A new study shows that terpenes, which cause that skunky cannabis smell, might be good for pain relief. The pungent smell and taste of cannabis is caused by aromatic compounds called terpenes (essential oils are also rich in terpenes, which causes their unique scents). Terpenes are distinct from cannabinoid compounds like THC or CBD. Researchers at the University of Arizona Health Sciences studied the pain relieving effect of 4 cannabis terpenes, used individually, and in combination with a synthetic cannabinoid agonist, which stimulates the body’s natural cannabinoid receptors.
This study found that when the terpenes were given along with the synthetic cannabinoid agonist, they amplified its pain relieving effect. Scientists were interested in the hypothesis of an entourage effect, which suggests that terpenes work synergistically with cannabinoids like THC and CBD to boost the pain relieving efficacy of cannabis. Cannabinoids bind to cannabinoid receptors, which stimulate nerve signals, that in turn trigger physiological changes, including dialing down pain sensitivity.
Interestingly, when the terpenes were isolated and given individually, they mimicked the effect of cannabinoids! All four terpenes activated cannabinoid receptors, which usually bind to THC. In fact, other plant compounds have been found to act on cannabinoid receptors, and these compounds are said to be cannabimimetic. “Cannabimimetic [compounds], can… play a role in immune-mediated inflammatory and infectious diseases, neuroinflammatory, neurological, and neurodegenerative diseases, as well as in cancer, and autoimmunity.”**
This recent study adds support to the entourage effect theory. It builds on previous research, which has has shown that terpenes also have anti-inflammatory properties. If you use cannabis for pain, look for “full spectrum” extracts, oils, edibles or vape cartridges because these include terpenes. Sometimes terpenes are removed from extracts to eliminate the skunky aroma/taste. Of course, if you smoke or use a vaporizer, the original bud is naturally full-spectrum.
Reference:
LaVigne, J.E., et al. (2021) Cannabis sativa terpenes are cannabimimetic and selectively enhance cannabinoid activity. Scientific Reports.
The Evidence: Fibromyalgia may be an autoimmune condition
In a paradigm shifting new study, researchers were able to trigger fibromyalgia symptoms in healthy mice by injecting them with blood from fibromyalgia patients. Specifically, scientists injected the mice with IgG antibodies from individuals with fibromyalgia in England and Sweden.
IgG antibodies (immunoglobulin G) are immune proteins that attach to foreign substances so the immune system can neutralize them. IgG antibodies recognize and target pathogens and toxins. Sometimes rogue IgGs, called autoantibodies, turn against our own bodies, and are directed against our own tissues, like joints or organs, which is what characterizes autoimmune disorders.
When IgG antibodies from fibromyalgia patients were injected into healthy mice, the mice developed fibromyalgia-like symptoms, such as an increased reaction to pain, less physical activity, and reduced muscular strength. After two weeks, once the IgG injections wore off, the fibromyalgia symptoms experienced by the mice reversed. In contrast, IgG injections from healthy people into mice did not cause any symptoms. Importantly, injecting mice with blood from fibromyalgia patients that had been filtered free of IgG antibodies also had no effect on pain sensitivity in the mice.
From these results, the researchers concluded that “fibromyalgia pain is caused by IgG autoantibodies,” and is likely an autoimmune condition. This is a profound change in how we understand and treat fibromyalgia.
But how do IgG antibodies trigger fibromyalgia pain?
The answer lies in where fibromyalgia IgGs appeared to target their activity in the body – the nervous system. Researchers examined tissues from the mice that had been injected, and detected fibromyalgia IgGs in specific nervous system cells that affect sensory nerves. In order to understand these findings, let’s define a few areas of the body:
Sensory neurons are nerve cells that carry information about sensations, like temperature, pressure, or pain.
Glial cells support, protect and take care of nerve cells by providing structural support, insulation, and nutrients, as well as modifying nerve signaling.
A dorsal root ganglion is a cluster of neurons around the root of a spinal nerve, just outside of the spinal cord. The cluster includes sensory neurons carrying information from the body to the spinal cord. Glial cells in the cluster form a layer around the cell bodies of these sensory neurons.
In this study, the researchers primarily discovered fibromyalgia IgG antibodies in glial cells of the dorsal root ganglia (the support cells in the cluster of sensory neruon cell bodies).
This finding means that fibromyalgia IgGs target glial cells that support and regulate sensory nerves, sensitizing them to pain signals. In other words, the immune system has gone haywire, and IgG antibodies are being directed against sensory nerve structures carrying pain signals. Hyperactive sensory nerves send more intense and frequent signals communicating the presence of pain.
But this isn’t the first time a discovery like this has been made. “Autoimmune pain” is a new term that describes how specific IgG antibodies can target different nerve structures, causing sensory nerves to become hyper-sensitive to pain and other sensations. But autoimmune pain has never previously been linked to fibromyalgia.
Putting this all together, fibromyalgia may be an autoimmune condition in which specific IgG antibodies target glial cells in dorsal root ganglia, causing the sensory neurons supported by the glial cells to become hypersensitive to pain.
How will this discovery change future research and treatments for fibromyalgia?
As a disorder of the immune system, a number of new treatments will open up for fibromyalgia that have previously been used for other autoimmune conditions. As we saw in the mouse study, the depletion of fibromyalgia IgG antibodies (once the human IgG injection stopped) reversed fibromyalgia symptoms. Theoretically, treatments currently used for autoimmune conditions like myasthenia gravis, which filter out the amount of IgG antibodies circulating in your bloodstream, could reduce fibromyalgia symptoms! “Plasma exchange is a dialysis-like procedure that is performed on a patient’s vein. An individual is hooked up to a machine that nearly simultaneously removes the blood and puts it back in. The machine “skims” the blood of harmful antibodies. Removing the antibodies prevents them from causing muscle weakness.”
It’s important to remember that this study was conducted on mice, not humans, so much more needs to be done before we can understand or treat fibromyalgia as an autoimmune condition.
Autoimmune pain explains why fibromyalgia is a pain condition without inflammation, because the immune system (IgGs) directly targets the nervous system. The absence of inflammation, a hallmark of most injuries, and pain conditions like arthritis, has historically been used to suggest fibromyalgia is “all in your head” or “psychosomatic.” Studies like this one will hopefully be the nail in the coffin of the doubts about the physical pathology of fibromyalgia – it’s “all in the body!”
Critically, no fibromyalgia IgG was discovered in the brain or spinal cord (brain and spinal cord) tissues of the affected mice, demonstrating that the fibromyalgia pain was caused by the sensitization of sensory neurons in the body.
Previous research has shown substantial alterations in central nervous system activity in people with fibromyalgia compared with healthy individuals. The researchers suggested that the hyper-sensitization of sensory nerves in the dorsal root ganglia, which are located just outside of the spinal cord, could alter nervous system activity in the spinal cord, thereby causing the patterns of central nervous system characteristic of fibromyalgia. However, further research needs to clarify the body vs. brain debate over the mechanisms of fibromyalgia pain processing dysfunction.
Goebel A, Krock E, Gentry C, Israel MR, Jurczak A, Urbina CM, Sandor K, Vastani N, Maurer M, Cuhadar U, Sensi S, Nomura Y, Menezes J, Baharpoor A, Brieskorn L, Sandström A, Tour J, Kadetoff D, Haglund L, Kosek E, Bevan S, Svensson CI, Andersson DA. Passive transfer of fibromyalgia symptoms from patients to mice. J Clin Invest. 2021 Jul 1;131(13):e144201. doi: 10.1172/JCI144201. PMID: 34196305; PMCID: PMC8245181.
Muscle and joint pain are a debilitating part of chronic illnesses like fibromyalgia, arthritis, and M.E., among others. Ridiculously ordinary activities can trigger muscle and joint strains and injuries in people with chronic illness, but have no effect on healthy individuals. I recently went to physiotherapy with neck and upper back pain. I could feel the ropey muscle spasm and trigger knots causing the pain, which just wasn’t resolving. My physiotherapist asked whether I had been taking any hormones, and I was surprised by the question, because it just so happened that I was. I decided to do some research, and what I found frustrated me. How was it that after years of seeing doctors and researching online, no one had explained the connection between the menstrual cycle and muscular pain to me? This is the beginning of a series on hormones and flare ups that I hope will make this information, buried in scientific journals, more widely available.
We know that, in general, women experience significantly more pain and injury than men, particularly mid-menstrual cycle, around the time of ovulation, when estrogen is high. One study found that the risk of muscle and tendon injury in women athletes is almost twice as high around ovulation than at other times in the menstrual cycle.[1] These injuries included “muscle ruptures, tears, strains, and cramps, as well as tendon injuries and ruptures.”[2] Other studies have shown that women experience more anterior (front) knee pain, ACL injuries (torn knee ligaments), and plantar fasciitis foot pain around ovulation.[3]
But why?
The surprising answer may lie in the impact of ovarian hormones like estrogen. During ovulation, when estrogen peaks, the elasticity of ligaments, tendons, and muscular tissue increases, heightening the risk of strain, pain, and injury.[4]
Estrogen & Your Monthly Cycle: Back to Health Class
Estrogen is a sex hormone most well-known for regulating the menstrual cycle, although it also has many other functions in the body too. Hormones enable communication between different parts of the body. When hormones are released, they work like keys that fit into receptors on cells, activating or deactivating specific functions.
Let’s go back to high school health class. Your menstrual cycle begins on the first day of your period. Once your period is over, the ovaries begin to produce eggs in small sacs called follicles. The first part of your period, called the follicular phase, lasts about two weeks on average. Estrogen is released from your ovaries, and this stimulates the lining of the uterus to thicken. Estrogen peaks at the end of the follicular phase, triggering a process that results in ovulation, when one mature egg bursts through its follicle.
During the second half of your cycle, called the luteal phase, which lasts about two weeks, estrogen levels are much lower. If the egg does not become fertilized, then this eventually triggers the uterine lining to shed, which is the beginning of your next period, and the start of a new cycle.
The bottom line – estrogen rises during the first half of your cycle, peaking prior to ovulation, and then falls in the second half of your cycle.
Estrogen, Muscles And Connective Tissue
But estrogen also plays an important role in other parts of the body, including connective tissue like muscles, ligaments, fascia, and tendons. The latest research shows that there are estrogen receptors on these connective tissues.[5] Rising or falling estrogen levels communicate messages to these tissues, triggering changes in their form and function.
During ovulation, when estrogen peaks, the elasticity of ligaments, tendons, and muscular tissue increases.[6]This is also true in pregnancy, when the elasticity of your connective tissues increase in order to expand and make space for a growing fetus.[7] When the connective tissue becomes more elastic, it makes joints like the knee, SI joint, and ankle unstable, increasing the risk for injury.[8]
In contrast, when estrogen levels are low, immediately before and during your period (late luteal and early follicular phase), connective tissues become stiffer and more rigid. In turn, joints are stabilized, reducing the risk for injury. Researchers suggest that some biomechanical pain may improve when estrogen is low and connective tissues are less elastic, stabilizing joints .[9] Women who take the pill appear to have fewer injuries, and more consistent pain levels because their hormones do not fluctuate to the same degree.[10]
Fascia, which is a network of connective tissue made mostly of collagen, encases muscles, organs, nerves, and blood vessels, holding them in place. We know that inflammation of the fascia surrounding muscle tissue may drive fibromyalgia pain,[11] and also, possibly, myofascial (muscle and fascial) pain in other chronic illnesses. Fascia also contains estrogen receptors.
When estrogen is high, the consistency of the fascial collagen changes, becoming more elastic, and stiffens when estrogen is low.[12] Researchers explain that “hormonal imbalance damages myfascial tissue, leading to drastic changes in its constitution in collagen and elastic fibers, and thus modifying its biomechanical properties.”[13] In other words, hormone imbalances may play a role in chronic pain in muscles and connective tissue. It is possible that imbalances in hormones like estrogen may contribute to myofascial pain and injury in women with fibromyalgia and other illnesses. More research is needed to determine the effect of hormone imbalances on myofascial pain.
But even if you do not have a hormone imbalance, the increased elasticity of your muscles and connective tissues mid-cycle can increase your flares.
Track Your Period To Reduce Your Strains, Pains, and Injuries
Tracking your period may help you to understand how your cycle impacts flares of muscle and joint pain, strain, and injury. Over the course of several months, you may notice that your bad knee, low back ache, foot pain, wrist pain and other overuse strains, which chronic illness amplifies, cluster around ovulation. If true, avoiding significant activities around this time, or pacing yourself more, could help to reduce pain related to strains, overuse, hypermobility, poor posture, and injury (biomechanical pain)..
A few days after you ovulate may be the perfect time for a physiotherapy (physical therapy) appointment or massage, to treat ovultion related flares. Since knowledge is power, the more you can learn about which variables most affect your pain and strain levels can put you in the driver’s seat for managing more effectively. Tracking your period and ovulation might be the first step.
There are many period tracker apps that can help you to log your cycle. To work out the length of your menstrual cycle, record the first day you start bleeding (first day of your period). This is day 1. The last day of your cycle is the day before your next period begins. Pinpointing ovulation is a bit harder. If your average menstrual cycle is 28 days, you ovulate around day 14. But this varies significantly from woman to woman and even cycle to cycle.
You can use an ovulation calculator like this one to roughly figure out when you ovulate, which is usually 14 days before your period begins. Recording body changes, like temperature, that fluctuate through the month, can be used to predict ovulation. Or, you can purchase ovulation predictor kits at the drugstore that include urine test sticks to pinpoint ovulation. Learning more about your body and how it works is an empowering step women can take to manage their health.
Works Cited
Fede, C. e. (2019). Sensitivity of fasciae to sex hormone levels. PLoS One, 14 (9).
Liptan, G. e. (2010). Fascia: a missing link in our understanding of the pathology of fibromyalgia. Journal of Bodywork Movement Therapy, 14 (one), 3 – 12.
Fibro fatigue comes in different flavours. Like a wine taster, you become an expert at distinguishing all of the varieties of fatigue flavours. Who knew there were so many? Today, for example, I’m feeling like I pulled an all-nighter and had 5 shots of espresso. All I want to do is lie down and rest, but my body is practically vibrating, it’s so wired. I call it “Twitchy Zombie” fatigue.
Then there is the “Molasses Wader” fatigue flavour. You know, that feeling when every thought and every action feels like it requires the effort you would need to wade chest-deep in thick, syrupy mollasses? You can only function in slow-mo, but everyone else is zipping along on fast forward. Your brain just can’t keep up.
Other times, your brain slows, your breathing deepens, and you drift off to slee- Not so fast! Pain, like a rope tying your boat to the shore, keeps you tethered to wakefulness. You drift out to the outer reaches of consciousness, but can’t make it to dreamland. Often labelled painsomnia, I think of this as the “Hounds of Hell” fatigue flavour, where you are chained like a dog to your own wakeful pain hell-scape.
Another common fatigue is what I call “Nighttime Ninja.” You wake up and your body aches and you feel like you ran a marathon, then partied all night. Or, are secretly a night ninja. But definitely not like you slept restfully on a soft mattress under a cozy comforter.
At most doctor appointments, I’ve been asked to rate my pain between 0-10. It goes like this:
Dr.: How would you rate your pain?
Me: Which one?
Dr. Ummm….Overall.
Me: Like an average of all my current pains right now? Or the worst one I’ve experienced today? Or a median of my pains on a typical day? Or-
Dr.: ???????????
The doctor usually tells you to rate your pain with 0 representing no pain, and 10 being the worst pain you’ve experienced in the “pain numeric rating scale.” But by asking patients to rate their current pain as one reductive, simplistic overall number, your doctor may miss the multi-dimensional impacts of living with chronic pain.
I’ve Got PainS
Chronic pain fluctuates widely across the location(s) in the body where it is experienced, and over time. Right now I have a 7 in my right SI joint/sciatic nerve, 5 in my right shoulder, 4 in my left pelvis, 4 in my right wrist, 3 in my neck, and 3 in my right foot. In a few hours, those numbers will change completely, and perhaps even become inverted. So knowing how I would rate these pains in this moment doesn’t really indicate anything about the clinical significance of the pain. For example, I experience my most significant pelvic pain at night, so asking me to rate it at my afternoon appointment will not accurately reflect the severity of the pain. Intermittent pain, breakthrough pain, and pain flare-ups are not captured in present moment pain ratings. It would be more accurate to record each pain over a week or month in a pain journal, to see how each part of my body is affected over time.
If you’re trying to understand the cause of pain, the knowing its quality or characteristics – aching, throbbing, shooting, stabbing, etc. – gives important clues. The 0 to 10 rating scale misses this important aspect of the experience of pain.
Most chronic pain patients have multiple overlapping conditions. You lose the ability to understand and treat these very different issues when you ask the patient to lump all their pains together and give one overall number. My pelvic pain and sciatic pain is neuropathic, the shoulder, wrist and neck pain is muscular, and my foot is mechanical pain from uncomfortable positioning. The doctor cannot determine how a treatment is affecting the pain levels of a specific condition, such as endometriosis vs mechanical joint problems vs neuropathy, if you average all body pains together.
My Pain Isn’t Your Pain Isn’t My Pain
Or being the worst you can imagine. These are two very different 10s. Since the onset of my chronic pain, I’ve experienced worse pain than I ever could have imagined in my life before illness. And now, I can imagine the worst pain I’ve ever experienced expanding to affect every part of my body, and it fills me with terror. In other words, my ‘worst pain I can imagine’ 10 has been recalibrated by my experience of having chronic pain. You can’t really compare these two 10s to each other, given how subjective and experiential pain is. Comparing 10s between patients only multiplies these discrepancies and confusion.
You are asked to rate pain between 0-10, where 10 is the worst pain you’ve experienced. Or 10 is the worst pain you can imagine. These are two very different 10s. Since the onset of my chronic pain, I’ve experienced worse pain than I ever could have imagined in my life before illness. And now, I can imagine the worst pain I’ve ever experienced expanding to affect every part of my body, and it fills me with terror. In other words, my ‘worst pain I can imagine’ 10 has been recalibrated by my experience of having chronic pain. You can’t really compare these two 10s to each other, given how subjective and experiential pain is. Comparing 10s between patients only multiplies these discrepancies and confusion.
Missing The Impact Of Pain On Daily Functioning
Why are we rating pain at all? In order to evaluate the severity of pain as a symptom on the health and daily functioning of a person. Put differently, we rate pain in order to evaluate its clinical significance, which can be defined as ” (1) pain that interferes with functioning and (2) pain that motivates a physician visit” (Krebs et al., 2007).
One study assessed the primary care pain numeric rating scale as a screening test for accurately identifying clinically significant pain in patients seeking treatment at a primary care clinic. They found that it was only modestly accurate, and it “missed [identifying] nearly 1/3 of patients with clinically important pain” (Krebs et al., 2007).
The core failing of the pain numeric rating scale is that it completely misses the impact of pain on daily functioning. And in doing so, it misses the clinical significance of pain in the lives of patients. In the 2007 study, they compared the 0-10 pain ratings with ratings from an alternative pain assessment tool called the Brief Pain Inventory interference. The BPI “measures pain-related functional impairment in seven domains: general activity, mood, walking ability, normal work, relations with other people, sleep, and enjoyment of life” as a rating between 0 (does not interfere) to 10 (interferes completely)” (Krebs et al., 2007). They found that the pain numeric rating scale missed almost 30% of patients which the BPI showed had pain that significantly interfered with their daily functioning.
How To Make An End Run Around the 0-10 Scale At Your Appointments
Always list the worst pain you have experienced today, or this week, not the current pain, or the average of current pains.
Make comparisons like, “it’s worse than when I broke my finger” or “it’s worse than when I was in recovery coming out of surgery.”
Don’t go with 10 unless you are in a crisis where you pain is about to kill you. Unfortunately, credibility, involves not saying “15 out of 10”, because pain patients are not given grace or understanding.
Do give pain descriptors like aching, burning, shooting, stabbing.
Make a list of the limits on your daily functioning caused by your pain, like, “My neck pain is so bad I can no longer hold a book and read more than 1 page.”
Bring a pain journal you’ve kept over the past week, and a list of your worst pain levels, your average pain levels, in all your pain areas, and what limits these impose on your life.
Krebs, E. E., Carey, T. S., & Weinberger, M. (2007). Accuracy of the pain numeric rating scale as a screening test in primary care. Journal of general internal medicine, 22(10), 1453–1458. https://doi.org/10.1007/s11606-007-0321-2
Walsh, John (2017, Jan 10). How Much Does It Hurt? Independent. Retrieved from:
You’re sitting in the doctor’s office, being told you have an incurable illness. Maybe you have to leave your career, or pull back on your workload, with set accommodations. You can’t live up to being the involved wife, parent, sister or daughter you planned on being. Travel become difficult, athletic ability falls off, and favorite hobbies or pastimes become more challenging. But mostly you just don’t feel like you. A period of grief ensues over your previous life, and it crashes over you in waves.
Eventually you start asking the big questions. Can you live a good life despite pain? How do you find meaning again amidst all the change?
I don’t have THE answer, but I did find some answers. Why is something sustaining, nourishing, enjoyable? That’s what I had to ask myself in order to find meaning again. I came back to the saying, “A life well lived is a life fully experienced.”
I was very career focused B.F., finding satisfaction in the field of global health (HIV/AIDS prevention and treatment). Once all that stopped, I felt stuck and lost. The one thing I had been certain of, my “calling”, was gone. Making a difference through my career had given me a sense of purpose.
Before fibro, travelling was one of my favorite activities. Experiencing different cultures and ways of life was important to me because it had made my own worldview expand. Broadening my horizons made me feel vital and alive.
How to replicate that feeling from my couch at home? Can you broaden your horizons from home? Yes! By learning something new. On the traveling theme, free virtual live tours from local guides in English in Heygo are a lovely way to spend an hour. Time that feels spent on rewarding things makes it meaningful.
Learning via podcasts and audiobooks during my enforced rests turn a limitation into an adventure. I’ve found I enjoy learning about history, as a way to travel from my armchair. (I’m a 🤓). Learning feels like time well spent, whether it’s listening to a historical mystery or an episode of a podcast on ancient Egypt. After all, curiosity keeps your brain healthy and young. What do you geek out about? It can be anything, from an academic subject, to a hobby, to DIY project techniques. Intentionally find ways to learn about things you find interesting, from online classes, podcasts, audiobooks, or just connecting with interesting people online and asking them questions.
Over time I came to see that there is a lot of life to live here, in ordinary life, without globetrotting or being career driven, which is what I believed at 20. But in learning to be mindful and still, I’ve found how much I missed before in my search for New Experiences, and how much being present enriches my life. Being on autopilot, or always looking ahead, meant I whizzed past sunsets, birdsong, long hugs, savoured meals, belly laughs and so many other moments. Connecting to the beauty and wonder all around us via our senses is possible, even while in pain, even at home. Finding ways to feel that makes life more worthwhile. Mindfulness as a practice, or just realizing the need to be present, means showing up for moments big, and small. Choose to stay with an experience instead of reaching for a distraction.
And the difficult experiences of chronic pain, surviving the limitations, still mean that you are living fully. I’ve grown in strength, resilience, compassion, self confidence and patience in ways I never would have before my illness. After all, what else really is the point of life other than to become a better, wiser version of ourselves on this journey? This is another way to have a purpose in life. I’ve come to value growing as a person as one of my most important accomplishments, instead of getting promotions, keeping up with the Joneses, or any of the other markers we are taught to measure our success by. Without fibro, I would have let external factors determine my self worth. It’s not that I’m grateful for fibromyalgia, or that I’m glad I have it, but I have found a way to make meaning out of it, and find a silver lining. I’m developing as I go; it’s a work in progress, but a worthwhile one.
I’ve written before about the critical importance to our happiness of self expression and contributing to something greater than ourselves. We are often taught that the only way to do this is to work and be a “productive citizen.” However, there are so many other ways to find connection, such as sharing your story and finding online relationships, to learn from and support others. Writing on my blog and now writing as a freelancer, has transformed my life. Supporting others online, teaching, mentoring, and sharing your experience are all ways to contribute, big and small.
Fiction writing has engaged me again in a new way through imagination. (I’m writing a historical mystery set in Niagara Falls during the American civil war, when the area was a hotbed of spies and intrigue). Creativity can be a form of salvation, as a craft, an art, music, interior decoration, in the kitchen, the garden, on the page, or anywhere else. We shift into an active mode, not passive mode when creating. Yet we also refrain from intellectualizing, analyzing, number crunching or any other left brain thinking. Creativity is about engaging intuitively, emotionally, and symbolically with the world, through self expression, using the right brain. It’s good for your heart; it’s good for your soul. Don’t disparage it as “unproductive” or unimportant, because it is a meaningful source of intrinsic pleasure. It’s meaningful because it’s a way of being open and engaging with the world around you (sensing a theme yet?), via your senses and interpretations, from your own unique perspective.
We find meaning in our relationships, in our faith and in our philosophies. But we have to be present, open and engaged to really benefit from these resources. That doesn’t happen overnight! But tuning in to our senses, our inner strengths, our creativity, our intrinsic interests and sources of pleasure allows us to connect to the world in ways that create and cultivate meaning in our lives. This is a form of strengths based healing – leveraging your inner resources to create a life fully experienced, and well lived – in spite of adversity.
I think we need a paradigm shift in how we view physical activity and fibromyalgia. Consider what we mean when we talk about ‘exercise’. Usually, it’s defined as a routine program of physical activity to improve fitness. We associate working out with breaking a sweat, feeling our heart pumping and our muscles burning. It’s something you have to push yourself through – just look at all the painful terms were use: whipping yourself into shape, hitting the gym, or burning fat. Fun stuff. Also, not going happen when you live with chronic pain. For most of us, ‘exercise’, defined as above, is a recipe for a fibromyalgia flare-up.
The conventional wisdom gives us s a false choice between “exercising” and being “sedentary”. For the vast majority of us, it seems obvious that we can’t “exercise”, so we resign ourselves to being those much-criticized coach potatoes. Based on my experience living with fibromyalgia for five years, I think there is a third way- focusing on movement.
In Part 1, we discussed how to start with stretching and gentle range of motion activities, like modified yoga, tai chi and qi gong, as the foundation for gently moving more.
Layer on Aerobic Activity
The next step is to begin to incorporate gentle aerobic activities. Research has consistently found that aerobic movement is one of the most effective forms of exercise to reduce FM pain. One expert in the field argues that ” aerobic exercise is the most effective weapon we have” to treat fibromyalgia.[vii] It doesn’t need to be intensive to be effective. One study looked at increasing “lifestyle physical activity”, measured by increasing daily step counts, in patients with FM. The study found that “Accumulating 30 minutes of Lifestyle Physical Activity throughout the day produces clinically relevant changes in perceived physical function and pain in previously minimally active adults with FM”.[viii]
Walking: For many of us, the easiest and most low-cost form of aerobic movement is walking. How you begin walking depends more on where you’re starting from:
If your pain has significantly limited your mobility, the best place to start walking is in your own home. Dr. Allison Bested, an expert in FM, recommends “perimeter walking“, which she explains means “walking just inside the walls of your house or apartment” or “up and down your hallway”.[ix] This is a simple and safe way to begin gentle aerobic activity. Perimeter walking is also a great technique to use when you are having a flare. Even if you’re already able to walk out of doors, when you get stuck at home with a flare-up, you can still include some gentle movement in your day by walking laps every few hours. If balance is a problem, make sure to use any necessary mobility aids.
Start low and go slow. An excellent investment for anyone living with chronic illness is a step counter. You can use a pedometer, a Fit Bit, or an app on your cell phone like Google Fit to count your steps. This will enable you to gently increase your aerobic activity without crashing. Gradually increase the number of steps you take by 10% from your baseline. So if you take 1000 steps per day at the moment, then try adding 100 steps to your daily total. Next week, increase by a further 10%. A step counter will also allow you to compare different outings so that you stay within your limits. I was surprised to discover that a trip to my doctor included all my daily steps. This enabled me to avoid overdoing it by still trying to take a walk after my doctor appointment.
Aquatic Activity: Research shows that aquatic activity can also greatly benefit people living with fibromyalgia. Exercising in water is low-impact but provides gentle resistance, a win-win for chronic pain sufferers.[x] It’s important to only sign up for a low impact class like “Aqua Arthritis” or “Range of Motion Aquafit”. I’ve found some of these classes to be surprisingly intense, so I recommend observing one before you participate. Another alternative is to go “aqua jogging”. Many community pools have leisure or free swim (not lap swimming). If you find a time with only a few other swimmers (call ahead!), you can walk or jog back and forth across the width of the pool. If you are comfortable in the deep end, use a flotation belt so you can walk or jog. It is very liberating to have such easy range of motion in the water, which many of us with FM cannot experience on land.
Housework: Housework also counts! This a great way to avoid crashing, because you can include daily chores as your activity for the day. Of course, this greatly depends on what you’re able to do. But if you are able to dust, sweep or put away laundry on a non-flare day, then make sure to count this as part of your daily activity. The key here is pacing. Try completing only 25% of the activity, then rest, and continue only if you feel able to. Under no circumstances should you push yourself to finish something just because you started it!
Slowly Strengthen
What I was first diagnosed with fibromyalgia, I thought muscle strengthening was an impossibility. After all, just thinking about lifting weights, doing push-ups or anything remotely similar, makes my muscles hurt. Over time, I have realized that gentle strengthening activities are not only possible but one of the best ways to reduce my pain. How do you know if you are ready to begin strengthening? Dr. Bested suggests that “if you’re able to walk for 15 to 20 minutes, it is time to start doing some strength training on a regular basis”.[xi]
If you can, I highly recommend to seeing a physiotherapist (physical therapist), athletic therapist, or a private pilates/yoga instructor. Doing a program of exercises that have been tailored to your abilities/limitations and designed for your specific needs is ideal.
One option is to use one of the at-home instructional videos for people living with fibromyalgia produced by the Fibromyalgia Information Foundation. There is a Strength and Balance DVD and a Pilates routine adapted for FM. The genius part is that the videos demonstrate modifications at three different intensity levels, so you can tailor the routine to your abilities. Personally, I enjoy the Pilates DVD particularly. The Strength & Balance DVD is at a higher level of difficulty and requires specific equipment. http://www.myalgia.com/VIDEOS/Video_Introduction.htm
Dr. Bested recommends an excellent general strengthening program found in the book Strong Women Stay Young by Dr. Miriam Nelson. This program recommends eight exercises that target every major muscle group in the body and describes proper technique in detail to avoid injury, no personal trainer necessary. While this book recommends using free weights, Dr. Bested explains how to adapt the program for FM: start your strength training program by doing only 2 repetitions without using any weights
Break the exercises into upper body and lower body, and alternate them on different days (Upper Body on Mon. & Thurs., Lower Body on Tues. & Fri.) Keep track of when you do them in a journal.
Add one repetition every two weeks, as you feel able.
If you have a flare and cannot exercise for several days, then start at a lower number of repetitions than where you left off, and gently build back up.
My personal two cents: Only add weights if you can comfortably do 2-3 rounds of eight repetitions per exercise, but start back at only 3 repetitions per exercise.
Don’t Forget Balance
Balance is a common challenge for people living with FM. Luckily, there are some excellent resources for improving your balance.
One of the best resources is the Tai Chi for Arthritis program developed by the personable Dr. Paul Lam. This evidenced-based at home program has been shown to relieves pain, improve quality of life and prevent falls by improving balance http://us.taichiproductions.com/dvds/arthritis/12-lessons-free-first-lesson/
You may feel more secure walking with Nordic Walking Poles, and may in turn notice greater improvements in your fitness and quality of life! It’s important to use any mobility aids you need, because safety comes first.
The most important aspect of moving more is to do what you can, when you can. I typically stretch every day. I walk 5-6 days a week for my aerobic activity for about 20 minutes. I do my physiotherapy strengthening about 3x per week. If I have trouble getting out because of a flare, I will do a gentle yoga routine or do perimeter walking in my house.
Change positions often. Because of pain and fatigue, we are often sedentary. However, even the most ergonomic position will cause discomfort after too long. I use a break reminder app that notifies me after 30 minutes of sitting. Ideally, I perimeter walk around my home or do a couple of stretches and then sit down again. This relieves a lot of pain, while contributing to my movement goals for the day.
Don’t push it! I would like to do more yoga and more strengthening, but it can be hard when dealing with constantly fluctuating symptoms. I try to keep guilt out of it. When my inner critic comes out with a negative comment on what I haven’t done, I try to challenge that with an encouraging thought about what I have been able to do. Under no circumstances should you push yourself to finish something just because you started it!
Track Your Progress: One of the best ways to really stick with a commitment to move more is to record what you do in an activity journal. This might be as simple as noting “Stretching”; “3000 steps”, or “Completed Yoga Routine” for the day. You may also want to note any factors, like “increased back pain today”, that affected your ability to move that day. As Dr. Nelson explains “Study after study has shown that if you record your progress in a fitness program, you are much more likely to be successful”.[xii] Keeping an activity journal will motivate you, help you identify connections between movement and symptoms, and make you routines more efficient by helping you to know how much you were able to do last time. Dr. Nelson advises that keeping a log “is probably the single most important step you can take to ensure your success”.[xiii]
Create a Cue: Another technique for keeping a new habit is to link it to another daily activity. For example, I always stretch after I have my morning coffee. Because I know I will never miss my morning coffee, I’m less likely to forget to stretch by linking those two activities. I usually go for a walk with my husband when he gets home from work, so that is another ‘cue’ that I use to remember to walk daily. This may sound simple but it is a powerful way to ensure you stick to your new habit.
Tech Helps: Finally, don’t forget to take advantage of technology. Put timed reminders in your phone to support your new habits or a download a habit tracking app. I like to use a break reminder app that tells me when I have been sitting for too long, so that I can take a few steps or do a stretch. I use a stretch timer app to make sure I hold my stretches for at least 30s. There is a whole wide, wonderful world of apps to help you out and they are especially helpful for those of us with fibro fog!
Works Cited
Bested, A. (2006). Hope and Help for CFS and FM. IL: Cumberland House.
Busch, A. J. (2011). Exercise Therapy for Fibromyalgia. Curr Pain Headache Rep, 15 (5), 358–367.
Fontaine, K., Conn, L., & Clauw, D. (2010). Effects of lifestyle physical activity on perceived symptoms and physical function in adults with fibromyalgia: results of a randomized trial. Arthritis Research & Therapy, 12, R55.
We need to rethink exercise, and focus instead on movement, starting with gentle stretching and range of motion activities. However, there seems to be a persistent [false] belief that if fibromyalgia patients would only get off the couch and exercise, their symptoms would miraculously melt away. This perspective permeates the health care field, from articles on managing fibromyalgia to advice from your ‘helpful’ specialist.
For example, a recent research review notes that “Several exercise studies over the past three decades demonstrated that persons with fibromyalgia are able to engage in moderate and even vigorous exercise”.[i] One research team articulated this point of view further by saying that, while fibromyalgia patients are “worried that [exercise is] going to be painful, [it’s] more of a psychological effect”.[ii] Further dismissing the real pain people with fibromyalgia feel when they attempt to exercise, the researchers went on to compare fibro flare-ups to ordinary muscle soreness: “Starting off too vigorously before building up endurance can be painful for anyone, with or without fibromyalgia”.[iii]
I always wonder – who are these fibromyalgia patients that are going running, hitting the gym or lifting weights at home? These vigorous exercisers seem to be the stuff of researchers’ fevered dreams – unicorns amongst us. But don’t worry, that is not the kind of advice you’re going to get here.
I think we need a paradigm shift in how we view physical activity and fibromyalgia. Consider what we mean when we talk about ‘exercise’. Usually, it’s defined as a routine program of physical activity to improve fitness. We associate working out with breaking a sweat, feeling our heart pumping and our muscles burning. It’s something you have to push yourself through – just look at all the painful terms were use: whipping yourself into shape, hitting the gym, or burning fat. Fun stuff. Also, not going happen when you live with chronic pain. For most of us, ‘exercise’, defined as above, is a recipe for a fibromyalgia flare-up.
The conventional wisdom gives us s a false choice between “exercising” and being “sedentary”. For the vast majority of us, it seems obvious that we can’t “exercise”, so we resign ourselves to being those much-criticized coach potatoes. Based on my experience living with fibromyalgia for five years, I think there is a third way- focusing on movement.
A Gentle Guide for Moving More
What if you forgot about exercise and tried ‘moving more’? Yes, forget about sweating and fat burning and doing reps and whipping… anything.
Movement has been shown to improve fibromyalgia symptoms, but it doesn’t need to look or feel like “exercise”.[iv] So the question becomes, how can you move more without triggering the kind of flare-up you might usually associate with exercise? In order to answer the question, we need to understand what movement really means.
There are actually four types of movement:
Flexibility/range of motion: lengthening tight muscles and moving joints through the full span of movement they are intended to achieve. Includes stretching, yoga, Tai Chi and Qi gong.
Strength: building up the capability of muscles. Inactivity leads to weakened muscles and atrophy -a common challenge for people living with chronic illness.
Endurance (aerobic activity): the efficiency of your heart and lungs to send oxygen-rich blood to your muscles (cardiovascular fitness) and the fitness of your muscles to use that oxygen for continuous activity. Aerobic activities includes walking and aquatic activity.
Balance: having the strength and coordination to prevent falling, especially in the torso and legs. Tai Chi has been associated with fall prevention and improved balance.
Any type of plan to increase movement should gradually include all four elements.
Start with Flexibility: Stretching and Range-of-Motion Practices
Five years ago I had trouble bending forward, which meant I needed help with basic tasks like shaving my legs. I had trouble getting up or down from sitting on the floor. I rarely took the stairs and had trouble walking or standing for longer than ten minutes. Almost all of these limitations were significantly improved by stretching. This makes sense, considering that “Limited flexibility can cause pain, lead to injury, and make muscles work harder and tire more quickly”.[v]
Stretching: I was inspired to begin stretching by a physiotherapist (physical therapist). I had avoided trying to stretch because it was painful. The reason turned out to be simple- I was trying to stretch the way I had pre-fibromyalgia.
The goal for stretching now is to be gentle – only stretch until you feel a slight pull, not a painful burn.
You may need to try different modifications of stretches. Listen to your body and do not push through any pain.
Make sure you breath while you stretch.
Hold each stretch for at least 30-60s for it to be effective.
It’s best to see a healthcare provider like a physiotherapist or athletic therapist for recommendations specific to you. But this can be expensive and there are valuable online guides:
Every morning, I spend about half an hour stretching every major muscle group. Sometimes I repeat stretches during the day if I’m tight in a particular area of my body. Once I started doing this daily, I gradually began to notice improvements in my physical abilities. Now I can get up and down comfortably from the floor, easily bend forward, and do more activities without tiring as quickly. It can help to warm up before you stretch. A warm shower, several laps around your home or applying a heating pad over your major muscle groups can all help. Stretching is foundational to moving more and I encourage you to try to incorporate this practice in your daily wellness plan.
Flexibility and Range-of-Motion Practices: Yoga, Tai Chi, and Qi Gong, are all range-of-motion or flexibility exercises.
Research is clearly on the side of trying these practices to manage your fibromyalgia symptoms. The Oregon Health and Science University published a study in 2010 that compared the impact of an eight week yoga program on FM patients against a control group who received standard FM treatment. Researchers found that “pain was reduced in the yoga group by an average of 24 percent, fatigue by 30 percent and depression by 42 percent”.[vi] Decreases in pain have also been found in studies on the benefits of Qi Gong[vii] and Tai Chi for fibromyalgia.
Many flexibility/range-of-motion exercises programs also share a common feature as mind-body movement practices. “Yoga is a set of theories and practices with origins in ancient India. Literally, the word yoga comes from a Sanskrit work meaning “to yoke” or “to unite”. It focuses on unifying the mind, body, and spirit, and fostering a greater feeling of connection between the individual and his/her surroundings”.[viii] Greater body awareness, stress reduction, emotional balance, and improved energy are all benefits of mind-body exercise programs.
Below is a quick primer on these types of practices so you can pick the right one for you and a link to programs that I have tried and enjoyed:
Yoga: “Yoga involves directing your attention and breath as you assume a series of poses, or stretches”.[ix]
The Fibromyalgia Information Foundation produced an excellent at-home instructional yoga video for people living with fibromyalgia. It includes modifications at three different intensity levels (from seated to standing). http://www.myalgia.com/VIDEOS/Video_Introduction.htm
Qi Gong and Tai Chi: “The term Qi Gong (or chi kung) describes the complete tradition of spiritual, martial and health exercises developed in China. Tai chi is one of the most common of these. Practicing Qi Gong involves performing a series of movements while paying attention to the body and staying aware of the breath. The exercises are especially effective for developing balance, focus, coordination and graceful, centered movement”.[x] Tai Chi for Arthritis by the personable Dr. Paul Lam is an evidenced based at-home program that relieves pain, improves quality of life and prevents falls (also provides a seated program): http://taichiforhealthinstitute.org/programs/tai-chi-for-arthritis/
Part 2: A Gentle Guide to Aerobic Activity, Strengthening and Balance Training When You Live With Fibromyalgia
You may be surprised to learn that research shows some essential oils have medicinal effects that may help improve fibromyalgia symptoms. There are three main symptoms that essential oils can help relieve: anxiety, insomnia/fatigue and pain.
Essential Oils for Stress and Anxiety
Living with chronic pain and illness can be emotionally overwhelming. There are days when I feel anxious over an upcoming appointment, frustrated by the limitations caused by pain and fatigue, worried about the uncertainty of flare-up…and the list goes on and on. Managing stress by making time for relaxation can help you cope with anxiety. There are a number of essential oils that help promote relaxation. For example, according to the University of Maryland Medical Center, “Scientific evidence suggests that aromatherapy with lavender may slow the activity of the nervous system, improve sleep quality, promote relaxation, and lift mood in people suffering from sleep disorders”.[i] Many of the same essential oils used for relaxation can also be used to promote sleep.
One of the best ways to use essential oils for anxiety is through aromatherapy (diffusing the oil through the air and inhaling its sent). Essential oils are believed to work when compounds that are inhaled enter the blood stream and are carried to the brain or other organs. You can use a diffuser, which mists droplets of oil through the air, or an aromatherapy oil burner, which uses the heat from a candle to vaporize the oil. For a very inexpensive alternative, you can put a few drops in the melted wax of a burning candle!
Other oils to consider for anxiety relief include: rose otto, frankincense, clary sage, sweet orange, bergamot, grapefruit, ylang ylang, sandalwood, neroli, sweet marjoram, petitgrain, mandarin, lavender, rose geranium, tangerine, jasmine.[ii]
Essential Oils for Fatigue and Brain Fog
Aromatherapy can also be used to promote energy and mental clarity. Fatigue and brain fog are two of the most challenging symptoms experienced by people living with fibromyalgia. They are also two of the most difficult to treat. I was excited to learn that rosemary oil can help with brain-fog symptoms. According to a recent study, rosemary oil diffused throughout a room helped participants perform significantly better on a memory test than participants in a control room.[iii] This appealed to me because brain fog affects my word recall and short term memory. The refreshing smell of lemon oil and other citrus oils is thought to be energizing. Peppermint and wintergreen oil are also used to improve vitality.
Essential Oils for Pain
Finally, essential oils can help alleviate the muscle pain that is a constant companion for many people living with fibromyalgia. Essential oils relieve pain by improving circulation, reducing inflammation and calming irritated nerves.[iv] The most efficient way to use essential oils for pain relief is through massage. A few drops of essential oil should be diluted in a carrier oil of cold-pressed nut, seed or vegetable oil – approximately 10-12 drops of essential oil in 1 ounce of carrier oil.
Pain relieving herbs include: spike lavender, sweet marjoram, lavender, petitgrain, Roman and German chamomile, clary sage, lemongrass, helichrysum, peppermint, ginger and black pepper. Spike lavender with peppermint and helichrysum creates an anti-inflammatory synergy.
Blending essential oils is a creative art. In general, most floral oils blend well together, as do most woody oils. Massage Today recommends three blends for fibromyalgia[v]:
4 drops of lavender, 1 drop of frankincense, 4 drops of sweet orange, and 1 drop of neroli
4 drops of sweet marjoram, 1 drop of Roman chamomile, 4 drops of mandarin, and 1 drop of rose
4 drops of lavender, 4 drops of rose geranium, 2 drops of rosemary, and 1 drop of lemongrass
I hope the tips here can help you to feel more comfortable and confident communicating about your pain, and setting boundaries with others, so that you can focus on taking care of your health. Explaining pain in words is like trying to translate a word from one language into another, except that there is no equivalent word in the other language with the same meaning.
Chronic pain presents significant communication challenges for our relationships, such as needing to constantly cancel plans or having to ask for help. After all, relationships can be tricky enough without the additional complexities of living with chronic pain!
Communicating With Your Doctor About Your Pain
Doctors often attempt to simplify the problem of describing pain by asking patients to rate their pain on a number scale out of ten. Personally, I find this frustrating because one number cannot capture the whole picture of what my pain feels like. When I researched this topic I found a great tool, called the LOCATES scale (Health), for overcoming this challenge. It provides a framework for explaining all the dimensions of chronic pain:
L: Location of the pain and whether it travels to other body parts. O: Other associated symptoms such as nausea, numbness, or weakness. C: Character of the pain, whether it’s throbbing, sharp, dull, or burning. A: Aggravating and alleviating factors. What makes the pain better or worse? T: Timing of the pain, how long it lasts, is it constant or intermittent? E: Environment where the pain occurs, for example, while working or at home. S: Severity of the pain. Use a 0-to-10 pain scale from no pain to worst ever.
Try writing out your answers to each corresponding letter before your next appointment and share them with your doctor. I hope it helps you feel like you’ve communicated all of the dimensions of your pain!
Communicating With Your Loved Ones About Your Pain
When it comes to friends and family members, pain is a thorny subject. Chronic pain causes stress and heightened emotions. It’s completely natural to snap or get upset during a difficult conversation when you’re in pain. Sometimes just letting your loved ones know how you’re doing that day can help them adapt accordingly. You can try to use the LOCATES scale with your family members to help them understand more fully what you are experiencing.
The Chronic Pain Couple recommends “logging your daily pain levels in a pain app, [then] screenshot and text the daily summary to your partner before they get home from work…This will help your partner understand what your physical capacity is so that they can adjust their expectations of you accordingly.”
Sometimes family members or friends may doubt that your chronic pain is real, criticize how you handle your pain or even accuse you of being lazy if you have to cancel plans because of pain. Even the most supportive people can sometimes be insensitive or say the wrong thing.
I’ve found that knowing how I want to handle different communication challenges associated with chronic pain ahead of time is helpful to improving my communication with the important people my life.
De-escalate Tension to Express Yourself Clearly
Feeling like you aren’t being heard or that you are being judged when you communicate about your pain is frustrating. On top of that, it’s difficult to express yourself clearly when you are hurting and feel emotionally reactive or defensive.
One way to de-escalate tension and have a more productive conversation is to take a pause before responding to an upsetting comment. The first step is to notice that you feel angry, hurt or upset. If identifying the feeling is tricky, look for physical cues of emotional reactivity – clenched jaw, stomach knot, tight chest, constricted throat or increased heart rate. Then intentionally take a pause until you feel ready to respond from a place of self-awareness. This could be as short as counting to 10 or as long as waiting until your pain flare has passed to continue the conversation. Sometimes I find going into another room and taking a short mindful meditation break (focusing on my breath for three minutes) really helpful.
Dealing With Unwanted Advice
In my experience there are two types of advice: well-meaning suggestions from someone who genuinely wants to help and judgmental statements framed as “advice.” In responding to the former, I like the advice from Live Plan Be: “The key is to find ways to respond to others that don’t drain you or get you riled up… You can give them a positive response without agreeing or committing to follow their advice.” An example might be “Sure, I’ll keep that in mind.”
Dealing with judgment in the form of advice (“maybe if you got off the couch and exercised more then you would feel better”) is another story altogether. Rather than feeling the need to explain yourself, and going around in circles, it’s best just to be direct and say politely that you aren’t interested in their advice: “When it comes to my health, it’s important to me that I do what I think is right. When you tell me what you think I should do, it’s not helpful to me. It would mean a lot if you would not do that anymore.”
Establishing Boundaries And Sticking To Them
Setting healthy boundaries is good for everyone, but it’s particularly important for people with chronic pain. The reality is that we face physical limitations, and pushing them has severe consequences in the form of pain and fatigue. It can be hard for the people around us to accept these limitations and to not take them personally. These limitations can put a strain on our partners and families, whose lives are also changed by our chronic conditions. The urge to avoid disappointing people is hard to resist and learning to put your health needs first is a difficult transition for many of us. But speaking up is important for your health and well-being! There are many positive personal benefits that result from learning to advocate for yourself, like greater self-confidence and agency, feeling more centered, and feeling that you are living with greater authenticity.
If possible, try to make a request to set a new boundary in a constructive way. Ask in a calm but firm manner, at a time when the other person is more likely to be receptive. When you clarify a new position in a relationship, speak in terms of “I” rather than “you” to minimize defensiveness on the part of the other person. It’s important you also stick to the boundary you have set, otherwise it’s unlikely the other person will too. Live Plan Be suggests a helpful tool for setting boundaries called the ‘Feedback Formula’:
When you … call me at 11pm at night (describe the person’s behaviour),
I feel… upset and frustrated (describe the emotion you feel),
and the result is…my sleep is interrupted, and it that increases my pain (describe the effect of you experiencing that emotion).
Would you be… willing to call me before 8pm instead?” (make your request).
In this example, after setting the boundary, don’t answer the phone after 11 pm, in order to reinforce the line you have drawn.
Ultimately, there’s no way to express yourself perfectly in every situation, and you aren’t to blame if other people can’t or won’t listen. If someone protests the boundaries you have set, try to remember that it’s their problem, not yours. It’s just further proof that the boundary line is needed. Focus on nurturing your healthy relationships, and put toxic relationships on the backburner. “Remember, you don’t need to apologize for setting good boundaries that help you stay healthy, manage your symptoms, and feel your best while living with chronic pain” (My Chronic Pain Team).
Hopefully these tips can help you communicate more clearly about your pain, and establish boundaries with others, so that you can prioritize your self-care.
Skillfully Well & Painfully Aware 