobesova, A., & Kolar, P. Clinical Commentary: Dynamic Neuromuscular Stabilization and Sports Rehabilitation. The International Journal of Sports Physical Therapy | Volume 8, Number 1 | February 2013 | Page 62-73
  • Cresswell, AG, Grundstrom H & Thorstensson A. Observations on intra- abdominal pressure and patterns of abdominal intra-muscular activity in man. Acta Physiol Scand 1992, 144: 409-418.
  • Cresswell AG, Thorstensson A. The role of the abdominal musculature in the elevation of the intra-abdominal pressure during specified tasks. Ergonomics. 1989;32(10):1237‐1246. doi:10.1080/00140138908966893
  • Cholewicki J, Juluru K, McGill SM. Intra-abdominal pressure mechanism for stabilizing the lumbar spine. J. Biomech. 1999a;32(1):13–17.
  • Cholewicki J, Juluru K, Radebold A, Panjabi MM, McGill SM. Lumbar spine stability can be augmented with an abdominal belt and/or increased intra-abdominal pressure. Eur Spine J. 1999;8(5): 388-395.
  • Gardner-Morse MG, Stokes IAF. The effects of abdominal muscle co-activation on lumbar spinestability. Spine. 1998;23(1):86–92.
  • Hodges PW, Eriksson AE, Shirley D, et al. Intra- abdominal pressure increases stiffness of the lumbar spine. J Biomech. 2005;38(9):1873-80.
  • Hodges PW, Gandevia SC. Changes in intra- abdominal pressure during postural and respiratory activation of the human diaphragm. J Appl Physiol 2000;89(3):967–976.
  • Shirley D, Hodges PW, Eriksson Ae, Gandevia SC. Spinal stiffness changes throughout the respiratory cycle. J Appl Physiol. 2003;95:1467-1475.
  • Nachemson AL, Andersson GBJ, Schultz AB Valsalva maneuver biomechanics Effects on lumbar trunk loads of elevated intraabdominal pressures. Spine. 1986;11:476–479.
  • McGill SM, Norman RW, Sharratt MT. The effect of an abdominal belt on trunk muscle activity and intraabdominal pressure during squat lifts. Ergonomics. 1990;33:147–60.
  • Arjmand N & Shirazi Adl A. Role of intra-abdominal pressure in the unloading and stabilization of the human spine during static lifting tasks. Eur Spine J, 2006;15:1265–1275.
  • Hodges PW, Cresswell AG, Daggfeldt K, Thorstensson A. In vivo measurement of the effect of intraabdominal pressure on the human spine. J Biomech. 2001;34:347–353.
  • Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 2004; 29(11):1254–65.
  • McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordination of muscle activity to assure stability of the lumbar spine. J Electromyogr Kinesiol. 2003;13(4):353-359.

The Diaphragm – More Than Just a Muscle

“There is arguably no other muscle in the human body that is so central literally and figuratively to our physical, biochemical and emotional health as the diaphragm. From its obvious role in respiration to its less obvious roles in postural stability, spinal decompression, fluid dynamics, visceral health and emotional regulation, the diaphragm has a repertoire of function that is broad by any muscle’s standard.”

– Matt Wallden MSc Ost Med, BSc (Hons) Ost Med, DO, ND doi:10.1016/j.jbmt.2017.03.013

It became obvious early on in my career that the diaphragm was central to the rehabilitation of not just the spine, but of all four limbs as well. What wasn’t as obvious at the time was the fact that the diaphragm has a function or an influence on every system of the body. Once I wrapped my head around this, I started to include diaphragmatic breath as a component, if not the first component, of every patient’s treatment plan. Similar to myself as a new grad, I find that many people don’t quite understand how important diaphragmatic breath is and let’s face it, focusing on breath is pretty boring especially when you are looking to decrease pain and get strong. But once you know the why behind it all, I think you will start questioning any health professional that doesn’t put an emphasis on diaphragmatic breath.

Embryologic Connections

Before I dive into what the diaphragm does, let’s talk about where the diaphragm comes from as in what tissue it is derived from when we are a ball of cells turning into a tiny human in utero. There are 5 major contributors to the formation of the diaphragm:

  1. Mesoderm (from the third and/or fourth cervical myotome…various articles cite different levels)
  2. Pleuroperitoneal membrane (also forms pericardium)
  3. Esophagus (contributes a layer of connective tissue where it passes through the diaphragm)
  4. Anterior body wall (also forms abdominals, intercostals, scalenes and pelvic floor)

I know there are a lot of big words in there and for anyone that isn’t an anatomy nerd like myself, that list may mean nothing to you which is totally fine. Here is the big take away: the tissues that form the diaphragm come from the neck and also go to form the sac around the heart, the esophagus, the abdominals, pelvic floor and muscles in the neck. This can give us a little insight into how connected the diaphragm is to the neck, abdomen, heart, esophagus and pelvic floor. It also means that dysfunction in the diaphragm can result in heart problems, swallowing issues, neck pain, incontinence and spinal instability.

Anatomical Connections

Ok let’s get into what the diaphragm looks like once we are all grown up or at least out of our mama’s belly. Many research articles go into ridiculous anatomical detail describing the diaphragm, I will spare you all of those words and highlight some fascinating anatomical connections that may give light into how this muscle has interplay with so many surrounding structures.

First off, it’s important to note that the diaphragm is a dome shape at rest and flattens when it contracts. This is unlike most muscles in our body other than the pelvic floor. The diaphragm supports the lungs and heart from above while sitting on top of the liver and stomach below. The front portion is connected to the tip of our sternum (xiphoid process), the side portion is attached to the inside surface of our lower 6 ribs and the back portion is attached to the upper segments of the low back in addition to the arcuate ligaments that extend out to both sides and wrap around the trunk. This means that any rib or lumbar spine dysfunction will influence the diaphragm’s ability to contract and relax and vice versa. It’s also important to note that the arcuate ligament fascia is blended with the quadratus lumborum, psoas and transversus abdominis so any disruption in these muscles could either drive or be caused by diaphragm dysfunction.

The diaphragm also has ligaments that attach the muscle to the viscera. This includes an attachment to the base of the lungs, one to the heart, two to the liver and a few to the intestines. Whoa right?! I hope you are starting to grasp how connected the diaphragm is to practically everything above and below it on a structural level.

Neural Connections

The diaphragm is also connected to most everything through its neural innervation aka what nerves make up the pathway for a signal to come from the brain to the muscle and back to the brain. The diaphragm receives both motor and sensory signals from the phrenic nerve which is comprised of spinal nerves C3, C4 and C5 (sometimes C6). These spinal nerves are also involved in making up the cervical and brachial plexus so any abnormal signaling from the diaphragm may alter motor control in the neck and into the shoulder and arm. This implies that shoulder and neck pain could be a symptom of diaphragm dysfunction.

The pathway of the phrenic nerve gives even further insight into what can influence messages sent to and from the diaphragm. Upon exiting the spine, the phrenic nerve goes through the anterior scalene muscle. This muscle is located at the front of the neck and is very vulnerable to injury with whiplash. It is also put under a large amount of stress with forward head posture.

The phrenic nerve later blends with the vagus nerve as it passes through the opening in diaphragm on its way down into the abdomen. This is how diaphragmatic breath can assist in “massaging” the vagus nerve thus putting our body in rest and digest mode instead of fight or flight. I mean that function alone makes diaphragmatic breath worth any effort it takes to find it.

“The diaphragm is one of the most remarkable areas of the body in that it has so much influence and the consequences of its dysfunction can manifest anywhere from the head to the toes”

Caroline Stone. Science in the art of osteopathy. Osteopathic prin- ciples and practice. Stanley Thornes Ltd, Cheltenham 1999.

Respiratory Function

You would think I would be done there but we haven’t even talked about the actual functions of the diaphragm yet! Let’s start with the most obvious role as the prime mover of breathing. When the diaphragm contracts (flattens) it creates a negative pressure in the chest to draw air in. Then when it relaxes (domes) it pushes air out. It is designed to match the demands of an activity and controls our ability to go from whispering to yelling.

Postural Function

While I consider respiration to be absolutely essential to human life, my main interest in diaphragmatic function has always been its role in postural stability because it is most directly correlated with pain-free function.

When the diaphragm contracts, it increases intra-abdominal pressure which then stabilizes the spine but studies have also shown that the diaphragm contracts to stabilize regardless of the phase of respiration. In other words, the diaphragm stabilizes the spine indirectly through intra-abdominal pressure but also directly through stiffness generated by a contraction.

Research has demonstrated that the diaphragm is one of the first muscles to contract in preparation to lift something or move a limb. It has also been shown that individuals with limited ability to contract their diaphragm for stabilization and those with uncoordinated diaphragm activation have a higher likelihood of back pain.

While the diaphragm is able to perform respiration and stabilization at the same time, the stabilizing contraction will decrease as the respiratory demand increases. This makes sense in that our ability to breathe and oxygenate our brain is far more important than spinal stability for survival so it’s the first to go. Those that have low back pain are shown to have earlier respiratory fatigue aka the stabilizing function drops off sooner at lesser respiratory loads.

Gastro-Esophageal Function

In my opinion, the most surprising function of the diaphragm is its role in swallowing, vomiting and prevention of stomach contents refluxing up into the esophagus. I was amazed not by the what but the how of this function.

There are actually two parts of the diaphragm, the crural portion and the costal portion. Up to this point I have been mostly talking about the costal portion which is the perimeter of the muscle. The central portion in the crural part.

But that’s not the cool part. These two parts actually work separate of each other to allow for swallowing and vomiting. For example, in vomiting, the crural (central) part relaxes to allow for ejection of the stomach contents while the costal (outer) part contracts with the abdominals to increase intra-abdominal pressure to force the contents outward. Crazy right?! The vagus nerve is what innervates the crural portion of the diaphragm so sympathetic tone could be a contributor to acid reflux.

Lymphatic Influence

The diaphragm is also the primary mover of organs. I included the video above to illustrate just how much movement occurs in an individual that diaphragmatically breathes. This massaging of the organs is important not only for proper organ function but also for the drainage of lymph (fluid). Sixty percent of lymph nodes are located just under the diaphragm. The rhythm of diaphragmatic breath stimulates the cleansing of these nodes by creating negative pressure pulling the lymph fluid back into the lymphatic system.

Contraction of the diaphragm also narrows the diameter of the vena cava thus assisting in the return of blood back to the heart. Therefore, if someone has swelling in their lower limbs, diaphragmatic function should be assessed.

Cardiac Influence

There are a few ways the diaphragm effects the cardiovascular system. As I just mentioned above, it promotes venous return by narrowing the vena cava but it also does this by creating a pressure gradient facilitating the flow of blood back to the heart. This effect is maximized in slow and deep respiration. Another connection already noted is the ligament that goes from the heart to the diaphragm. This means that a lack of diaphragmatic movement may reduce the ability of the heart to contract and therefore impair blood circulation.

Heart rate is also heavily influenced by respiration. On an inhale heart rate increases and it decreases on an exhale. This cyclic change in heart rate is known as respiratory sinus arrhythmia (RSA) and is thought to improve gas exchange in the lungs.

If we just look at heart rate as it is measured through pulse, diaphragmatic breath decreases it by reducing sympathetic (fight or flight) activity. This is accomplished by stimulation of the vagus nerve and activation of the hering-breur reflex through an increase in tidal volume (amount of air passing through lungs).

Emotional Influence

The separation between heart and emotional influence of the diaphragm is a blurry line. A local entity called Heartmath (https://www.heartmath.com) has done a ton of research connecting stress to an increase in what they call heart rate variability which is the amount of change in heart rate between inhalation and exhalation aka RSA. They have shown through extensive research that heart rate variability (and therefore our stress response) is improved with diaphragmatic breath. Blood pressure and other parameters of cardiac function are also improved. The overall conclusion is that emotional states affect the diaphragm and vice versa, the degree of which is measured through RSA. If any of you have the Apple Watch, it uses heart rate variability (aka RSA) as a trigger to remind you to breath. And I’m sure most of you have experienced this connection in life. When under acute stress, your breath will shorten and move upward into your chest while your heart rate increases. If you haven’t been aware of this up to this point, pause for a moment the next time you are stressed. Acknowledge the sensation of this physiological shift and then focus on diaphragmatic breath to return back to homeostasis. Its powerful stuff.

The diaphragm is also the muscle that is responsible for the expression of emotions so it makes sense that it is a key component of somatoemotional release techniques. Physical expression of stress and emotions occurs when we don’t release them. The act of crying involves a sharp inhale (aka a diaphragmatic contraction) followed by a pause and then wailing followed by further gasps of air and further wailing. The gulps of air are diaphragmatic contractions and the wailing is an abdominal contraction with diaphragmatic relaxation. The act of crying is pain/emotional tension being exported from the nervous system. If we don’t cry and we hold our breath, the diaphragm may hold this tension while the abdominals are off and distended. Long story short, this isn’t good.

“By (diaphragm) action we live, and by its failure we shrink, or swell, or die”

Andrew Still. Philosophy of osteopathy. Mo: A.T. Still, Kirksville 1899.

So why spend all this time learning about the diaphragm and all it does? Most of us don’t diaphragmatically breathe. In fact 83% of those with anxiety have a dysfunctional breathing pattern. And who isn’t anxious these days? In other words, this information is applicable to almost every single one of you. So the next time we start your treatment working on breath, you will know exactly why.

Want to see the research?

Kocjan J et al. Network of breathing. Multifunctional role of the diaphragm: a review. Advances in Respiratory Medicine 2017, vol. 85, no 4, pages 224-232. doi: 10.5603/ARM.2017.0037

Prevention & Rehabilitation: Editorial. The Diaphragm – more than an inspired design. Journal of Bodywork & Movement Therapies 21 (2017) 342-349. doi:10.1016/j.jbmt.2017.03.013

Bordoni B, Zanier E Anatomic connections of the diaphragm: influence of respiration on the body system. Journal of Multidisciplinary Healthcare 2013:6 281-291 doi: 10.2147/JMDH.S45443Hodges PW, Eriksson AE, Shirley D, et al. Intra­abdominal pressure increases stiffness of the lumbar spine. J Biomech. 2005; 38(9): 1873–1880, doi: 10.1016/j.jbiomech.2004.08.016, indexed in Pubmed: 16023475.

Hodges PW, Butler JE, McKenzie DK, et al. Contraction of the human diaphragm during rapid postural adjustments. J Phy- siol. 1997; 505 ( Pt 2): 539–548, indexed in Pubmed: 9423192.

Hodges PW, Gandevia SC. Changes in intra­abdominal pressu- re during postural and respiratory activation of the human diaphragm. J Appl Physiol (1985). 2000; 89(3): 967–976, in- dexed in Pubmed: 10956340.

Frank C, Kobesova A, Kolar P. Dynamic neuromuscular stabi- lization & sports rehabilitation. Int J Sports Phys Ther. 2013; 8(1): 62–73, indexed in Pubmed: 23439921.

Skladal J, Skarvan K, Ruth C, et al. propos de l’activitie postu- rale du diaphragme chez l’Homme. Journale de Physiologie. 1969; 2: 405–406.

Hemborg B, Moritz U, Löwing H. Intra­abdominal pressure and trunk muscle activity during lifting. IV. The causal factors of the intra­abdominal pressure rise. Scand J Rehabil Med. 1985; 17(1): 25–38, indexed in Pubmed: 3159082.

Hodges PW, Gandevia SC. Activation of the human diaphragm during a repetitive postural task. J Physiol. 2000; 522 Pt 1: 165–175, indexed in Pubmed: 10618161.

Kolar P, Neuwirth J, Sanda J, et al. Analysis of diaphragm mo- vement during tidal breathing and during its activation while breath holding using MRI synchronized with spirometry. Phy- siol Res. 2009; 58(3): 383–392, indexed in Pubmed: 18637703.

Kolar P, Sulc J, Kyncl M, et al. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric as- sessment. J Appl Physiol (1985). 2010; 109(4): 1064–1071, doi: 10.1152/japplphysiol.01216.2009, indexed in Pubmed: 20705944.

Hodges PW, Heijnen I, Gandevia SC. Postural activity of the diaphragm is reduced in humans when respiratory demand increases. J Physiol. 2001; 537(Pt 3): 999–1008, indexed in Pubmed: 11744772.

Stauss H. Heart rate variability. American Journal of Physiolo- gy ­ Regulatory, Integrative and Comparative Physiology. 2003; 285(5): R927–R931, doi: 10.1152/ajpregu.00452.2003.

Montano N, Cogliati C, Porta A, et al. Central vagotonic effects of atropine modulate spectral oscillations of sympathetic nerve activity. Circulation. 1998; 98(14): 1394–1399, indexed in Pub- med: 9760293.

Bernardi L, Gabutti A, Porta C, et al. Slow breathing reduces chemoreflex response to hypoxia and hypercapnia, and incre- ases baroreflex sensitivity. J Hypertens. 2001; 19(12): 2221– 2229, indexed in Pubmed: 11725167.

Abu­Hijleh MF, Habbal OA, Moqattash S McCoss, C., Johnston, R., Edwards, D., Millward, C., 2017. Preliminary evidence of Regional Interdependent Inhibition, using a ‘Diaphragm Release’ to specifically induce an immediate hypoalgesic effect in the cervical spine. JBMT 20-22. Apr 2017.

Hodges, P., 1999. Is there a role for transversus abdominis in lumbo-pelvic stability? Man. Ther. 4 (2), 74e86.

Perry, S., Similowski, Thomas, Klein, Wilfried, Codd, Jonathan R., 2010. The evolu- tionary origin of the mammalian diaphragm. Respir. Physiol. Neurobiol. 171 (2010), 1e16.

Keleman, S., 1 Jun. 1989. Emotional Anatomy, first ed. Center Press, U.S.

Childre, D., Martin, H., 1999. The Heartmath Solution. Harper, San Francisco.

Manheim, C., Lavett, D., 1989. Craniosacral Therapy and Somato-emotional Release: the Self-healing Body. McGraw-Hill Professional.

Respiratory Sinus ArrhythmiaYasuma, Fumihiko et al.CHEST, Volume 125, Issue 2, 683 – 690 https://doi.org/10.1378/chest.125.2.683

Telehealth

As a manual therapist, I never thought I would be writing about Telehealth let alone offering it but thanks to the coronavirus, here we are. I started offering virtual appointments because there was simply no other choice. Even though physical therapy is part of the essential list, I had to reflect on whether it was absolutely essential and furthermore, whether seeing people in my gym was mandatory in providing effective care. I started to research the efficacy of virtual physical therapy and was surprised to find that the results are just as positive if not more effective in some patient populations. Then I started seeing patients virtually and got to have first hand experience of what research indicates. I figured that if I needed convincing Telehealth was a viable option for physical therapy, I’m sure my current patients and even prospective ones are hesitant as well. So here is what research and my own experience says about virtual physical therapy. In a nutshell, don’t knock it before you try it and it’s worth giving it a try. A virtual visit will, more likely than not, help and it is guaranteed to be better than not doing physical therapy at all.

Before I started providing Telehealth appointments, I had two major concerns: 1) how was I going to be able to properly evaluate, assess and diagnose without being able to perform most special tests or palpate? and 2) how was I going to be effective in treating my patients if manual therapy wasn’t an option?

I was happy to find a lot of research regarding my first concern. In a typical evaluation, a physical therapist starts with what we call a subjective interview. This is when we ask very targeted questions almost like a detective to understand the nature and behavior of a person’s pain. From this we generate a hypothesis (or a few) and then we use special tests and movement assessments (referred to as the objective exam) to confirm or deny our hypotheses. I would add that I double confirm through treatment and reassessment. So what does research say? First off, it shows that special tests are not specific or sensitive in provoking the tissues or structures that they are said to. This means that they aren’t accurate enough to rule in or rule out much of anything. In fact, 50% of the time a therapist changed their diagnosis to the wrong one after performing the objective exam. With that said, a physical therapist was able to accurately diagnose 7 out of 8 patients with just their subjective exam. Upon reflection, I have to agree from my clinical experience as well. I very rarely change my hypothesis after my subjective interview. And when I do, its because of the response to treatment rather than any objective measurement or special test. Palpation should also be included in this. The consensus is that palpation is not reliable (regardless of experience level) unless it is pain provoking which has been shown to be clinically significant. The good news: I can direct a patient to self palpate for pain and any use of palpation for further diagnostics isn’t shown to be useful whether it was me or my patient doing the palpating so we can be ok with just skipping it.

  • Somerville, Lyndsay E., et al. “Diagnostic Validity of Patient-Reported History for Shoulder Pathology.” The Surgery Journal 3.2 (2017): e79.
  • Cuthbert, S. C., & Goodheart, G. J. (2007). On the reliability and validity of manual muscle testing: a literature review. Chiropractic & osteopathy, 15(1), 4. 
  • Seffinger, M. A., Najm, W. I., Mishra, S. I., Adams, A., Dickerson, V. M., Murphy, L. S., & Reinsch, S. (2004). Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine, 29(19), E413-E425. 
  • Stochkendahl, M. J., Christensen, H. W., Hartvigsen, J., Vach, W., Haas, M., Hestbaek, L., … & Bronfort, G. (2006). Manual examination of the spine: a systematic critical literature review of reproducibility. Journal of manipulative and physiological therapeutics, 29(6), 475-485.

Research regarding my second concern is a bit more complicated. Most of the research provided by Telehealth proponents is all about disproving manual therapy as being an effective modality but I am not out to undermine the value of hands on treatment that has clinically worked for my patients thus far. If you look at ALL of the research regarding manual therapy, these are the conclusions that have been made:

  1. Manual therapy, as a stand alone treatment, provides short term pain relief, improved range of motion and marginal functional gains when compared to exercise based therapy.
  2. There is little explanation for why manual therapy actually works. Some theorize placebo or patient expectation.
  3. The most effective physical therapy for pain and function involves both manual therapy and exercise.
  4. In some patient populations (research looks mostly at post-operative), a patient-guided home exercise program has been shown to be more effective than a supervised rehabilitation program.

So what does all that mean? There are two take aways: 1) palpation and manual therapy are not absolutely necessary for proper diagnosis or effective treatment and 2) in not seeing a patient physically, the patient is required to be independent in their home exercise program thus increasing their self-efficacy and control of their own pain. The research regarding self-efficacy really hit home for me and was ultimately why I started not only being ok with treating virtually but actually excited about the possibilities that might come out of it. Being a manual therapist, I often find it challenging for patients to be compliant and learn to become effective in their home exercise program because they know they can just come see me if they need it to be fixed again. In this respect, I think being forced into Telehealth is actually providing a great opportunity for patients to start being in complete control of their own pain, rehab and health. Having had several virtual appointments under my belt, I can also say that it is challenging me to teach patients manual techniques that I would have previously never considered possible for a patient to do on their own at home. It is opening my eyes to how truly independent patients can be and I will definitely be taking this into my practice even when I start to see patients face-to-face again.

  • Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3 PubMed PMID: 20184717; PubMed Central PMCID: PMC2841070; eng DOI:10.1186/1746-1340-18-3.
  • Clar C, Tsertsvadze A, Court R, et al. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropr Man Ther. 2014; March;22(1):12 PubMed PMID: 24679336; PubMed Central PMCID: PMCPMC3997823 DOI:10.1186/2045-709X-22-12. 
  • Bialosky JE, George SZ, Bishop MD. How spinal manipulative therapy works: why ask why? J Orthop Sports Phys Ther. 2008; June;38(6):293–295. PubMed PMID: 18515964; eng DOI:1417 [pii] 10.2519/jospt.2008.0118.
  • Grant, J. A., Mohtadi, N. G., Maitland, M. E., & Zernicke, R. F. (2005). Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomized clinical trial. The American journal of sports medicine, 33(9), 1288-1297. 
  • Voogt L, de Vries J, Meeus M, et al. Analgesic effects of manual therapy in patients with musculoskeletal pain: a systematic review. Man Ther. 2015; April;20(2):250–256. PubMed PMID: 25282440 DOI:10.1016/j.math.2014.09.001. 
  • Fredin, K., & Lorås, H. (2017). Manual therapy, exercise therapy or combined treatment in the management of adult neck pain–A systematic review and meta-analysis. Musculoskeletal Science and Practice, 31, 62-71. 
  • Bandura, A. (1986). The explanatory and predictive scope of self-efficacy theory. Journal of social and clinical psychology, 4(3), 359-373. 

At this point I can say that I provide virtual physical therapy not only because I have to, but also because I am confident I can deliver an effective service that results in a reduction of pain, improved functional outcomes and long term benefit for my patients. Sooooooo, “see” you soon?


Need to hear if from someone else?

“Jenny is amazing. I was in urgent need of a Physical Therapist for a sudden hip issue. A friend recommended Jenny, so I reached out. I had never met her, but I emailed her on Friday. By Sunday morning, she and I had a fabulous online session (she said I was her first client over the internet, but she made the whole session so clear and visible that I felt like I was right there with her.) She remembered everything that we talked about and followed up with an email summary and videos showing me everything I needed to do. I have already recommended Jenny to so many of my friends because I have never met any Physical Therapist so in tune and dedicated. She not only saw the most current situation with my hip, but she also found underlying issues and causes that I would never have imagined. I am looking forward to our next online session for continued strengthening help and advice. I started out afraid that I would need a hip replacement at age 55. I left with my spirits high, hopeful and excited.”

– New Patient

“I think the Telehealth video experience worked well with Jenny Putt.  We were able to identify new areas to address on my tibia/fibula/ankle issue.  Jenny was able to instruct me by example on her leg and the skeleton to manipulate my bone area in the front of my leg related to ankle/tibia/knee tracking.  We then used a small ball to work on the  inflammation issues on the outside and inside of my lower leg to ankle.  Her instructions were clear and I felt that a lot was accomplished.  I would recommend working with Jenny through Telehealth to continue to work on issues during the Coronavirus shelter in place and beyond.  Thank you Jenny!”

– Existing Patient

Coronavirus Coping – A Health and Happiness Guide

Oh man. Strange times. In some respects, that’s all that needs to be said. We are all on information overload with everything related to COVID-19 these days. The numbers and rates, the precautions, the closures, the predictions and survival guides. So why produce more content? Two reasons: one is that it’s becoming more and more clear that this is just the beginning of something we need to settle into for the long haul. If that is indeed the case, I think it’s important to have a strategy and plan for comfortably and effectively doing so. Secondly, I think this is an opportunity. A lot of us have been given the gift of time with the shelter-in place order. It’s a chance to finally be able to start prioritizing priorities. A time to form lasting habits that we should have been doing long before the coronavirus arrived and should continue to do long after our lives return to some version of normal again.

My research on this started with one goal in mind: avoid getting and spreading the coronavirus aka do my part to flatten the curve. In addition to taking the shelter-in order seriously, I wanted a strong immune system. But I was also functioning on a high level of stress, anxiety and panic which has more power to suppress an immune system than any multivitamin can counter. The wellness formula didn’t stand a chance and I knew it. So I invested my time and energy into figuring out how to deal with the challenges of today in a way that would result in physical and mental strength and resilience and therefore, a strong AF immune system. In the end, I basically developed a how to guide for finding health and happiness in the face of adversity. Here is what I have learned and have put into practice as well as the research to back it all up. In living this out, I have found more resonance than I had prior to this pandemic. These things are all habits I should have prioritized a long time ago. I can thank this pandemic for giving me no choice but to finally do what I have needed all along. I am sure to live a happier, healthier and longer life for it.



Stop watching the news.



This was a big game changer for me. It was the first step I took and it gave me the space and the capacity to do everything else. I still think it is important to be informed so that you know what guidelines to following but that requires very little exposure to the news. Pick one reliable resource that you can check in with quickly to get what you need and then move on. There is an abundance of research that links watching the news with compromising the emotional well-being of viewers especially when the coverage is of traumatic or negative content (for example, a pandemic). Increased frequency of viewing the news is associated with anxiety, depression, uncontrolled fear, pessimism, irrational beliefs and sleep difficulties. Negative news has even been shown to exacerbate a range of personal concerns that aren’t even related to the viewed content. None of us need that right now! You might also want to consider limiting your time on social media if it has a similar effect on your affect. Research shows that social media often results in comparisons that lower our self-esteem and increase depression. Two things that are also of no use to us right now.

  • Richard Potts & Dawn Sanchez (1994) Television viewing and depression: No news is good news, Journal of Broadcasting & Electronic Media, 38:1, 79-90, DOI: 10.1080/08838159409364247
  • Moran Bodas, Maya Siman-Tov, Kobi Peleg & Zahava Solomon (2015) Anxiety-Inducing Media: The Effect of Constant News Broadcasting on the Well-Being of Israeli Television Viewers, Psychiatry, 78:3, 265-276, DOI: 10.1080/00332747.2015.1069658
  • Mary E. McNaughton-cassill (2001) The news media and psychological distress, Anxiety, Stress & Coping,14:2, 193-211, DOI: 10.1080/10615800108248354
  • Johnston, W.M. and Davey, G.C.L. (1997), The psychological impact of negative TV news bulletins: The catastrophizing of personal worries. British Journal of Psychology, 88: 85-91. doi:10.1111/j.2044-8295.1997.tb02622.x
  • Vogel et al. (2014). Social comparison, social media, and self-esteem. Psychology of Popular Media Culture, 3(4), 206-222.


Have a schedule. Prioritize your priorities.



Did you know that an affluence of time makes us happier than an affluence of money? I don’t know about you but I very quickly found myself with an excess of time and a shortage of money when the shelter-in place was ordered. At first all I felt was panic and distress. Our society makes us think that money is a measurement of our success and therefore our happiness but the opposite is actually true. It wasn’t until I developed a schedule that I could actually feel the happiness associated with having time. Sure, my schedule may only consistent of meditate, yoga, play with kid, work a little, get outside and exercise but by having them scheduled into my day, I wake up with a plan and I get them all done. Before having a schedule I would start the day having no clue what to do with my time which would spiral me into thinking about how I wasn’t able to do anything I used to. There is also a certain kind of joy that comes from being able to stray from the schedule without any negative consequences. It lets me be in the moment with each thing I’m doing without worrying about making it to the next one. I believe this is what they are referring to when they say time affluence is bliss.



Meditate daily.



I’ve always been a bit scared off by meditation. I can barely sit still and the idea of silence for any period of time sets my mind off racing to my to-do list which would in turn just stress me out more. Needless to say, I have avoided it up to this point. But then I started to research different methods of meditation and the science behind it. Ashok Gupta describes meditation as a shower for your brain. A way of cleaning it out, getting rid of anything not needed, allowing your brain to start a day fresh and light. Now that sounded like something that might be worth figuring out. I began to play around with different guided meditations and visualizations. The body scan has never worked for me. Neither has counting with awareness of the breath. But in my search, I came across a plethora of strategies. They all have the same goal: mind control with a detachment from your thoughts. It’s just a matter of finding what strategy gets you there and once you do, its freeing. I can literally go from heart racing panic to calm cool and collected in a matter of minutes. It’s a miracle drug and research even proves it as such. Most of today’s diseases can be attributed to a breakdown in our immune system because of stress. The ability to separate our body from our thoughts through meditation can prevent all physiological consequences of stress therefore boosting our immune system and preventing disease. One mechanism of this is through diaphragmatic breathing which stimulates the vagus nerve and can bring us out of the fight or flight mode. The other is that by not being attached to our thoughts, our body never takes on the stress of them therefore avoiding fight or flight in the first place. So its no wonder why extensive research shows mind-body therapies decrease inflammation, improve immune function and reduce sickness through minimizing physiological manifestations of stress and anxiety.

  • Fredrickson et al. (2008). Open hearts build lives: positive emotions, induced through loving-kindness meditation, build consequential personal resources. Journal of personality and social psychology, 95(5), 1045-1062.
  • Morgan N, Irwin MR, Chung M, Wang C. The effects of mind-body therapies on the immune system: meta-analysis. PLoS One. 2014;9(7):e100903. Published 2014 Jul 2. doi: 10.1371/journal.pone.0100903
  • Obasi CN, Brown R, Ewers T, et al. Advantage of meditation over exercise in reducing cold and flu illness is related to improved function and quality of life. Influenza Other Respir Viruses. 2013;7(6):938–944. doi: 10.1111/irv.12053.
  • Black DS, Slavich GM. Mindfulness meditation and the immune system: a systematic review of randomized controlled trials. Ann N Y Acad Sci. 2016;1373(1):13–24. doi: 10.1111/nyas.12998
  • Kaliman P, Alvarez-López MJ, Cosín-Tomás M, et al. Rapid changes in histone deacetylases and inflammatory gene expression in expert meditators. Psychoneuroendocrinology. 2014;40:96–107. DOI: 10.1016/j.psyneuen.2013.11.004
  • Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res. 2004;57(1):35–43. DOI: 10.1016/S0022-3999(03)00573-7
  • Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol. 2010;78(2):169–183. DOI: 10.1037/a0018555
  • Sampaio CV, Lima MG, Ladeia AM. Meditation, Health and Scientific Investigations: Review of the Literature. J Relig Health. 2017;56(2):411–427. DOI: 10.1007/s10943-016-0211-1
  • Lindsay EK, Creswell JD. Mechanisms of mindfulness training: Monitor and Acceptance Theory (MAT). Clin Psychol Rev. 2017;51:48–59. DOI: 10.1016/j.cpr.2016.10.011


Move daily.

This is a recommendation I give pretty much everyone all the time, and this time is no different. If anything, it’s even more important today than every before. Our bodies were meant to move. Increasing your heart rate for 30 minutes a day has been shown to decrease chronic pain and working out 3x a week has been shown to be just as effective as Zoloft in treating depression. There is also a ton of research that associates exercise with boosting immune function. So get moving! The key is to keep it light to moderate for right now. High intensity workouts tend to speed up gains but they are also a stress on the system and can actually compromise immune function. So less is more during this time of high environmental stress. If possible, make it outside as well. Walking 20-30 minutes a day with exposure to direct sunlight has been shown to improve immune efficiency and living close to the natural environment has been linked to many long term health benefits so lets take advantage of living in a Santa Cruz. Nature is at our doorstep! And if you’re not in Santa Cruz, just look a little harder. Nature is everywhere even in the middle of a metropolis.



Eat nutritious, unprocessed foods.



Diet is it’s own rabbit hole so I like to keep it extremely simple. Eat nutrient dense real food. If you wanted to take it a step further, I would recommend limiting sugar, alcohol and refined carbohydrates because they are inflammatory by nature. There might be reason to decrease your caffeine intake as well if you find it increases your anxiety. I would also increase your fruit and veggie intake in addition to drinking a lot of water. Research has shown those that eat 5 or more servings of fruit and veggies had an 82% greater antibody response when compared to those eating 3 servings so when I say increase, I mean load that plate up! Research has shown that what we eat does matter and is a large determinant of our immune system function. Some research does support the use of vitamin A, B, C and D supplements (zinc as well) to boost immune defense but I believe these vitamins are more available when they come from food. Research has also shown that sunlight is more effective than vitamin D supplements. But if you aren’t great about eating a lot of fruits and veggies or getting outside, probably best to take a multi-vitamin to fill in the gaps. I also boost my immune system with a blend of herbs (the wellness formula is my preferred but there are many out there).



Connect to those you love.



Even introverts like myself need social connection. Physical distancing is not social isolation. Connect with your loved ones, family and neighbors as often as possible. We are so fortunate this is happening at a time where most everything can be done virtually. We have a deep-seated need to feel trusted and loved and this feeling of connectedness increases our psychological and physical well being therefore decreasing the risk of depression and physical ailments. Sure, human contact and hugs have their own healing power but research shows that having social ties and being social makes you happier, virtual or in-person.

  • Diener & Seligman (2002). Very happy people. Psychological science, 13(1), 81-84.
  • Baumeister, R. F., & Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psycho- logical Bulletin, 117, 497–529.
  • Brown, S. L., Nesse, R. M., Vinokur, A. D., & Smith, D. M. (2003). Providing social support may be more beneficial than receiving it: Results from a prospective study of mortality. Psychological Science, 14, 320–327.
  • De Vries, A. C., Glasper, E. R., & Detillion, C. E. (2003). Social modu- lation of stress responses. Physiology and Behavior, 79, 399–407.
  • Hawkley, L. C., Masi, C. M., Berry, J. D., & Cacioppo, J. T. (2006). Loneliness is a unique predictor of age-related differences in systolic blood pressure. Psychology and Aging, 21, 152–164.
  • Hutcherson, Cendri A., Emma M. Seppala, and James J. Gross. “Loving-kindness meditation increases social connectedness.” Emotion 8.5 (2008): 720.
  • Lee, R. M., & Robbins, S. B. (1998). The relationship between social connectedness and anxiety, self-esteem, and social identity. Journal of Counseling Psychology, 5, 338–345.


Serve those in need.



There is a ton of research that associates acts of kindness with increased happiness. So much research that I would consider it a fact. And haven’t you experienced that before? I personally enjoy the act of giving gifts over receiving them. There are a lot of people that could use the help, encouragement and/or support right now. Opportunities to give are everywhere and they don’t have to require money or material posessions. We are participating in the bear movement. You put a bear in your front window so that children in the neighborhood can go on a bear hunt, “gonna catch a big one”. Something as simple as this has brought a lot of joy to me and my toddler. If you have the means to support any of the local small businesses, they could really use the help. Especially those of services that aren’t deemed “essential” by paying them even when you aren’t receiving anything for it or ordering take out from your favorite restaurant, or just writing a review for them on yelp. Buying a burrito has always brought me joy but these days it brings a whole new level of satisfaction and happiness.



Laugh, smile and be grateful.



I didn’t need to research whether laughter makes us happier because everyone knows that’s true but did you know even a fake smile and forced laughter releases the happy chemicals? That was news to me. I started smiling when I felt the most amount of stress, anger grief or panic and subjectively, my mood totally improves! So yes, I will be that person smiling to herself for no reason but really for all the reasons. Also thinking about all the things you should smile about brings happiness. Gratitude practices or journals have been shown to improve health and well-bring. It’s impossible to be sad or angry when you are grateful.

  • Emmons et al. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of personality and social psychology, 84(2), 377.
  • Seligman et al. (2005). Positive Psychology Progress: Empirical Validation of Interventions. American Psychologist, 60(5):410-21
  • Mora-Ripoll, Ramon. “Potential health benefits of simulated laughter: A narrative review of the literature and recommendations for future research.” Complementary Therapies in Medicine 19.3 (2011): 170-177.
  • Neuhoff, Charles C., and Charles Schaefer. “Effects of laughing, smiling, and howling on mood.” Psychological reports 91.3_suppl (2002): 1079-1080. laughing more than smiling. laughing and smiling but not really howling.
  • Sheldon, Kennon M., and Sonja Lyubomirsky. “How to increase and sustain positive emotion: The effects of expressing gratitude and visualizing best possible selves.” The journal of positive psychology 1.2 (2006): 73-82.


Sleep 7-9 hours a night.



Nothing works right if you don’t sleep. Thats a fact. But what is considered enough? Research says that anything less than 6 to 7 hours a night will have negative physiological consequences but even 7 hours a night is worse than 8 or 9 with regards to your system’s well being. The less sleep you have, the higher the chance of getting sick. The quality of sleep also matters. It’s important to have a “winding down” routine that starts at least an hour before getting into bed and eliminating blue light (from screens) is absolutely essential to calm down the nervous system in preparation for sleep.

Credit Where Credit is Due

Aside from pretty extensive google searching, webinar listening and article reading, the following people are really the ones that know what they are talking about:

Laurie Santos (Professor of Coursera Course: The Science of Well-Being through Yale University)

Chris Kresser (A Leader in Functional Medicine)

Ashok Gupta (Developed the Gupta Program for re-programming the brain)

More Information, Guidance & Coaching

If you want more:

Books

What is Functional Medicine?

“Functional Medicine is a systems biology–based approach that focuses on identifying and addressing the root cause of disease. Each symptom or differential diagnosis may be one of many contributing to an individual’s illness.” 
www.ifm.org

In non-scientific terms, functional medicine is the practice of figuring out the cause of disease and treating it rather than managing symptoms through medications aka bandaids that often cause further harm. 

How I see it is this: every disease or condition is simply a name given to a cluster of signs and symptoms. In the traditional western medical model, treatment of such diseases and conditions involve medications and/or surgeries that only address the symptoms rather than getting to any underlying cause and in the process, often lead to additional symptoms aka side effects. Let’s pick cancer as an example; the uncontrolled division of abnormal cells in the body. Treatment can be monitoring, chemo, radiation or a combo of it all. But what does that actually treat? It attempts to kill the group of abnormal cells but does it actually address why those cells are uncontrollably dividing in the first place? No it doesn’t. And what does it do in the process? It kills a ton of good stuff in the body that may ultimately be the reason someone dies from cancer rather than the cancer itself. Don’t get me wrong, there is a place for traditional western medicine. Someone with aggressive cancer needs to be treated. But what if we didn’t stop with the chemo? What if we went further to figure out why the cells divided in the first place and treat that? My hypothesis would be that the cancer would never come back.

“The precise manifestation of each cause depends on the individual’s genes, environment, and lifestyle, and only treatments that address the right cause will have lasting benefit beyond symptom suppression.”
www.ifm.org

 

Functional medicine asks the question “why?” and with that answer, actually treats the cause of disease. In this light, you can look at every diagnosis as the same. It is simply a sign of the system functioning at a suboptimal level. Sometimes a diagnosis can be the result of more than one cause or sometimes a cause can be the reason for multiple diagnoses. For example, depression can be caused by vitamin insufficiencies, decreased thyroid function or over-growth of bad bacteria in the gut. On the flip side, an overgrowth of bad bacteria in the gut can be the cause of depression, arthritis, cancer, heart disease and more. 

https://www.ifm.org/functional-medicine/what-is-functional-medicine/

In some respects, this simplifies the entire study of disease states. There is almost no need for an emphasis on the diagnosis of a condition. Instead the microscope needs to be on the root cause of systemic breakdown. Let’s go back to the cancer example. If the genetic marker for cancer is present, it explains why an individual ended up with cancer versus having heart disease, diabetes or depression BUT that’s still not the actual cause. The true cause could be an ineffective immune system due to chronic systemic inflammation from a leaky gut caused by poor diet, a history of viral infections and excessive stress hormone release that then enabled that genetic mutation for cancer to be expressed. This might sound daunting because most everyone is stressed, has been treated with antibiotics for an infection and doesn’t have the best diet BUT it can also be empowering. Could we actually stop the expression of the cancer gene by optimizing the environment it lives in?I believe the answer is yes, we can. And that is pretty freaking cool. Welcome to functional medicine.

“Functional Medicine is true healthcare. Conventional medicine is really disease management: its doctors focus on controlling illness once it has already occurred, usually by suppressing symptoms with prescription drugs.” 
Chris Kresser

Pain Neuroscience Part 5: How to Decrease Pain by Decreasing the Perception of Threat

There is one thing I have left out up to this point and it happens to be the single most important factor when it comes to my experience of pain; perceived threat. At the time of the accident, my entire being was under a large amount of stress and to the nervous system, stress equals threat.

I was in a high stress residency, a stagnant romantic relationship and a job that brought me no joy. I was putting my head down and getting through it but my body was likely experiencing the equivalent of running away from tigers with a headwind. Then the accident happened. It came out of no where. There was no time to react, no time to prepare and barely time to comprehend what had happened. When something so unlikely happens, you start living life on the edge, afraid the odds will be against you again any second of any day.

Then there were the doctors. They made sure I remained fearful for the rest of my life. There was the doctor that told me I would never be able to lift my eyebrow again and would need botox to even out the wrinkles on my forehead; the doctor that said I would never be able to smell or taste food ever again; and the one who told me to never ride a bike because I would immediately die if I suffered another head injury. Even my mom got into the mix. She told me I should have a cesarean birth for my theoretical baby because the pushing involved with natural labor would burst the “weak” blood vessels in my brain leaving my theoretical husband a single parent. Looking back on it, its painstakingly obvious I would be the 1 in 4 that would have chronic pain. RESEARCH has listed psycho-social yellow flags that predict who the 1 in 4 will be but the common theme is simple: threat perception. If you perceive threat, your nervous system will remain on high alert and you will have a heightened and prolonged experience of pain.

What I didn’t know then but I know now is this: once your injuries have healed, the first and only way to treat persistent pain is to eliminate the perception of threat. For five years I did physical therapy, acupuncture, massage, chiropractic, functional medicine, rolfing, cortisone shots, herbal and dietary changes. Sure, I got better in some respects. I returned to work and returned to some physical exercise but I was still in pain. I was functioning but I was functioning with pain. In some way, these treatments fed my perception of a threat. All of the tests, examinations and diagnoses made me think my pain was a sign something was still very wrong. The fact that even I couldn’t change my pain had to mean it was serious and beyond repair. I even went to a neurosurgeon. Yes, you read that right. I, Jenny Putt the physical therapist, went to a neurosurgeon. Thats how threatened I felt.

Then there was a shift. The first significant improvement in my pain came after I attended a lecture on neuroscience at a physical therapy conference. Remember how I have been saying that simply reading these blog posts and increasing your knowledge of how pain works decreases your pain? I’m a real life example of this but just incase you don’t want to take my word, RESEARCH shows it too. Why? How? Well once you know that your pain does not mean something is seriously wrong, once you learn that your physical injuries are healed and once you understand that it’s just your nervous system that is still on alert, the threat decreases. With a decrease in perceived threat, the nervous system starts to calm down and poof! your pain disappears.

Aside from pain neuroscience education, we have many other tools that have been shown to decrease the perception of threat, decrease the sensitivity of our nervous system and decrease pain. RESEARCH backs up the use of aerobic exercise, graded activity exposure, manual therapies, meditation, relaxation, diaphragmatic breathing, sleep, social interactions and humor as strategies to eliminate pain. This looks a lot different than our typical model of tests, medication and surgeries but thank goodness! Because the old model isn’t working all that great. The current narcotic epidemic is proof of it! Here are a few pointers from research so you can bulk up your tool box:

AEROBIC EXERCISE has been shown to improve sleep, improve motor function, improve memory, improve cortisol changes, aide the immune system, decrease chronic inflammation, decrease anxiety, decrease depression, improve mood and decrease nerve sensitivity. Aerobic activity is defined as working out at an intensity of 60-70% your age-predicted max heart rate (220 minus your age) but that can be intimidating when you have pain. The point is to get moving and the strategy of “kissing the pain” is best when it comes to returning to activity. Gradually increasing the distance and intensity while nudging the pain has been shown to have great results. The motto here is “hurt does not equal harm”. Start with 3-5 minutes at 50% of your max heart rate. Add 1-2 minutes every other day until you have worked up to 30 minutes. Then slowly start increasing the intensity to the goal of 60-70% your max heart rate.

GRADED ACTIVITY EXPOSURE has been shown to be just as effective as aerobic exercise in decreasing pain intensity and disability. So if you’re not much of an exerciser, pick an activity you want to return to and apply the same principle of starting slow, kissing the pain and gradually increasing amount and intensity.

SLEEP has so many benefits to our whole being and we just don’t get enough of it! Here are some strategies to help develop a more healthy sleep pattern: set a time to go to bed (before 11pm), stop using all screens (computer, TV, phone, iPad etc) at least an hour before bedtime, reduce fluid intake (especially alcohol and coffee) in the evening, darken and cool your bedroom, remove kids and pets from your bed, relax, meditate or read a book before bed, stay in bed even if you can’t fall asleep right away, eliminate naps or restrict naps to <20 min during the day and exercise during the day so you are more tired come night.

RELAXATION whether it be through meditation, diaphragmatic breathing or a trip to the spa, is key to calming the nervous system. The goal is to live more in the parasympathetic state (rest and digest) than the sympathetic state (fight or flight). This will look different for each individual. I am not a person that finds tranquility in meditation or yoga but being with family and friends or working on a puzzle puts me in a state of ease. Find whatever does this for you and do more of it.

OTHER THERAPIES including mobilization, manipulation, soft tissue massage and trigger point dry needling have been shown to be the most effective in decreasing chronic pain when used in combination with pain neuroscience education. So all of the time and money I spent seeing physical therapists, chiropractors and acupuncturists would have been more effective if education regarding my pain had been included.

The happy ending to this story and this series of blog posts is that most likely, some of your pain is coming from your brain and you can 100% change that. I still have pain when I’m stressed, sleep deprived, over committed, eating poorly and not moving. BUT that’s my fault. I can chose to not do these things. I can chose to be pain free. Thats some powerful sh*t.

Still have more questions about pain?

Want to see the research?

Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long term disability and work loss. Wellington: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee; 1997. Full text.

Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 2011;92(12):2041-2056. Full text.

Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297-302. Full text.

Van Oosterwijck J, Meeus M, Paul L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. The Clinical journal of pain. Oct 2013;29(10):873-882. Abstract.

Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain. Physiotherapy Theory and Practice. Jul 2016;32(5):385- 395. Full text.

George S, Wittmer V, Fillingim R, Robinson M. Comparison of Graded Exercise and Graded Exposure Clinical Outcomes for Patients With Chronic Low Back Pain Journal of Orthopedic and Sports Physical Therapy. 2010; 40(11):694-704. Full text.

Fulcher KY, White PD. Randomized controlled trial of graded exercise in patients with the chronic fatigue syndrome. BMJ. Jun 7 1997;314(7095):1647-1652. Full text.

Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice. Jul 2016;32(5):332-355. Full text.

Aure O, Nilsen J, Vasseljen O. Manual Therapy and Exercise Therapy in Patients with Chronic Low Back Pain: A Randomized, Controlled Trial with 1-Year Follow-up. Spine. March 2013: 28(6):5250531. Full text.

Click here for a full list of articles on pain neuroscience

Pain Neuroscience Part 4: A More In-depth Explanation of Pain Using My Experience

It was June 12, 2011. I was out on an evening walk when a very fast car decided to join my friend and I on the sidewalk. I will spare both you and myself the details of the accident and instead, focus on my nervous system and it’s interpretation of pain over the years…yes, years.

At the time of the accident there was significant tissue damage. Significant enough to warrant a large amount of pain however, I felt nothing. My brain had decided that the threat of my injuries did not outweigh the threat of the car that was still present and trying to reverse to flee the scene. So I quickly got up and ran out of harm’s way kind of like a super human.

Once out of harm’s way, my super human powers disappeared and I started to experience pain. Bummer. Simplified for teaching purposes, there are three nerves that pass a message from the injured tissue to the brain for interpretation. Peripheral nerves go from the body to spinal cord, in the spinal cord there is a small interneuron that acts as a gateway to the third nerve which is ironically called a second order neuron because medical terminology likes to be confusing. This second order neuron travels up the spinal cord to the brain where multiple areas go into the processing of the signal to determine what meaning the message has.

Upon impact, my injured tissues started sending signals through peripheral nerves to my spinal cord. At first, they were either stopped by the interneuron or my brain decided they weren’t a threat because a bigger threat (the car) was present. Once I was removed from danger, the messages were allowed to pass through and my brain interpreted them as the next most immediate threat so I started to perceived pain. At first, the pain experienced directly correlated to the extent of my injuries but over time, my pain became disproportionate to the tissue damage.

At first, my body’s top priority was to heal and in order to heal, the body must rest. Even as tissues started to repair, my nerves remained extra sensitive and my brain continued to interpret everything as a threat (pain) so I would minimize my movement and allow for further healing. Makes sense right? Now typically this protective pain will go away once the tissues have healed because it is no longer needed but 1 in 4 people will experience persistent pain long after the injury has resolved. I am one of those lucky people. Yay me! At first I thought this was just due to chance but knowing what I now know about pain, I believe this has nothing to do with chance and everything to do with the adaptations of my nervous system.

Let’s start with the peripheral nerves: the ones going from the body to the spinal cord. Nerves have a level of charge that must be met in order to send a message. If the threshold is met, the nerve will fire. Nerves reach their firing charge by allowing ions from the outside to the inside through ion channels. There are many types of ion channels that open or close in response to different stimuli. Some respond to chemicals (stress, immune, inflammatory) while others respond to mechanical stimuli like tension and pressure. Temperature also opens and closes ion channels. The more ion channels that are open, the more likely the nerve is to fire. With my original injury, the mechanical impact and the inflammatory response opened more than enough ion channels for nerve firing. Ion channels are only present where there isn’t myelin (a sheath that improves the speed of signaling). Over time, inflammatory chemicals can demyelinate nerves allowing an increase in ion channels and a perpetually more sensitive nerve long after the inflammation is gone. So fast forward a few months and even a few years, my nerves still have increased ion channels and still reach their firing threshold more easily. I experience pain when I’m sick, when I’m stressed and even when I’m cold all because there are more ion channels.

Moving on to the spinal cord where the peripheral nerves meet interneurons before going to the brain for interpretation. If this interneuron is bombarded by messages, it will die off. This eliminates the gate keeper of messages and allows all of them to get to the brain easier. I’m pretty sure my interneurons were obliterated. My injuries took a really long time to heal on a tissue level which meant a lot of messages were sent for a long time. The brain can also ease the passing of messages from the body through the spinal cord if it believes there is a threat. The brain becomes more interested in the danger signals and will therefore increase nerve sensitivity by keeping ion channels open longer so it can receive more information more often. For good reason, my brain perceived threat for a long time so it likely made it as easy as possible for messages to pass through.

Another thing to note is that the nervous system is messy in its organization and adaptations. These changes occurred at the nerves corresponding to the areas that were injured but there is crossover in representation of an area as the nerves enter the spinal cord and within the brain. As a consequence, the area of my perceived pain spread over time. Not because of further tissue damage but because the adaptations of my nervous system and the interpretation of where the signals were coming from are not precise.

Just like the rest of the nervous system, the brain is also adaptable. When an area of the body is used more or generates a disproportionate amount of signals, the representation of that area in the brain will grow and borders of it will become less defined. This is another reason why pain can go from being isolated to the injured tissues, to being more diffuse.

All of the magic really happens in the brain. Up to this point, all messages are just an electrical signal traveling down a nerve. It’s the brain that gives meaning to this electrical charge. It’s the brain that decides whether the message is pain, a different sensation or not worthy of any feeling at all. Many areas of the brain participate in this decision making process. The areas for sensation, emotions, memory, cognition, movement planning and stress response have all been shown to be activated during the experience of pain. This complex interaction varies for each individual and each pain experience. The specific pattern of activation is called a neurotag. Other experiences and memories also have their own neurotag. The more often a neurotag is used, the more it becomes reinforced and the easier it will be accessed. This is where the phrase “its like riding a bike” comes from. The more we practice something, the easier it is to do automatically and this can occur with a movement, a memory or the experience of pain. Specific movements and activities had become so strongly associated with the experience of pain within my neurotag that even after my body healed, these movements still generated pain.

So with all of these adaptations, am I destined to be in pain for the rest of my life because I am literally wired to experience more pain? For years, the answer was yes but once I started learning about pain neuroscience, the answer became heck no. If the nervous system can adapt in one direction, it is also capable of reverse adaptations and the key to this switch is actually quite simple. It all lies in the perception of threat.

Stay tuned for the final post of this series: How to Decrease Pain by Decreasing the Perception of Threat.

Want to see the research?

Louw A. Why Do I Hurt? A Neuroscience Approach to Pain. Minneapolis: OPTP; 2013. Textbook.

Moseley, G.L., A pain neuromatrix approach to patients with chronic pain. Man Ther, 2003. 8(3): p. 130-40. Full text.

Melzack, R., Pain and the neuromatrix in the brain Journal of Dental Education, 2001. 65: p. 1378-1382. Full text.

Woolf CJ. Central sensitization: uncovering the relation between pain and plasticity. Anesthesiology. Apr 2007;106(4):864-867. Full text.

Moseley GL. Reconceptualising pain acording to modern pain sciences. Physical Therapy Reviews. 2007;12:169-178. Full text.

Gifford LS. Pain, the tissues and the nervous system. Physiotherapy. 1998;84:27-33. Full text.

Woolf CJ, Salter MW. Neuronal plasticity: increasing End the gain in pain. Science. Jun 9, 2000;288(5472):1765-1769. Full text.

Click here for a full list of articles on pain neuroscience

Monthly newsletters containing all the good stuff. No spam. Nothing boring. I promise. Subscribe Here