You may have problems with regulating yourself and your emotional states.  You may also have pain issues.  All these difficulties can combine and be very hard to untangle.  This clip is a little bit about my horses shifting between anxiety and curiosity as they explore leaving the barn for the yard near my horse trailer.  They knew the plan was likely about going riding somewhere.  The two horses have different attitudes about coming out into the yard and staying near the trailer.

I shortened a 45 minute period into 5 and a half minutes, so you can see a little bit about using the idea of stress ramping up and stress ramping down, approach and retreat concepts, and some of the idea of pacing.  I let my horses take a long time to decide that they wanted to come out into the yard.  This was an exercise for my horses in exploration within a certain amount of boundary.

People also experience a dynamic between anxiety and retreat, and curiosity and exploration when facing situations that are challenging.  A therapeutic approach for people and horses too, is to find a way to scale the challenge to a manageable amount.

Here’s the link to a video instruction  on regaining movement  in the region just below the head.  If this area is really tight, you will substitute movement in other parts of your neck. Lack of movement in this area, can be part of headaches, upper neck pain and pain lower in the neck.  Loss of movement here can come on from a number of causes including habit, accidents, posture, computer use, medical procedures or dental procedures when your head must be turned to one side for a long time.  It can also occur if you use one eye more than the other, or one ear more than the other.

This part of the body is called the suboccipital region.  The head bone in the back of your head is called the occiput.  Many very strong muscles attach from the occiput to the neck.  some muscles are long, like the Upper Trapezius, and others are very short and deep.  The short and deep muscle group is generally called the suboccipital muscles.  These are just lots of fancy ways to name the muscles below the skull.

One important goal in decreasing back pain is to get your individual spine segments moving.  It’s an uphill battle however in the presence of arthritis, degenerative changes, narrowing (stenosis) and nerve pain (sciatica).  This simple “exercise” really helps because it triggers your spine segments to move while you rest and take the load off your discs. Take an ironing board, yes, really, an ironing board, standard model cross leg pattern.  Collapse the legs and put it on the floor.  Pad the top with a blanket.  Now lie down slightly offset from the middle. Legs are usually  best with knees bent. The idea is to help your low back flatten on the board while the board is in a tip.  The ironing board will tip surprisingly more than you would have expected.  Stay tipped one way for 5-7 minutes, then slide over so you tip the other way for 5-7 minutes.  Do this once a day.  In 10 sessions or less you’ll start to notice better spinal movement and increased comfort. Use this on an ongoing basis to help maintain motion in your back.

“That ironing board is a great idea.  It really helps.  I notice that my vertebrae get looser and I can help manage the numbness I get from my nerves”

If your back is stiff, lacks movement, and gives you pain, you may benefit from the gentle movement this exercise triggers.  Here’s the link to the video on youtube.

http://www.youtube.com/user/BoulderPT?feature=mhee#p/u/1/2EH4mc3-dnU

If you have problems with turning your ankle or pain in the muscles of your foot, this video guided stretch can help you with your foot problems.

Here’s the link:   http://www.youtube.com/user/BoulderPT?feature=mhee#p/u/0/K7FGDZ6UFiU

Using principles from a trauma treatment method, called Somatic Experiencing, and a new, gentle Physical Therapy method called Sensory-Motor Manual Therapy  you can make gains in recovering from RSD/ CRPS pain.  Some clients have a full recovery.  Some clients have significant but not a full recovery with these methods.

RSD/CRPS stands for Reflex Sympathetic Dystrophy and the newer term is Complex Regional Pain Syndrome. This condition is characterized by a range of pain that at it’s worst can be utterly severe, constant, and debilitating.  The pain may be characterized by burning, pressure, sense of a limb being absent but at the same time in severe pain. Typically a person with RSD/CRPS cannot stand for someone to touch the affected area.

Every case is different and must be addressed in it’s own unique way.  However, that being said, there are often issues that are common to this condition.  One of the common problems is moderate to extreme changes in sensory perception.  Also there are changes in muscle control.

A unifying principle in RSD/CRPS is extreme disconnection from the body part(s) affected. This is what drives the amazing range of sensory distortions that are part of this condition.  For example it’s not uncommon for someone to feel like they have only 2 or 3 toes or fingers. Body parts may be experienced as being an abnormal size, and like wood. Movement if present may  be accompanied by the sensation of not moving and/or inaccuracy in position sense.

In traumatic stress language this is called dissociation.  In the field of psychology, the term dissociation tends to refer to a person’s identity or sense of self.  A person can become numbed out, have reduced sensations, and disconnect from their relationships. RSD/CRPS is in many ways bodily dissociation of an extreme nature.

Another term for dissociation is a freeze response.  We tend to think of a freeze response as a whole body reaction like the deer in the headlights that gets stuck in place.  Another example is a turtle burying itself in it’s shell.  Imagine though, being a turtle with only one arm or leg stuck in the shell and no way to communicate to the limb to get it back into normal function.

Here’s an example of this situation.  I once had a client come to me who had RSD/CRPS in her right arm. She went into a 40 degree below zero freezer at work in everyday clothes and the door stuck and wouldn’t open. With no way to call for help she had to save herself.  Recognizing that she’d be dead if she didn’t get out fast she pounded on the door with her right hand until she got free. She didn’t give up and succumb to the inevitable.

She mobilized enormous amounts of energy, like a mom lifting a car off a child, into her arm.  That’s a protective reaction in our powerful instinctive arsenal. It’s called a fight response. She fought her way out.

But, the right arm became sacrificial, it was expendable.  Her arm became disconnected/dissociated so she could pound away at the door with it.  The arm went into a freeze response which is also another powerful part of our instincts that enable us to survive overwhelming situations. Imagine trying to pound a door down with a noodle arm.  That wouldn’t work.  The arm needed to become somewhat more rigid which involved the muscles tightening on both the bending and straightening sides of all the joints.

In this person’s case, she survived but was left with an arm that was “stuck in the turtle’s shell”.  Looking at traumatic stress through the concepts of Somatic Experiencing, we see instinctive protection strategies at work. Treatment includes addressing being stuck in a powerful biologic survival process. It wouldn’t be very smart of our protective systems to give us survival strategies that put us “in the turtle shell” but never gave us an impulse or ability to get back out again.

The built in method for getting back out of a freeze response is another instinctive process we’re capable of, which is called discharging.  Normally after an overwhelming threat or experience we will release energy in a variety of ways and go back to normal.  A turtle in it’s shell will use it’s senses to determine  the coast is clear, it will let go of the retracting pull of it’s muscles and go back to moving about.

Another example we all recognize is the story of the possum who “plays dead” (think freeze). If coyote leaves and possum doesn’t quit playing dead, it will be dead.  So possum needs to get itself back to normal.  On one hand this seems so natural it isn’t worth thinking about, but for someone with RSD/CRPS these processes are critical to understand and utilize in treatment.

In people, we sometimes don’t go through this discharge process thoroughly, or completely, or at all and can get very stuck in a bad moment in time.  This can often be part of the RSD/CRPS problem.  Also, some people with RSD/CRPS have had multiple situations earlier in life, that were very overwhelming. This can sensitize someone even more to go into a pattern of freezing.  This isn’t true for everyone, but it can be an additional layer of complexity.

Using Sensory-Motor Manual Therapy(SMMT) and Somatic Experiencing(SE) methods, a sense of safe space around a person’s boundary, and eventually into the affected part becomes part of treatment.  Words alone aren’t enough.  A person needs to restore their ability to sense their environment outside their self and inside their self.  They need to be able to feel what is okay, and gradually expand on that to regain access to their built in capacity to discharge any residuals from the bad situation in time that started the RSD/CRPS.

Sensory-Motor Manual Therapy  and Somatic Experiencing treatment help shift a person back to normal sensation and normal muscle control using brain body connections in a tolerable, gradual way. This is very complimentary to the two other emerging treatments which are described below. And by the way, I’ll say right here that with RSD/CRPS, I do not start touching patients near or in their pain area!

Two other emerging treatment methods focus on brain body connections. They are more exercise focused and do not incorporate traumatic stress concepts into the programs.

Mirror visual feedback technique (MVF) can be used with RSD/CRPS that is in an arm or leg.  A mirror is positioned in such a way that looking into the mirror, you will see the normal limb but it will look to you like you are seeing the painful limb. Movement of the normal side are combined with efforts to move the painful  limb. Your brain will register what you see as motion in the side that doesn’t tolerate movement or contact.  Another part of mirror therapy incorporates looking at images of an arm or leg in various positions and efforts are made to recognize and mirror the picture.

Mirror therapy is credited with having been initially begun by Dr. V.S. Ramachandran, MD, PhD  in 1995, at the  University of California in San Diego’s department of psychology.

Another method of treatment involves more direct engagement of the painful limb.  Stress Loading was developed by Lois Carlson, Occupational Therapist and H. Watson, MD, and published in 1987.  It involves engaging in back and forth scrubbing motion while bearing weight on the limb and secondly carrying weight.   This method can clearly help restore use of the limb and decrease pain significantly.

If that sounds  painful to you, you are right.  Scrub and carry treatment is acknowledged to increase pain initially before it begins to be helpful. Modifications may need to be made for a stiff wrist so that a brush can be held.  A person needs to get through an initial increase in swelling and pain. Some people are in such bad shape that they just cannot handle adding pain to their situation even though this treatment has shown positive responses.

The mechanism that enables a scrub/ carry program to help is twofold. Both activities add increasing doses of sensory signals from the disconnected body part back and forth to the brain. Additionally, the scrub activity engages the limb in back and forth motions that help counter the clenching action in the limb.

In some ways the scrubbing is a rudimentary and voluntarily driven mimic of some types of instinctive and involuntarily regulated discharge patterns. When the natural healing properties within the body can be moved through, and engaged, the healing will be more complete. The combination of these methods can help patients who have failed to respond to one alone.

What can we do to help patients that are not yet able to progress treatment with mirror therapy exercises,  or the scrub and carry method?  Also, RSD/ CRPS sometimes involves the abdomen or the back.  Neither of these areas is going to work  with mirror therapy or scrub and carry.

Sensory-Motor Manual Therapy also adds in a progressive set of sensory signals. One difference between SMMT and mirror and scrub/carry methods is a whole body approach versus focus primarily on the painful limb.  Initially attention is paid to many areas including, thinking patterns, protective reactions to the boundary space around ones self, and re-establishment of clearer sensory processing in the client’s best places before venturing closer to the painful areas.

Sensory-Motor Manual Therapy can be a part of treatment before other methods are tolerated, and can help support the entire process.

All these methods make use of sensation and  movement connections in the brain in the pre-motor and motor cortex. Additionally, Somatic Experiencing methods address the threat centers in the deep and instinctive nuclei in the brain. Reacting to threats is linked to the muscle system.  Otherwise, we’d just be plants.

We often learn movement by watching movement.  There is a whole new class of brain cells that’s being discovered and researched that happen to also be called Mirror Neurons.

These specialized nerve cells enable us to have a personal experience of 3 types of information which are emotion, thought, and movements.  We can internally understand the emotions of others. Our empathy in part, comes from our internal signaling and body experience of seeing what others show in their emotional expression. When we see someone smile, our face muscles subtly mirror the smile we see, and we interpret that subtle data as smile/happiness.  That’s part of how a mood is contagious.  The second type of mirroring is in understanding the thoughts and intentions of others.

The third kind of mirror neuron cells that most concerns us here, is understanding and experiencing movement.  When we learn how to do a motion we are often taught by someone who demonstrates it first.  When we watch a motion, we subtly make the motion in our muscles and learn by an inside sense of doing even though on the outside we may not be making an observable motion.

This effect is even more powerful if  the observed movement is purposeful, and or involves hand to mouth motions. Imagine someone eating an ice cream cone, and you will feel yourself doing it too.  This is part of the way that mirror therapy helps the painful limb get going again.

The problem with RSD/CRPS is sometimes the condition has disrupted normal signaling to such a degree, that a person doesn’t have the ability to feel or re-connect the sensations signaled via mirror therapy. So little is registering in the brain from the images, that little progress occurs.

In the situation of newly developing RSD/CRPS which in the general scheme of this condition could be classified as mild, treatment might look like this:

Say for example a person has had a fracture and part of the arm is immobilized with or without surgery.  The hand is painful to move and so the person avoids moving it. Weeks go by and the time to begin activity comes.  Now the hand and limb are showing signs of RSD/CRPS with swelling, sensation changes, heightened reactivity to any painful stimulus like the necessary stretching that comes with starting Physical Therapy.

Typically the advice is to just get going and make the hand function. Often the thinking is that if the tissues don’t get moving, scar tissue will build up and permanently limit motion and use.  In a hyper protective situation like this, there is developing scar tissue that is also being guarded by the muscle system.  I think of the muscles as the police.  The police say you’re not going to stretch or move and it becomes a battle to get the muscles out of guarding.

I advise establishing recognition of  where the transition between “feels normal” and “doesn’t feel right” is at.  Then with Sensory-Motor Manual Therapy, sensory signals are specifically added in from the normal area towards the abnormal areas in a gentle respectful approach and retreat pattern.  Attention is paid to calming in the person’s whole nervous system as well as the affected area. Touch needs to be progressive and delivered in a completely tolerable way so the touch doesn’t become a further trigger for pain, withdrawl and dissociation.

With Sensory-Motor Manual Therapy, the police action of the muscles is gradually quieted down.  Sensation can be explored more from a brain state of curiosity than fear, distress, and pain.  This further helps ramp down the hyperactivity of the nervous system and the alarm bells going off in the deep brain centers.

Once the person and their limb is shifted into a calmer state, any use of mirror therapy, or scrub/carry becomes even more effective.

Let’s assume we are in a situation where there is no threat to our safety from people or animals.  Let’s also assume we are blessed to have a reasonable ability to walk and keep our balance.When we move about, we’re often on surfaces that cause the most minimal challenge to our balance and physical capacity.

If you are someone who has chronic problems with your body’s muscles or joints or pain issues, you will likely have a reduced capacity to move freely on some kinds of surfaces.  The pain or problem may be in a the feet, ankle, knee, hip, back, neck or even a shoulder. Or maybe you’ve had a brain injury and altered vision, and balance skills when you get on more challenging surfaces.

If you walk on challenging surfaces you will be familiar with a sense of your guard coming up, and you will feel yourself moving differently, and often cautiously.  You may feel emotions of fear or worry, or anxiety, or self protectiveness about hurting yourself or falling down.  The voice in your mind may reinforce the guarding by telling you, to keep being on guard that it’s necessary and prudent.

Just the same way we think of the gym as a necessary part of  building ourselves up…. walking challenges can be very helpful.  Read on to understand what I mean.  Part of the process is really fine tuning your challenges to your unique emotionally regulated comfort zone.

You want to find the boundary of feeling secure in your movements, and feeling a bit of anxiety.  Try being like a child exploring the edge of the water at a sandy beach.  Have you ever had a chance to run  in up to the ankles then zoom back out?  It may be so long ago that you don’t remember that it was your instinctive sense of safety that turned you automatically back to dry ground.  As a child you likely had a fluid comfortable body to run around the world in.

So now, it’s not the same.  You have the wisdom to avoid threats, and also ailments to safeguard.  But, ultimately, pain conditions and muscle and joints do better if you can keep moving.  Does the advice to keep moving only apply to staying well within your capacity?? I think not.

If you can, find kinds of surfaces to walk, or shuffle, or glide on like you once explored in your past.  For me, I grew up in cold, dreary and icy Michigan winters, walking daily a mile to elementary school. It was so much fun to find ice puddles to crack or totter across.  In the spring there would be large puddles of melt water on the grass in a park I crossed.  Unfortunately I once got my golashas stuck in the mucky grass and fell over into a sit down right in the deepest part. Definately a WHOOPS moment.

I often go to a lake near my home for walks all year.  Every winter I look forward to the lake having ice.  If I can, I skate, and other times I just walk around on the edge.   I stay within my knowledge of the water’s depth  usually not more that 2-3 feet deep. I know there’s no way I’ll die in the water. I also am careful to be on thick ice so I’m not breaking through.

Today the snow was blown off, the surface a mix of white and bubbles, clear like glass and slick ice.  The edges were thin and made lots of popping, cracking , and splitting sounds.  Just like being a kid again.  I slid my feet like cross county skiing, and wandered the edge.  Because it kept cracking but not breaking, I kept getting the instinctive drive to shriek and scuttle back to safety of the ground. But, overall it was a blast to play around with a manageable level of slick surface, beautiful ice patterns in a beautiful setting , and the feeling in my body that comes from strengthening capable movement in the face of emotional and physical challenge. It was more of a dance away from the danger feeling than a panic.

You can play with these ideas too, like walking on uneven ground and feeling for what the edges are of your guarded motion or fluid motion capacities.

You need to feel what movement you lost with the injury and gradually move into the tight places to regain all lost motion.

For example, if you sprain your hip in a fall or a sport activity, you will have limited movement as your tissues heal. Gradually you need to seek out motion into the “tight” places to return to pre-injury status.  Typically you will be limited in the motion of pushing off your leg as you walk because the “hurt paw” type of pattern will protectively shorten muscle length on the front side of your hip.  As the pain and protective guarding lessen, you will want to move into the tightness in the front side of the hip joint to stretch yourself back out.  You can do specific hip stretches for this but ultimately you need to regain action into the lost range in normal activities like walking.

Unfortunately with more complicated joints, like the shoulder, it becomes harder to regain normal motion without substitution by other less injured parts of the whole chain of motion.  If you can let your sense of pre-injury quality guide you instead of only “where can I get my hand to”, you can do a lot of good work on your own.

You may have health issues that have some relationship to current or past stress or trauma.  Body based stress reducing techniques may be of help to you in achieving the calmer states, patience, and self regulation that you seek. By being in calmer states more of the time, you decrease stresses on your heart and blood vessels.  You may have tried other methods with partial success and need some other options.  Rachel Katz, PT, SEP has experience working with very difficult situations.  She can teach you how to incorporate Mind  Body methods into your skill set.  She customizes all programs to your unique and individual needs.  Your doctor may recommend this and your insurance may also cover you.  Please contact me to discuss your needs and how I may be able to help you.

Boulder Physical Therapist, Rachel Katz, PT, SEP, continues the conversation about Muscle spasm, chronic pain, neck pain, Car accident , whiplash, Freeze Response, Shoulder pain, Shoulder injury, exercise, and Somatic Experiencing applications in rehabilitation.