Flower Power: Looking At These Pictures Will Reduce Your Anxiety Right Now

The power of flowers: did you know that just looking at images of nature is enough to reduce your stress and anxiety? A 2015 study published in the International Journal of Environmental Research and Public Health found that just five minutes spent gazing at natural photos promotes relaxation and recovery after experiencing a stressful period. Who doesn’t need some of that right now?!

If you weren’t able to get outside into nature during the last few days, then I hope these photos bring nature to you! Flowers offer hope and joy, which is so important during the specific stressors of the global pandemic on those of us living with chronic illness. And the power of flowers means that savoring their beauty helps to improve our well-being.

Apple Blossoms

Magnolia Blossoms

Blue Phlox

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Does anyone know what these gorgeous blooms are?

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Daffodils

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Crocuses

Empowering People Living With Chronic Pain Through Pain-Neuroscience Education

I’m excited to share a guest post by Ann-Marie D’Arcy-Sharpe, a freelance writer and blogger who lives with chronic pain. She writes for Pathways Pain Relief, a chronic pain relief app and blog, which is created by pain patients and backed by the latest pain science. I definitely learned a new thing or two by reading her article, so I hope you do too! 

Empowering People Living With Chronic Pain Through Pain-Neuroscience Education

Chronic pain affects a vast proportion of the population. A 2019 study from the Journal of Pain states that, “Chronic musculoskeletal pain (CMP) affects about 20% of the population in western countries, causing suffering, disability, and a significant loss of quality of life”. Not only does chronic pain affect many people’s lives, it also takes up a great deal of health resources and accounts for many people being out of work. 

For a long time, those with chronic pain have received little in the way of effective treatment options. Thankfully, the face of modern day pain treatment is changing. Pain-neuroscience education (PNE) has become a cornerstone of chronic pain treatment. Understanding the science of chronic pain can be a powerful tool to empower people in pain to retrain their brain away from pain. Having people living with chronic pain understand that the brain produces all pain, and that it’s neuroplastic, helps to instil the confidence that pain is changeable.

PNE is often part of chronic pain treatments such as physiotherapy, cognitive behavioural therapy (CBT)  and other psychological treatments. This form of education teaches those in pain about the science of acute and chronic pain, so they can have a clearer understanding of pain moving forward. Often metaphors and stories are used to help people in chronic pain relate the science to their own lives and provide a deeper understanding. 

This study explains that PNE, “incorporates the multidimensionality of a pain experience and helps patients reconceptualise pain through understanding the multiple neurophysiological, neurobiological, sociological and physical components that may be involved in their individual pain experience.”

At Pathways (our pain therapy app), we found the best results by starting our program with PNE. Those in pain often tell us that understanding the science behind their pain was key to their recovery. Understanding that pain doesn’t equal damage, and that our brain and body learns pain, helped them to change their perspective on pain, as well as strategies to deal with it.

A 2019 study on PNE states that, “The use of pain neuroscience education (PNE) has been shown to be effective in reducing pain, improving function and lowering fear and catastrophization.”

The way those living with chronic perceive pain has a significant impact on pain levels. This study clearly states that, “Pain is complex and it is well established that various cognitions and beliefs impact a patient’s overall pain experience”. 

Giving people living with pain hope and the ability to see why and how treatments work can lead to more positive, adaptive perceptions of pain and the pain experience. This in turn reduces symptoms and encourages more adaptive coping strategies. People are far more likely to really engage in their treatment when they have this basis of understanding to work from.

Often people in pain experience deconditioning from lack of activity. This can contribute to pain levels and make daily activities harder. With more positive perceptions of their pain and the understanding that engaging in activity is not going to harm them, people can start to recondition their bodies. As muscles become stronger and the body becomes fitter, pain is reduced. 

Once fear is tackled with knowledge, the stress that accompanies chronic pain can be reduced. This in turn helps to break the stress and pain cycle. Since stress worsens chronic pain, this is actively helping to reduce symptoms and enabling patients to feel more in control of their lives. 

Through PNE people in pain are made aware of the difference between maladaptive and adaptive coping strategies and learn that their behaviours directly influence their symptoms. They can come to understand the need to implement more adaptive behaviours and can feel more motivated to do so. Given that so many people with chronic pain feel powerless, understanding that they have more control over their pain levels than they may have thought can be incredibly liberating.

Giving people a sense of hope that their symptoms can improve is a vital and significant part of pain treatment. It’s so important that PNE is part of pain treatment moving forward to set people living with chronic pain up for success! When there are effective treatments available, nobody should be left in chronic pain without hope. 

References

Galán-Martín, M.A., Montero-Cuadrado, F., Lluch-Girbes, E. et al. Pain neuroscience education and physical exercise for patients with chronic spinal pain in primary healthcare: a randomised trial protocol. BMC Musculoskelet Disord 20, 505 (2019). https://doi.org/10.1186/s12891-019-2889-1

 

Louw, A., Puentedura, E. J., Diener, I., Zimney, K. J., & Cox, T. (2019). Pain neuroscience education: Which pain neuroscience education metaphor worked best?. The South African journal of physiotherapy, 75(1), 1329. https://doi.org/10.4102/sajp.v75i1.1329

 

Adriaan Louw & Emilio J Puentedura, (2014), Therapeutic Neuroscience Education, Pain, Physiotherapy and the Pain Neuromatrix. International Journal of Health Sciences, September 2014, Vol. 2, No. 3, pp. 33-45. DOI: 10.15640/ijhs.v2n3a4

Bio: I’m Ann-Marie D’Arcy-Sharpe. I am 33 years old and work as a freelance writer and blogger. I live with bipolar disorder, fibromyalgia and arthritis.

I write for Pathways Pain Relief, a chronic pain relief app and blog. The app is created by pain patients and backed by the latest pain science. We use mind body therapies to help pain patients achieve natural, long lasting pain relief.

You can download our app here: https://www.pathways.health/

 

Strength of Surviving: The Importance of Acknowledging Your Own Strength in the Face of Chronic Illness Adversity

Getting through adversity with endurance and determination is a trademark characteristic of every single person living with chronic illness. This is the strength of survivors. The coronavirus pandemic especially hard on those of us who are sick already but I hold on to the fact each of us is stronger and more resilient than we give our selves credit for, and these inner resources will help carry us through this time.But to acknowledge you own strength, you have to know what it really means. Think about it… what does it actually mean to be strong?

What is strength?

Strength is often described in terms of a fight for control – pictured as a physically tough warrior doing battle against the forces of opposition (Kabat-Zinn). In terms of life with chronic illness, being a fighting warrior can mean advocating for better care from your doctors or standing up for yourself to maintain boundaries in a challenging relationship. “I have the inner strength to fight for what I need.” But this metaphor is relatively limited in how it lets us conceptualize our own strength.Strength can also be understood as having the internal resources to cope in difficult situations. A strong person might be described as having the capacity to exercise physical, mental or moral power in challenging circumstances. You might have a strong mind, a strong support network, strong principles, or strong abilities that help you navigate through life experiences. Learning to cultivate and rely on these resources is an aspect of strength that I would call resilience, and it’s an important part of living a better life with chronic illness.Finally, and I think most importantly for individuals with illness, strength is about endurance, tenacity and perseverance – think of the phrase “a pillar of strength”. This is the strength of survivors. Getting through adversity with endurance and determination is a trademark characteristic of every single person living with chronic illness. I love the phrase “remember, your success rate for surviving your worst days so far is 100%”.Jon Kabat-Zinn, a pioneer of mindfulness in medicine, created a meditation based on the visual metaphor of a mountain to help patients in his programs learn how to adopt a mountain’s qualities of strength, stillness and stability as their own. I would include an additional symbol – a tree –which offers additional insights on how we can understand strength as adaptability in a way that helps us cope with chronic illness. What can the metaphors of a mountain and a tree can teach us about the strength of survivors? How can we come to know our own grounded presence, our ability to encounter both good and bad experiences one day at a time, and our own will to survive, uplifted from deep within?

Being Grounded

The base of a mountain is embedded in the Earth’s crust, and the deepest roots of a tree ground it in the soil. In the same way, we can anchor ourselves in the present moment, and root our attention in the here-and-now. This is what it means to be “grounded in awareness”, which is a stable foundation for living that can be very reassuring in the face of overwhelming circumstances.Growing deep roots in the firmament of awareness is a source of great inner strength. If we stay mindfully connected to the present, then we don’t get swept away by memories, imaginings, and other mental or emotional preoccupations. Whenever grief over losses caused by illness arises – or frustration about physical limitations, or anger over inadequate health care – staying grounded in the present, even as you feel your feelings, provides stability, continuity and reliability. You can always count on just this breath, moment to moment, to anchor you. It is sustaining and nourishing for our well-being to be grounded in the present in this way – just like it is nourishing for a tree when its roots absorb water and nutrients from the surrounding soil.Meditation instructors often liken thoughts, feelings, and experiences to the weather. How would you describe the forecast in your own life today? Sunshine and blue sky (happy), overcast (low mood), partly cloudy with sunny breaks (neutral), storm clouds with thunder and lightning (anger), blizzard conditions (turmoil) – using the emotions-as-weather metaphor is a wonderful way to check in with yourself to identify how you’re doing throughout the day. Jon Kabat-Zinn explains that the mountain experiences these conditions on its surface – but underneath, the solid base sits in unwavering stillness. In the same way, beneath the thoughts, emotions and experiences of our daily lives, is the foundation of unwavering stillness that is our awareness. If we can learn to sit mindfully, grounded in the same resolve and endurance as a mountain, no matter what the conditions on the surface landscape of our daily lives might be, we can adopt its strength as our strength.

Being Mode: Equanimity as Strength

A mountain is the quintessential symbol of endurance. The mountain rests in “being mode”– a calm, abiding presence withstanding the inevitability of change over time. A mountain knows at its core, of each experience, that “this too shall pass”. The mountain represents equanimity.Everyday life with illness is extremely unpredictable. Chronic illness exemplifies the saying “man plans, and God laughs.” Physical symptoms constantly fluctuate, which makes planning very difficult. Over time, forced periods of inactivity and rest due to flare-ups make it difficult to continue persevering at things – from friendships, to jobs, or projects. The stop-and-go nature of life with sickness makes it hard to accomplish things or to cultivate relationships, and the constant sense of uncertainty causes a pervasive feeling of powerlessness.The natural reaction to these changeable circumstances is to double down on “doing mode”. For example, you might stay up all night researching your illness, create a 40 item treatment plan, or drive yourself to “push through” tasks regardless of pain or exhaustion, in order to be more productive. “Pushing through” does require strength, but it is the fighting, warrior-type of strength we discussed earlier. This works in short bursts, and can sometimes be necessary, such as pushing through physical discomfort to attend a meaningful family event or to advocate for yourself with a dismissive doctor.But like clenching a handful of sand in a closed fist, these tactics don’t help you hold on to predictability or productivity for very long. We can needlessly expend our limited energy in a constant, exhausting battle to regain control of our day. But, as you likely know all too well, pushing through today usually only leads to a crash tomorrow. What might happen if we switched to approaching life’s challenges using the endurance and tenacity of “being mode” rather than engaging in the battle of “doing mode”?We can use the symbol of the mountain to represent what embodying equanimity as an inner strength could look like. When difficult experiences, thoughts or emotions arise, rather than always seeking to analyze and control these circumstances, we can rely on our inner awareness as a solid foundation – building on the enduring resolve and unwavering stillness of mindful presence to persevere through the storms of life. Releasing the need to control our life circumstances can feel like an enormous weight lifted from our shoulders. Instead, we allow circumstances to be like the weather on the mountain – ever-changing – even while the mountain endures as a still, rock-solid presence. In this way, cultivating equanimity allows us to build inner strength.

Strength in Flexibility

Like a tree, you have shown determination to survive, no matter how challenging the environment has been. You have endured, one day at a time. This inner strength comes from your core, which supports you like the trunk supports a tree.The tree has a powerful lesson about strength to teach us – because it is both strong and flexible. The trunk stands firm, yet the branches bend in the wind. If the wood of trees was unyielding, all trees would be brittle and snap in stormy weather. In fact, the trees that have adapted to survive hurricanes are the most flexible of all – picture a palm tree bending to withstand the onslaught of Category 5 hurricane strength winds one day – and then standing serenely under a tropical sun the next. Flexibility, and adaptability, in the face of adversity, increases resilience. No matter whether we face sunny days or storms, the tree teaches us to stay grounded in the present, to hold ourselves upright using our inner strength, and to be flexible in the face of the winds of change.

When I realized all of the strength I needed was already inside me, it changed how I approached the challenges of illness. Of course I feel anxious and worried; the feelings don’t disappear. But reminding myself to stop, breathe, and plant my feet in the present gives me hope that there is a path through whatever difficulties I face. I can deal with just.right.now. The stillness and stability of just being, of our awareness of each moment, is always there to count on, to ground yourself in. Endurance is made up of perseverance in moments, and days. I’ve gotten through every difficult minute, hour, day, and season I’ve ever faced, and so have you. I don’t know what the future holds, and I try to stay open to change. But I have an approach and a way to navigate what comes, and that is the strength of surviving. I know that now, and it makes all the difference.

to cope with You can find the mountain meditation in any Mindfulness Based Stress Reduction program, which is taught all over the world, in the book “Wherever You Go There You Are” by Jon Kabat-Zinn, or on the free, non-commercial site http://www.freemindfulness.org/download, under ‘Guided Imagery’.

Fear and Hope: The Hidden Realities of Being Chronically Ill In the Time of Coronavirus

 

Right now is especially hard on those of us who are sick already. The safety nets that each person has – medical care, social support, financial security, and access to basic necessities, among others – are being sorely tested at this time. But the individual safety nets of people with chronic illness are already weakened, and when you add a pandemic, they fray even more. We have to hope and pray that they hold.

Spring. It’s a beginning. More than that, it’s a beginning that starts in the cold and the dark. In the middle of winter, it’s hard to believe spring will come. But it does. I’ve taken photos of spring flowers to remind myself of that fact.  I hold on to the fact that the deep resilience and strength that everyone with a chronic illness has developed will help to get us through this time.

Physically, the risk of getting coronavirus has higher stakes for the chronically ill. Even if you are not immunocompromised, the fear of getting a terrible illness flare up, or setback is real. A cold virus once caused me debilitating fatigue for months, so of course I worry what coronavirus could do. My husband worries even more on my behalf than I do!

The financial crisis ahead will disproportionately hurt the chronically ill, who are far more likely to be underemployed or unemployed than the non-ill. I feel lucky my husband’s salary can support both of us, since I can’t work, although things in a single income family are often tight. But for years, many of those with chronic illness have lived in poverty on inadequate government disability assistance. Suddenly, the government has found the resources to give individuals who have just lost been laid off because of covid-19 as much as double the amount allocated for disability benefits. 

To be clear, I don’t begrudge anyone who has recently gotten emergency government financial assistance due to coronavirus. That’s the right thing for our governments to do, and in fact, they should give more than they are. But when the chronically ill and disabled get half as much on a regular basis – an amount that is below the poverty line- it feels like our governments are saying people like us are worth half as much. Meanwhile, many are still trying to get by on the inadequate amount given as disability assistance during the lockdown without any additional supplementation. 

We’re still living in an ableist world  in the time of coronavirus. There’s no way that I can stand in line for half an hour or longer to buy groceries or pick up prescription refills on my bad knee. But God help you if you want schedule grocery delivery. There are no times available, for love or money. My husband is able to try and shop around his work schedule, and I’m lucky to have that help, when others are on their own. In some cases, neighbours and strangers have stepped up to help out the chronically ill who iive alone, and that increases my faith in humanity a little bit more.

Like so many, all of my appointments and procedures have been cancelled. From monthly physiotherapy that helps to bring down regular flare ups, to a long scheduled nerve ablation that is supposed to reduce my neuropathic back pain, all of these pain management tools are now on hold and I’m trying to make do the best I can.

I won’t lie, it has been harder to sleep, which triggers more flares of pain. I feel more irritable, especially if I spend too much time on the news or social media. Regulating my news diet helps to bring some of the stress down. It’s just not feasible to try to worry about every corner of the world at once!

At the moment, it seems like everyone and their grandmother are having Zoom chats with all the people they’ve ever known. If I read one more post about how wonderful all this reconnecting is I think I will get an eye twitch.

Chronic illness is isolating for most of us. When you cannot regularly meet up with friends or join community events or chit chat with neighbours at the dog park, then your social support system shrinks. I’m fortunate to have a couple of good, old friends who have stuck with me. And since I’m old school, I skype with them on occasion (sorry, zoom!).

But I’ve lost a lot of friends and family members along the way. It’s hard to think about the people who were more fair weather friends at a time like this when we could have been there for each other.

That being said, I’ve learned to embrace solitude more over the years. This is the time for distraction therapy: writing, knitting, painting or whatever creative pursuits you have wanted to try. Or maybe just appreciate the creativity of authors, actors and musicians by reading, watching shows and listening to music that you’ve wanted to check out but haven’t had time until now. Here’s a list of my favourite free distractions to help you make the most of this time, despite the pain and fatigue.

Frustratingly, I had just started going to a local library book club before the pandemic hit and had found a new local fibro group I was hoping to go to. Looking forward to book club got me through some difficult days- thinking, “well, at least I’m living a little”. Same with going out to a cafe once in awhile with an audiobook, ted talk or an online course lecture. Those small things helped me to regulate my feelings about chronic pain- counterweights of connection and enjoyment to the isolation and limitations of illness.

Now though, that’s not possible, or re-creatable. When bad days hit now, it’s hard to know what to turn to other than a lot of distraction. Fortunately, there are some excellent online support groups, like Medical Musings for Friends on Facebook, or the general chatter of #chroniclife #spoonie #chronicpain #fibromyalgia on Twitter.

I hold on to the hope that this season will pass and a new spring will bloom, when we will be able to access the treatments and supports we need again, and build the relationships we want. Now more than ever, I value the strength I’ve gained, my current relationships (IRL and virtual), and mindfulness of simple enjoyments, like spring flowers, that I can savour. I hope I can carry the intention to focus on these things into the next season, post-coronavirus. We have strength forged by surviving our illnesses, and we can trust in our own tenacity and resilience during this time. Self-compassion and kindness can also go a long way right now. We need to give ourselves a break at present, since we’re all just muddling along trying to figure this thing out the best we can, one day  at a time.

 

Distract Your Pain Away: How to Make the Most of Your Time at Home with Chronic Illness

Distract Your Pain Away:

Living with daily pain can feel very limiting. The list of activities I can no longer do without increasing my pain levels or triggering flare-ups, which includes working, typing, holding a book, vacuuming, running, painting, and everything in between, is longer than the list of what I can do.  It can feel like a cage that that I’m confined to.

In this situation, I found it liberating to discover new activities that I can do even while I am still in pain. In fact, distraction is a valid pain management tool. A recent study found that “mental distractions actually inhibit the response to incoming pain signals at the earliest stage of central pain processing” (Science Daily). In the study, participants either completed an easy or difficult memory task while painful heat was applied to their arms. Participants who completed the most difficult memory test, which was more mentally distracting, perceived less pain– a functional MRI scan of their spinal cord actually showed less nerve activity compared to the group doing the easy memory task. The researchers concluded that these results show “just how deeply mental processes can go in altering the experience of pain” (Science Daily).

This study shows the importance of finding low-key activities that you can enjoy even while you are in pain. Over the past few years, I have discovered a number of different activities that have helped me to expand my horizons, and manage my pain using distraction. I hope that you find some of these (free!) suggestions useful for making the most of your time, even if you are in pain.

Tune Out

Music is a powerful tool for managing pain and depression. Researchers recently found that listening to music for an hour a day reduced chronic pain by up to 21% and depression by 25%! (Science Daily, Listening to Music). Importantly, participants in the study reported feeling more in control of their condition and less disabled by it.

Personally, when I am feeling more alert I listen to my favourite albums and when I’m feeling fatigued, I relax to music specifically designed to help people fall asleep (I simply search for ‘deep sleep music’ in YouTube). If you want to discover new artists, or enjoy music without the cost of buying new albums, you might want to try free music streaming apps and websites, like the free Spotify plan, Google Play Radio or iTunes Radio. These sites let you legally listen to music without a paid subscription. I also like Jango, which has custom radio stations you can stream based on artists that you like (and promises only one audio ad per day).

Learn Something New

Can we be honest about something for a minute? I’m a complete nerd. But I’ve also discovered that most people have at least one topic that makes them geek out! Learning is good for brain health and it can also boost feelings of well-being and self-esteem.

There are many ways to learn new things from the comfort of your home. One of the most rewarding options that I have found is to watch free online video courses from sites like Open Learn, edX, Coursera. Whether you are interested in art or archaeology, math or music, there are thousands of options to explore. Sites like Open Culture provide listings that link to hundreds of courses so that you can choose what interests you most.

I recently discovered the world of podcasts, which has quickly become a staple activity that I turn to on high-pain days. The great part about audio is that you can lie down and rest in the most comfortable position you can find while you learn. The variety of podcasts out there is almost overwhelming, and there really is something for everyone, whether you are a news junkie, sports fanatic, gossip addict, policy wonk or anything else!

Transport Yourself to Another World

Who doesn’t love a good story? Nobody, that’s who! Books, TV shows and movies are all obvious forms of distraction for people living with chronic pain. While you probably already have thought of these options, I want to share a few tips from my own experience that may give you some new ideas to try.

Actually reading a book may be a challenge, depending on your chronic pain condition. Whether physically holding the book is painful, or reading the words on the page causes fatigue or headache, a paperback may not always be practical. Enter the amazing world of audiobooks! A great performance by a talented narrator can really bring a book to life. Lying down and getting carried away in a new story is one of the best low-key activities I have found.

Your local library may have an online audiobook library where you can temporarily download free audiobooks from a digital content service, without having to check them out from a local branch. LibriVoxi s a free, legal, online audiobook streaming service with hundreds of classic books (no longer copyrighted), read by volunteers. Audible and similar companies sell audiobooks from their large online libraries, which you can download or play using their app (but these subscriptions are pricey).

Binge-watching is a tried-and-true method for getting through a bad pain episode. Many people with chronic pain literally ‘Netflix and chill’! Unless you’ve been living under a rock, you already know about Netflix and all the other streaming services. However, like audiobooks, these services can get expensive. Did you know that there are a number of free (legal) streaming services like Popcornflix that offer public domain films (classics), independent and foreign films, and even recent features, as well as a number of documentaries?  Sites like Pluto TV also offer an array of live tv options. My public library has a partnership with Kanopy, which offers 8 free videos per month of everything from Great Courses lectures to Oscar nominated films. Your library may offer a similar service!

Resources

Science Daily (Pain relief through distraction: It’s not all in your head)

Science Daily (Listening To Music Can Reduce Chronic Pain And Depression By Up To A Quarter)

 

Coping With Uncertainty: Going Where the Flow of Your Chronic Illness Takes You

Unfortunately, illness takes away much of our control over our own lives. But there is a blueprint for coping with life’s fundamental unpredictability. Putting the anxieties and unknowns of life under the heading ‘Future Events I Cannot Control’ helps to keep me sane, especially in the face of scary symptoms.

Coping With Uncertainty:

Spring lends itself to new beginnings, from planning spring cleaning, to starting up projects, to contemplating healthier choices.

When you live with chronic pain, it’s easy to decide on a new initiative, but difficult to actually accomplish it. The unpredictable and overwhelming nature of fibromyalgia and chronic illness symptoms mean that completing something isn’t only a matter of motivation and effort. Unfortunately, illness takes away much of our control over our own lives. This leads to feeling powerless, which is hard to live with. You have to go with the flow of your illness, wherever it takes you.

It can help to take the long view on the uncertainty of life. As they say, “humans plan, and God laughs.” All people have to contend with the fact that they cannot control the future. This truth may be more visible in the lives of people with chronic illness, but it applies to everyone. Striving and straining to attain the impossible — control of the future– can be an exhausting and defeating waste of mental and emotional effort.

I recently developed a mysterious knee pain, and my knee becomes red and swollen sometimes. This has significantly limited my ability to walk and drive, and do basic daily  activities. While I wait on multiple referrals to specialists, I have to live without knowing whether I will I have to permanently live with this new disability. Unknowns like this are scary, and naturally produce worry and anxiety. At times like this, I come back to the Serenity Prayer: “grant me the serenity to accept the things I cannot change, the courage to change the things I can , and the wisdom to know the difference.” Beyond containing a universal truth, I think that this prayer offers a blueprint for coping with life’s fundamental unpredictability.

During a period of heightened uncertainty, it’s useful to mentally review the worries that arise, and divide them into two categories: things you can change, and things you can’t control. For the first category, put the analytical, problem-solving part of your brain to work coming up with strategies and  to-do lists. In the case of my knee, that has included day-to-day coping strategies to make myself more comfortable. For example, I bought a chair for the shower to make washing easier.  I looked up ways to make at-home ice packs using water and rubbing alcohol in Ziploc bags so that I can ice my leg frequently to keep the swelling down. I’ve been keeping careful track of my daily steps so that I don’t go beyond what I can handle. While these proactive steps don’t address the fundamental question about what will happen in the future, they do make me feel more in control of the present. It isn’t easy to do something that makes me feel more disabled than a month ago, like sitting in the shower, but I’m doing what I can, and that feels much better than doing nothing.

So what about the second category — the things we cannot change? Sometimes the simple act of acknowledging  that there are things beyond our control can be a relief. When worry and apprehension take over your mental attention, they’re often based on the assumption that you have the ability to change external circumstances. Setting that burden down can be freeing. Of course this doesn’t mean that you stop caring about outcomes. It’s a fallacy to say that choosing to live in the present without always being preoccupied by future worries means that you don’t care about what will happen.

Putting the anxieties and unknowns of life under the heading ‘Future Events I Cannot Control’ helps to keep me sane, especially in the face of scary symptoms. My Grandmother used to say that “we’ll cross that bridge when we get there.” The older I get, the more I realize the wisdom of that saying. As mindfulness practitioners like to remind us, we only ever live in the present moment, not in the future, or the past. The visual of a mountain, sitting still and unmoveable in the face of all weather and seasons, is sometimes used in meditation because it captures the spirit of being grounded in the present. There are different practices that can help us to cultivate equanimity in the face of uncertainty, such as mindfulness, cognitive behavioural therapy, or prayer. The gist of these comes down to being self-aware about what we mentally focus on, and deciding whether the issue is something we can change or something we cannot control. We need to do what we can to address the things within our power, and let go or surrender what we cannot (over and over again, sometimes). In the long-term, I don’t know what will happen regarding my knee. Right now, I think I will go get another ice-pack and start thinking about what to make for dinner.

Coping With Uncertainty twitter

Habitually Healthier: How to Actually Stick to New Habits in 2020 to Improve Life With Illness

Managing fibromyalgia involves making multiple lifestyle changes. It’s like having a black belt in New Year’s resolutions. The science of habits can help you actually stick to your resolutions in 2020.

How to Actually Stick to New Habits in 2020 to Improve Life With Illness

Managing fibromyalgia involves making multiple lifestyle changes. I think it is like having a black belt in New Year’s resolutions. In the past six years I have added daily stretching, meditating, walking, resting and supplements to the things I do almost every day. I have found it to be very difficult to stick to making new habits, with lots of false starts and relapses into bad habits.

The intentional mind can change quickly, because what we wanted to do in the past may be different from what we want to do now. The habitual mind is much harder to change because our behaviour is automatic – in fact, we are on autopilot 40% of the time. It is hard to sustain the willpower to change and easy to revert to old habits. However, by understanding the science behind habit formation, it can be much easier to stick to the lifestyle changes that you have decided to make.

When you first try to start a new habit, you engage goal-directed brain regions in the prefrontal cortex. As you repeat your habit in the same context, such as always brushing your teeth in the bathroom before bed, the part of your brain you use to maintain your habit shifts to the ‘sensory motor loop.’ This is the habitual part of the brain that functions mostly outside of our awareness, by associating situational cues with a behaviour response. For example, when you stagger into the kitchen in the morning and make coffee, you are on ‘autopilot,’ and not making a conscious, intentional decision – your brain associates waking up and going to the kitchen with coffee.

Habits can be broken down into three parts:

  1. The Cue – a trigger, internal or external, that reminds you perform an action
  2. The Action – the habit behaviour you are trying to put into place
  3. The Reward – the reward your brain receives for implementing the habit

The Cue – The first step to creating a new habit is often to break the old habit. This means removing a situational cue which triggers the habitual response. When my husband and I decided we would try to walk every day after he got home from work, the first obstacle was to avoid sitting down in front of the TV soon after he came in the door. It was so much harder to get up the motivation to go outside after we had already begun to watch a show, even if initially we said “we’ll only watch one.” So instead, he now immediately gets changed and we head out the door, avoiding the couch altogether. Another helpful tactic is to remove any visual reminders, such as moving junk food to a higher shelf if eating healthier is a habit you’re trying to create. Think about how to remove negative cues that keep you stuck performing a bad habit.

The next part is to choose a positive trigger that will remind you to repeat the new habit you’re trying to cultivate. The most effective way to do this is to use something you do automatically already as your cue. For example, doing yoga after brushing your teeth in the morning. Alternatively, create a visual reminder, such as putting your smoothie blender beside the coffee maker or a note on the bathroom mirror to floss your teeth.

The Routine – put simply, repeating an action turns it into a habit. It only becomes automatic after you do it regularly. One of the biggest mistakes is trying to implement multiple new habits at the same time. I’ve been guilty of trying to make multiple lifestyle changes at the same time in order to improve my fibromyalgia, like taking new supplements, exercising, meditating and resting daily. I think this can just lead to treatment burnout where you lose the motivation to stick with any good habits. It’s also important for new habits to be realistic. You know yourself the best, so start with a realistic change and be patient.

The Reward – there’s a reason that bad habits stick around, and it’s because of the reward system in the brain that lights up when you eat sugar, play online games, or drink a lot of caffeine. While eating healthily or exercising more eventually become their own rewards, it can be helpful to consciously reward yourself when you cultivate new habits. This could be a small piece of dark chocolate, or a mental pat on the back for accomplishing your goal for the day.

Research shows that tracking your habits is one of the most effective means for sticking with a new lifestyle change. This could be a simple checklist on a piece of paper that you mark every day or downloading one of the multiple habit tracking apps onto your phone. Keeping a log of your progress helps to improve motivation, keep you accountable and note any obstacles or solutions to work on. I have found it helpful to just add a new habit to my daily pain journal. At the moment I am tracking my physiotherapy strengthening exercises and daily step count. Filling it out reminds me to keep up with it and also helps me see how it improves my pain levels during the day.

I believe that underneath the trigger and behaviour nature of habit formation is a more crucial factor – namely, your relationship with yourself. How do you respond to yourself when you make a mistake? It’s inevitable when you try to make a new change that there will be days when you fail and forget to do the One thing you swore you would do every day in 2019. If you react harshly, condemning yourself for your mistake and doubling down on negative self-talk, then you are actually less likely to stick to your new habit. This is because of “all or nothing thinking” which goes something like this: if you didn’t meditate one day this week then you consider your New Year’s resolution to be a complete failure and decide that you may as well just give up. In contrast, if you are compassionate to yourself for making a mistake – after all, making mistakes is something every person does – then you are more likely to keep up with your new habit. Be kind to yourself. You can always begin again. Try noting the negative thoughts in your daily log and then reframing them in a more helpful light. For example, “I can’t believe that I didn’t do my physiotherapy exercises this morning, I am never going to get this right, so why even bother?” can be changed to “it’s frustrating that it slipped my mind today, but I know that’s going to happen sometimes. It’s better that I do it more often than never, some I’m just going to begin again tomorrow.”

Sources:

Cooper, B. ‘Why you should be tracking your habits’. Lifehacker (www.lifehacker.com)

Science Daily. ‘How we form habits, change existing ones.’ (www.sciencedaily.com)

Go Beyond Self-Care: Why We Need To Talk About Self-Compassion Instead

Why We Need To Talk About Self-Compassion Instead

 

Bubble baths. Lit candles. Dark chocolate. Steaming cups of tea. These are the self-care recommendations we are regularly encouraged to add to our daily lives. I love these things as much as anybody else. But adding a list of temporarily enjoyable activities to your to-do list is ultimately only the frosting on the cake. It feels good, but it doesn’t substantially change anything. In fact, sometimes these activities can feel like extra obligations; something the average super-woman or man is expected to fold into their life, along with all the other demands on their attention.

Self-compassion means “cherishing yourself in the midst of emotional pain and distress” (Germer, 2009).[i] When you hear about a struggle that your best friend, child, partner or other loved one is facing, the feelings of support, good-will, and love that you feel for them together represent true compassion. Sadly, it’s much harder to feel those things for ourselves. Often we respond to challenging circumstances by criticizing ourselves for getting into the situation or pushing ourselves too hard to get out of it. This just piles on suffering on top of suffering.

In contrast, befriending yourself, and intentionally directing compassion towards yourself, changes your relationship to difficult thoughts, feelings and experiences. It sounds easy, but treating yourself with the same acceptance, kindness and understanding you extend towards your friends and family members is something very few people actually know how to do.

What Is Self-Compassion?

Researcher Kristin Neff has identified three elements of self-compassion– self-kindness, mindfulness and common humanity.[ii] Each element of self-compassion corresponds to an opposite element of negative emotional reactivity that increases suffering; namely self-judgment (the opposite of self-kindness), self-preoccupation (the opposite of mindfulness) and isolation (the opposite of common humanity). Let’s delve further into what each of these terms mean.

  • Self-kindness means to react with warmth and understanding to your own flaws and mistakes. By adopting this attitude, you treat yourself like a friend experiencing a setback rather than a critic evaluating a performance (self-judgement). Self-kindness means offering yourself the support and comfort that a close friend would. In a difficult moment, ask “what is the best thing I can do for myself right now?”
  • Mindfulness in self-compassion involves acknowledging the temporary and changing nature of your own thoughts and feelings, seeing that they come and go like clouds in the sky. Instead of ruminating on or avoiding feelings grief or frustration about the losses and limitations that chronic illness imposes on our lives (self-preoccupation), we recognize them, feel them, and let them move through us. Tara Brach says that “compassion honours our experience; it allows us to be intimate with the life of this moment as it is.[iii]
  • Common humanity means saying to yourself “I’m only human, just like everyone else,” instead of feeling alone in the world with your difficulties (isolation). It involves taking a wide perspective, remembering all the people in the world who also live with chronic illness, and knowing that it’s more than likely that someone else has been in the same spot you’re in. After all, having an illness or disability is a common thread woven into the fabric of human experience.

Self-Compassion Meditation Practice

Self-compassion sounds good, but how do you actually put it into practice? How do you go about befriending yourself and changing your approach to coping with difficult circumstances? A type of meditation called loving-kindness meditation, which a secular practice based on traditional Buddhism, can point the way. Sharon Salzberg, a pioneering meditation instructor who brought loving-kindness meditation to the west, describes it as “a living tradition of meditation practices that cultivate love, compassion, [and] sympathetic joy.”[iv] Based on the common principles of kindness, mindfulness and connection to our common humanity, I use the terms loving-kindness and compassion interchangeably. It may sound a bit sappy, or feel awkward at first, but that shouldn’t get in the way of pursuing your best interest.

In  loving-kindness meditation practice focused on direction compassion towards the self, the focus of awareness is the silent repetition of specific phrases in your mind. Your loving-kindness practice could use the following phrases:

May I be safe – we wish for safety in the first line because being free from danger is a prerequisite for well-being

May I be peaceful – a wish for equanimity in the midst of the unpredictability of chronic illness

May I live fully in the present – a wish to live whole-heartedly, to live a rich, fully experienced life

May I embody love and kindness – this is a wish to be compassionate to our bodies, even if they suffer

May I live with ease – a wish for daily grace in our lives, a lessening of our burdens and struggles

Try sitting with your breath for a minute, and then repeating these phrases several times. Or you can say them silently to yourself during a difficult moment.

When we say each phrase, we are setting an intention to be a good friend to ourselves, like planting a seed. We will reap the harvest – experience compassion for ourselves – in the future. As Christopher Germer (2009) explains, loving-kindness meditation is about learning to feel goodwill towards ourselves, not to generate good feelings in the moment. Each phrase is an expression of hope for the well-being of your future self. And just like you hope for nothing but the best for your loved ones and friends in the days and years to come, the phrases of loving-kindness help you to cultivate this “inclination of heart” toward yourself (Germer, 2009).

What Does the Science Say?

Loving-kindness meditation can reduce chronic low back pain, according to a pilot trial (Carson et al., 2005).[v] Compared to standard care, individuals who participated in the eight week compassion meditation program had lower levels of pain, distress, anger and tension. A second study looked at whether compassion meditation could reduce negative mental states, in addition to decreasing pain levels (Chapin et al., 2014).[vi] Participants in the nine week loving-kindness meditation course reported a moderate reduction in their pain severity. Importantly, participants and their significant others also reported a decrease in negative emotional states like anger by the end of the program.

After a seven week loving-kindness meditation course, one study found a cumulative increase in daily positive emotions, regardless of whether the participant meditated on that day or not. The overall increase in positive emotions was associated with a significant increase in positive personal resources, like self-acceptance, mindful attention, a sense of purpose, and developing supportive relationships (Fredrickson et al., 2008).[vii]

Whether you do a formal practice, or just consciously remind yourself in challenging circumstances of the principles of self-compassion – kindness, mindfulness and common humanity – ask yourself – if a close friend of yours was in the same situation, what would you say to them? Most likely you would encourage them to go easy on themselves. You would tell them that they don’t need to be perfect, and remind them it’s okay to have bad days. Practice saying these things to yourself. Then offer yourself comfort by saying “what is the best thing I can do for myself in this moment?” This is when the list of self-care activities take on a deeper meaning – a symbol of the self-kindness you are cultivating. I hope that taking this approach helps to reduce your suffering and increase your wellbeing in a more substantive way than discussions of self-care can typically promise to do.

Find other articles on fibromyalgia at the Fibro Bloggers Directory

Go Beyond Self-Care Why We Need To Talk About Self-Compassion Instead

[i] Germer, Christopher. (2009). “Chapter 4: What’s Self Compassion?” in The Mindful Path to Self-Compassion. Guildford Publications: New York.

[ii] Neff, Kristin. (2012). “The Power of Self-Compassion.” Psychology Today. Retrieved September 1, 2019 from https://www.psychologytoday.com/ca/blog/the-power-self-compassion/201207/the-physiology-self-compassion

[iii] Brach, Tara. (2003). “Chapter Two: Awakening From the Trance” in Radical Acceptance. Random House: London.

[iv] Salzberg, Sharon. (2011). “Introduction.” Lovingkindness: The Revolutionary Art of Happiness. Shambala Publications: Boston.

[v] Carson, JW et al. (2005). “Loving-kindness meditation for chronic low back pain.” Journal of Holistic Nursing: 23(3): 287-304.

[vi] Chapin, Heather et al. (2014). “Pilot Study of a Compassion Meditation Intervention in Chronic Pain.” Journal of Compassionate Health Care 1(4).

[vii] Fredrickson, Barbara. (2008). “Open Hearts Build Lives: Positive Emotions Induced Through Lovingkindness Meditation Build Consequential Personal Resources.” Journal of Personal Social Psychology 95(5): 1045-1062.

Forget Picture Perfect: How Photography is Teaching Me Perspective on Grief, Stress & Illness

I haven’t posted in awhile because I’ve been coping with some health issues that, well, I’m not ready put pen to paper and write about yet. It’s reminded me that grief over illness loss comes in waves, and isn’t limited to the onset of a condition. Body breakdowns fluctuate over the course of an illness. And limitations affect you differently at different stages of your life. In my 20s it was career and in my 30s it’s been more about family.

I’ve been trying to find those small, good moments and really appreciating them, whether they’re beautiful, or joyful, or hilarious, or super interesting. Not perfect moments. Waiting for those would be like waiting for pigs to fly. I’ve noticed that when something good is happening, I worry that it will be hijacked by…pain, fatigue, stress, GI issues (etc.,etc.,etc.) I’m constantly vigilant, waiting for another flare-up to make me cancel my plans or a painsomnia night to make me scrap my daily to-dos. Those may not sound like very serious problems to someone without a chronic illness. But never being able to accomplish anything makes you doubt your self-worth, especially in our productivity oriented culture. Disappointing the people you care about most threatens your greatest vulnerability, which is losing your community– losing love.

But hyper-focusing on what is bad won’t protect me from a flare or another illness-related loss. But it might prevent me from truly enjoying what is good, like getting a big hug from my husband when he comes home from work, or seeing a butterfly landing on a purple coneflower inches away from me.

I was missing out on those things because my mind was always probing each situation for how it could go wrong. Of course my brain was only trying to protect me, but it wasn’t making me any happier…or safer. I started photographing flowers on my daily walks as a way to stay mindfully present in the moment. (A very literal interpretation of the proverb to ‘stop and smell the roses’! Sorry, couldn’t resist). Each blossom feels like one counter-weight against whatever is bad or negative that day.

Once I started really looking I saw an abundance of opportunities to appreciate simple pleasures. And trust me, I’m still hurting over my losses. This is not me preaching that ‘thinking positive’ will make life all sunshine and rainbows. In fact, I started seeing a therapist earlier in the summer because I wasn’t coping well with recent losses. It felt like my illness were determined to take away every dream I’d ever had for myself. Not just ‘felt like’- my illnesses have taken away the possibility of fulfilling my old dreams. That is still heartbreaking.

But it doesn’t mean that nature isn’t still beautiful. It is. Sharing love still feels so good. Eating a great meal or laughing till I cry still makes my day. And discounting those moments because they aren’t perfect or are side by side with sad or difficult moments just gives more power to my illness, and just allows it to rob me of more of my life. But I won’t let that happen anymore.

Meditation has taught me how to concentrate on one thing, like breathing, while distractions go on around me, like sounds or random thoughts arising. Learning how to gain control over what I pay attention to has been life changing. Like a spotlight, I’m gradually getting better at focusing on good moments and putting them center-stage, while leaving the bad, like pain or worry, in the wings. It’s a skill, not a a one-time epiphany.

Photographing flowers has helped me keep perspective on my illness-related, by keeping the good as well as the bad in the frame. My therapist explained that being on a hair-trigger, ready to activate the fight-or-flight stress response adrenaline rush, or alternately, shut-down and numb-out (to horribly butcher several metaphors), is the natural byproduct of trauma. Chronic illness is traumatic. So finding ways of lowering the threshold for activating the stress response is really important for managing the mental health side of illness.

Natural beauty is a powerful healing force for me. I hope these pictures offered a moment to smile about today for you, too.

Surviving Summer: Tips You Haven’t Thought Of Yet To Help You Manage Your Illness In The Heat

 

Surviving Summer

Summer time is here. After a chilly spring, it’s finally sunny and H-O-T.  We usually associate this season with fun and relaxation. But for many people with chronic pain, the heat and humidity of summer weather only means an increase in their pain levels. If I step outside on a scorching summer day, with the sun beating down, it only takes a few minutes before I feel fatigued, and lightheaded.

What Causes Increased Pain in the Summer?

Chronic illnesses like fibromyalgia (FMS) are affected by summer weather. People with nervous system sensitization or disruption have trouble regulating their body temperature, especially when exposed to weather extremes (hot or cold). Specifically, exposure to hot temperatures can lead to muscle pain, headaches, and worsened fatigue. Excessive sweating can lead to dehydration and loss of electrolytes, which also contributes to muscle pain, headache, fatigue and other symptoms.

Joint pain can be worsened by summer weather, like high humidity or low pressure systems, which cause summer storms. Joint pain is a symptom of several types of arthritis, which commonly co-exist with fibromyalgia.

Did you know that there are sensory nerve receptors in your joints that detect changes in barometric pressure? They are called ‘baroreceptors’. High humidity or low pressure conditions can trigger baroreceptors, causing uncomfortable pressure in your joints. You may feel this as tightness or stiffness in your joints. Dehydration can also reduce the fluid in your joints. Since joint fluid helps to lubricate movement, less fluid can lead to more pain.

Insomnia is another significant cause of increased pain in the summer (often called “painsomnia” in the chronic pain community). It can be difficult to sleep during hot summer nights. Many studies show that poor quality sleep causes increased pain levels. Keeping cool at night is a top priority for people with chronic pain.

Finally, people tend to be more active during the warmer months of the year. Summer invites activities like walking outdoors, picnics, and swimming. Special events often take place in the summer, like weddings, national holidays, or vacations. Exerting yourself more than usual during this season can increase your pain levels.

Strategies for Pain Management in Warm Weather

Kick Dehydration to the Curb: You already know that, in the summer, it’s even more crucial to drink your eight glasses of water a day. You lose more water from your body through perspiration in warm weather. It’s important to replace that water so you don’t become dehydrated. Dehydration can lead to headaches, muscle cramps, fatigue and heat exhaustion – which can all exacerbate fibromyalgia symptoms.

But Don’t Forget Electrolytes: an often forgotten aspect of dehydration is replacing electrolytes lost by sweating. Electrolytes are substances that carry an electric charge and are responsible for nerve and muscle function, and regulating blood pressure, blood pH and other vital bodily functions. Electrolytes include sodium, potassium, calcium and magnesium. You might think of sports drinks like Gatorade as the best source of electrolyte replacement, but these drinks cause their own problems. The added sugar will only cause energy crashes after the initial sugar high, as well as long term harm to your liver, pancreas, and teeth.

Did you know fruit is an excellent natural source of electrolytes? Try making your water more hydrating (and tasty) by infusing it with fruit. Fruit-infused water is made by putting fruit into a pitcher of water and letting it soak for several hours or overnight. Think strawberry, lemon and basil water or watermelon and mint water, among other recipes. Try to use organic or well-washed fruit to avoid any pesticide residue. Put a small pinch of sea salt for additional electrolytes! Coconut water is another excellent source of natural electrolytes and can help replace lost potassium and sodium. Use it in your fruit-infusions or drink it on its own. You might be thinking “so why don’t I just drink juice?” Most juices contain the entire amount of daily sugar a woman is recommended to have in one glass! Instead of raising insulin and blood sugar levels, and then crashing later, fruit infused water contains far less sugar.

Carry a water bottle with you so that you can stay hydrated throughout the day. If you don’t like plain water, or haven’t infused it with fruit, try adding  lemon or cucumber to plain iced water, or making iced tea (think herbal or de-caffeinated if making a large pitcher).  Avoid more than 1 to 2 cups of coffee, because caffeine is diuretic, which can worsen dehydration. Ditto with alcohol.  If you have trouble remembering to drink water, try to tie this new habit to something you routinely do, such as having a glass of water before each meal, as well as when you wake up and go to bed.

Stay Cool on the Go: try a cooling fitness towel when you are out and about. When wet, these towels are designed to feel cooler than the air temperature, and  provide relief from the heat (but don’t drip). They can also wick away moisture from perspiration. Run the towel under cool water, put it around your neck, and feel cool for 2-3 hours.

One of my favorite gadgets is a mini USB fan that can plug into your smart phone! This helpful little fan plugs into your phone (where the charger goes) or power bank and provides instant relief for your face and neck in the heat. They typically weigh less than an ounce! This is such a life saver in a hot waiting room, vehicle or sidewalk. You can also buy chargeable electric handheld fans to take on the go.

Stay Cool at Home: it’s important to try to maintain a constant, cool temperature during a heat wave. You already know that air conditioning and fans can help to maintain a cooler indoor temperature.  Put a damp cloth in the freezer for several hours and then wipe your face, neck arms and legs with it to cool off.  Applying an ice pack to the back of your neck or the inside of your wrists can also help. If humidity worsens your pain, consider running a dehumidifier in your home. The temperature can be less of a factor causing your pain than dampness in the air, especially if your have joint pain. Blackout blinds are vital for keeping your bedroom cool for resting on hot summer days.

Sun Protection: this is key to avoid flare-ups that could be caused by sunburn or heat exhaustion. Try to stay out of direct sunlight, use sunscreen, and wear a hat; basically everything your mother told you to do in the summer. Sun protection clothing that blocks harmful UV rays can really help to lower the risk of sun burn and heat stroke. UV protection sunglasses can also help reduce the impact of brightness on your eyes, which is a migraine trigger for some.

Last summer I finally admitted that I needed more protection because I felt instant fatigue from the sun beating down on me every time I stepped outside. So I went online and found a UV protection umbrella, with a pretty floral pattern, that I use as a modern day parasol! It may look a bit eccentric, but I feel pretty pleased with my choice when I’m walking beside my husband (who is too manly to use a parasol),  while he squints and perspires from the heat!

Replace Heat Therapy with Cold Therapy: if you routinely use a heating pad for your pain, try replacing it with an ice pack, especially during a heat wave!

Pacing is particularly key during the increased activity levels we often associate with summer months. With the additional physical stress from heat,  it’s especially important to stick to your boundaries, no matter what expectations friends or family members may place on you.

Consider an Activity Tracker: I find a wearable actually tracker quite helpful for making sure I don’t overexert myself. It can be difficult to compare different activities, like a neighbourhood walk with an afternoon by the beach. Knowing how many steps I’ve taken helps me to pace myself during the day.

 Log Your Symptoms: if you are unsure what effect the weather has on your pain levels, try keeping a daily log of the temperature and weather conditions, along with your pain levels. This might help you to identify pain triggers. You can also note any strategies you have tried to reduce your pain levels, and what impact they may have had. Overtime this will help you to identify more effective solutions for coping with pain in the summer months.

Resources

Everyday Health (7 Smart Summertime Pain Solutions)

Everyday Health (Managing Fibromyalgia in the Heat and Humidity)

Metropolitan Pain Consultants (Summer Joint Pain: The Impact of Hot Weather)