The Window of Tolerance is a model of nervous system regulation developed by Dr. Dan Siegel.  It describes the optimal zone of arousal – the state where our physiology is balanced, we feel settled enough to connect with others, we can explore, learn and grow.  Inside the window emotions and challenges are tolerable, and we can respond rather than react – we can cope with life stressors.

Either side of the window are two dysregulated states — hyperarousal and hypoarousal.

• Hyperarousal is the fight or flight response, driven by the sympathetic nervous system.  Here we may feel, for example, anxious or agitated, or on high alert – our physiology is dialled up
• Hypoarousal happens when something is too much for too long, it’s the parasympathetic nervous system without the “vagal brake”, and we lack the enough mobilisation of the sympathetic nervous system that we need to function effectively day to day (this is not the same as the fight or flight response which of course we need too!).

Each of the three zones is associated with different emotions, thoughts, feelings, behaviours and physiology.  The window isn’t only about our emotions, it’s about the body and behaviour too – it’s about the whole person and being able to function in a balanced, or efficient, way aS much as possible.

The aim isn’t to stay in our window all of the time – that’s not realistic.  Instead, we can over time learn to spend more time there, gently expand the window and recognise its edges (a place of growth).  These edges are sometimes called our stretch zone: where we are challenged but not overwhelmed.  I’ve created an infographic below which illustrates these states.

(You’re welcome to use & share this infographic – please keep the copyright & logo visible so the work is credited)

(You’re welcome to use & share this infographic – please keep the copyright and logo visible so the work is credited)

Returning to Regulation 

To return to regulation we first need to notice:

• What’s present and what the nervous system state is (hyperarousal, hypoarousal or in our window)
• The signs that we are moving beyond the edge of our window into dysregulation.

There are some suggested practices for hyperarousal and hypoarousal below:

Practices for Hyperarousal

• Compassionate awareness of what’s present
• Somatic tracking (either with a sense of safety noticing and tracking an unpleasant sensation, or leaning into a pleasant of neutral sensation)
• Breath practices, for example diaphragmatic soft slow nose breathing (normal breathing), Buteyko recovery breathing, extended exhale, coherent breathing, bee breath
• Grounding practices, for example the 5-4-3-2-1 practice, or noticing your feet on the floor and gently swaying if gentle movement feels accessible
• Connection with others
• Time in nature in a way that feels soothing or settling
• Soothing self-touch
• Soothing music or nature sounds
• Rhythmic movement, for example somatic shaking, walking, dancing, jogging, or swimming.  Other movement for example stretching
• Humming
• Sensory stimulation, for example a soothing essential oil, listening to soothing music or nature sounds, touching objects with a soothing texture or temperature, looking around and naming objects
• Self compassion practices
• Let be, let go let in (I’ve written more about this here: https://unityphysio.co.uk/the-mindful-compassion-based-5-steps-stress-awareness-management-model
  

Practices for Hypoarousal

• Mindfulness and somatic techniques, for example tapping, squeezing, or self-massage
• Energising movement, for example walking, stretching, jumping, somatic shaking, swimming, anything to energise the body that feels accessible and within tolerance levels
• Sensory stimulation, for example the smell of coffee, an essential oil, or another strong scent, touching objects with different textures or temperatures, looking around and naming objects, uplifting sounds, eating something salty/cold/crunchy, drinking a cold drink with a straw
• Cold shower or splashing cold water on face
• Stimulating breath practices
• Time in nature, gently connecting with energising elements
• Walking barefoot on a safe surface (grass is one option)
• Grounding practices. for example the 5-4-3-2-1 practice
• Self-compassion practices

Expanding the Window

We can expand our window by understanding and noticing the early signs from our body of being at the edge of our window and gently working here in a way that feels safe enough.  I often describe it as having one foot (or even a toe) outside the window and the other in regulation.  This supports nudging the window in a way that feels possible.

“Expanding the window isn’t about staying regulated all the time – it’s about awareness and finding enough safety at the edges, and returning from dysregulation with more ease”

Some ways I support people in expanding their window includes:

• Awareness of the edge of the window
• Somatic and embodiment practices (e.g. somatic tracking, somatic check-in)
• Meditationand mindfulness-based practices
• Compassion practices
• Mindful language and reframing
• Downregulation practices to support regulation after nudging hyperarousal
• Learning to trust the body
• Holding outcomes lightly
• Supporting connection with others
• Lifestyle changes, such as pacing of activities, including some restorative rest each day, good quality sleep and a healthy balanced diet.

In Summary 

There are many things that support regulation — awareness, compassion, and regular practice are key. Expanding the window also takes gentleness, patience and time: finding what’s best for you, listening to your body’s signals, and trusting the wisdom within.  Remember, the aim isn’t to stay in the window all of the time – over time, we want to be able to return to it with greater ease, and to gently expand it.

You might like to reflect on:

• What are the signs of being in each of the three zones of the Window of Tolerance?
• What are the signs of being at the edge of your window, and what helps you to keep a foot in regulation?
• What supports you in returning to your window from hyperarousal or hypoarousal?
• What helps you expand your window over time?

The post The Window of Tolerance and Chronic Illness appeared first on Unity Physiotherapy and Wellbeing.

Somatic tracking is a mindfulness-based practice that involves gently bringing attention to physical sensations with a sense of safety, curiosity and without judgement or expectation of a particular outcome.

It draws on principles from a mindfulness, somatic experiencing, interoception and neuroplasticity research and pain neuroscience education.  The term “somatic tracking” was coined by Alan Gordon, who developed Pain Reprocessing Therapy, introducing this approach as a way to change how the brain interprets signals from the body – modulating the threat system and inviting a felt sense of safety.

Somatic tracking helps build safety in the body and supports retraining the nervous system– not by trying to “fix” or change sensations, instead by changing how we relate to them and increasing a sense of safety.   It can also be used for emotions and thoughts, by focusing on the physical sensations associated with the same curious gentle focus.

It can support inner awareness, emotional regulation, pain & symptom management, help facilitate changes in how symptoms are experienced, and sometimes even the contribute to the resolution of symptoms – though resolution is not the goal of the practice.  Its core aim is to shift how we relate to sensations with greater curiosity, non-judgement, gentleness, and safety.  By observing without trying to fix or control, we open space for the nervous system to recalibrate and for the body to be seen as a source of wisdom, not a problem to solve.

The way I guide somatic tracking is grounded in compassion and trauma-informed principles.  I also include other elements such as a whole-body check-in at the beginning and end of the practice to support integration and self-awareness.  This is something I was already using before I came across Alan Gordon’s work, based on my training in mindfulness, mediation, yoga, somatics and embodiment – and my personal practices.   I didn’t call it somatic tracking at the time, but since learning about Alan’s work, I’ve shaped one of my practices to include the core elements of somatic tracking more intentionally.

Key Elements of Somatic Tracking

I see the key elements of somatic tracking as being:

• Intention to be curious
• Outcome independence (holding outcomes lightly)
• Not having an agenda, there is no goal – the aim is not to “get rid of” the sensation
• Mindfulness – observing gently with curiosity, the way you might if watching a sunset or clouds in the sky
• Noticing the sensation as it naturally changes
• Cultivating a felt sense of safety whilst observing the sensation (paying attention from a place of safety and neutrality) – adding safety messages if helpful
• Acceptance of what’s present as it is in each moment (just for now)

How I Guide Somatic Tracking: Practice Steps

1. Settle and ground
Find a quiet space.  Set an intention to be compassionate and curious.  Take a few breaths and check in with how you’re feeling overall — noticing sensations, your breath, your energy levels, your thoughts and emotions, and how this all shows up in the body.

2. Bring your attention to the body
Gently notice a sensation of discomfort, tension, or pain you’d like to focus on.  This could be tightness, tingling, throbbing, or anything else.  You can also do this practice with neutral or pleasant sensations — I include this at the end of the practice.  This may be the place to start if it’s too hard – too dysregulating – to pay attention to unpleasant sensations.  If working with discomfort/pain, keep it around 3–4 out of 10 (no more than 5), as it can otherwise be rather difficult to slow down and pay attention.

3. Observe with curiosity
Let your attention rest on the sensation, without trying to change it.  Simply notice: Where is it?  What is it like?  Is it big or small?  Does it have a texture or temperature, or any other qualities?

4. Notice your responses
If thoughts or emotions arise (like anxiety, resistance, or self-criticism), acknowledge them gently.  You might label them (“thinking,” “worry,” “criticism”) and return to the sensation — or if you feel you’ve observed the sensation enough, you could move your attention to the physical sensations associated with the emotion or thought and observe those with the same compassionate, curious awareness.

5. Stay connected to a sense of safety
Connect to a felt sense of safety, messages of safety, or a sense of “okayness,” if needed, to support paying attention from a place of feeling settled/safe.   For example, remind yourself: “This is simply a sensation. It’s safe to feel.”  Let your attention be soft and compassionate, not effortful.

6. Close with a body check-in and a shift to ease (if helpful)
Notice how you feel now compared to when you began.  If it feels right, gently bring your attention to a neutral or pleasant sensation — perhaps the feeling of your hands resting on your body, the rhythm of your breath, or warmth in the body.  Observing this with the same soft, curious awareness can help reinforce a felt sense of safety, ease, and integration.  Take a few moments to move gently if needed, and journal anything that feels helpful to reflect on.

7. Journal if helpful
Writing down any reflections, insights, or observations can support integration and deepen awareness.

Interested in Exploring Somatic Tracking More?

I offer a guided Compassionate Somatic Tracking recording to people I work with one-to-one or in relevant group workshops.  You’re welcome to reach out if you’d like to explore this practice more deeply.

The post Somatic Tracking: A Mindful Body-Based Practice for Nurturing Safety appeared first on Unity Physiotherapy and Wellbeing.

This blog offers a compassionate trauma-informed introduction to nervous system regulation – what it is, why it matters, and how trauma and chronic stress can impact it.  We explore protective responses like fight, flight, freeze, and fawn, and share trauma-informed nervous system regulation frameworks such as Polyvagal Theory and the Window of Tolerance.  You’ll also be introduced to my own Compassionate Nervous System Regulation Framework, Polyvagal Theory infographics, and further resources that can support the journey back to balance, safety, and connection.

What Is Nervous System Regulation?

Nervous system regulation often refers to the state and balance of the autonomic nervous system (ANS).  This system controls automatic bodily functions like heart rate, breathing, digestion, and our stress responses.  Of these, breath is unique, as we can also influence it consciously.

The ANS is a network of nerves that extend throughout the body, with neurons originating in both the brain and spinal cord.  Two key brain regions involved in its function are the hypothalamus and the brainstem.  The ANS has two main branches: the sympathetic nervous system (SNS), which activates the fight-or-flight response, and the parasympathetic nervous system (PNS), which supports rest, digestion and restoration.

There’s also a third division: the enteric nervous system (ENS).  While it’s technically part of the ANS, it can also function independently and is often referred to as our “second brain.”  It governs digestion and communicates with the rest of the ANS, especially via the vagus nerve – the main part of the PNS, making up about 75% of it’s nerve fibres.  Like the rest of the nervous system, the ANS communicates through a complex network of electrical signals and chemical messengers.

The ANS is a functional division of the peripheral nervous system, which connects to the central nervous system (the brain and spinal cord).   When we talk about nervous system regulation, it’s broader than the ANS alone – everything in the body is deeply interconnected.

It’s important to understand: it’s normal to move in and out of regulation throughout the day.  No one lives in a perfectly regulated state all the time, and that’s not the goal.   Life includes challenges, and our nervous system is designed to respond.  Sometimes it may over-respond, but that’s still it doing its job based on previous experiences.  With time and support, the system can learn when we are safe, helping the threat response settle more easily, when the environment is actually safe.  The aim isn’t to avoid dysregulation, but to notice when it happens and gently support ourselves in returning to balance, again and again.  This helps build nervous system efficiency, capacity, and resilience.

Understanding our nervous system, gently coming home to a regulated place, and befriending the body can support many things including healing & thriving.

My Working Definition of Nervous System Regulation

When I talk about nervous system regulation, I’m not referring to being calm all of the time or never getting dysregulated – this is normal and part of being human (though when we are dsyregulated too often/too much, and struggle to return to regulation, is when it’s problematic).  Regulation isn’t a fixed state – it’s a dynamic process.

To me, helpful nervous system regulation means having the ability to move flexibly between different states, in response to life’s demands and stressors. It’s about matching the level of arousal to what’s needed in the moment – and being able to return to a more regulated state with some degree of ease when dysregulation happens.  This supports a sense of safeness, connection, optimal functioning, growth, and healing.

Understanding Dysregulation: The 5 F’s

When we experience threat/stress in general, chronic stress or trauma our nervous system shifts into protective states that help us survive.   These protective states are referred in different ways, one is the 5 F’s:

• Fight – activation of the SNS (mobilised)
• Flight – activation of the SNS (mobilised)
• Freeze –blends SNS activation (mobilised) with the PNS (immobilised), initially this is state is SNS driven – we are mobilised with physiological changes that are needed to flee or fight e.g. an increased heart rate and muscle tension.  It’s a brief pause whilst the options to get to safety are assessed automatically and quickly, if there is no escape we begin to shift into a state of dysregulated immobility (flop).  Freeze can be understood as part of a spectrum – with a more activated freeze at one end and flop (shutdown) at the other
• Flop – this is a shutdown state, it is the body’s last resort for protection when there is perceived to be no escape
• Fawn – this is also referred to as appeasing, the protection response is to please and pacify the threat for safety.  It’s a complex blended state of fight/flight and freeze

At its core, nervous system regulation is about returning to a place of balanced physiology and a sense of safeness after being in one of the dysregulated states.  It’s important for us all to be able to re-regulate quickly and efficiently, with some level of ease.  This can be challenging for people who have experienced chronic stress or trauma, and/or are struggling with chronic health conditions such as ME/CFS, PoTS, fibromyalgia, or Long Covid – dysregulating more easily, taking longer to return to regulation and getting stuck in dysregualtion, over time this can be changed.

Why Regulation Matters

The good news is that your body knows how to come back to regulation – it knows the way home.  Sometimes, it simply needs compassionate, trauma-informed support, this is part of my role in my work – to walk alongside people in the journey to remembering the innate state of regulation and connection.

Nervous system regulation is a foundational aspect of how we feel, think, move, and relate to others.  For example, when we are in a fight or flight state (SNS) our experience may include anxiety, restlessness, difficult concentrating and a racing mind, we may be impatient, there may be insomnia, stillness may be difficult and movements are likely to be quick.  When your nervous system is dysregulated, it can affect everything, including:

• Sleep and rest
• Pain and fatigue management
• Emotional resilience
• Concentration and memory
• Your ability to connect with others

Nervous system dysregulation is not a sign of weakness—these responses are wise protective responses, however, when they persist beyond the original threat, they affect our health and wellbeing and limit our ability to thrive – we can move from surviving to thriving.

What Regulation Isn’t

Nervous system regulation isn’t about pushing through, ignoring or fixing symptoms. It’s about learning to:

• Feel safer in your body
• Gently restoring balance
• Expanding capacity to be present and grounded even when life is challenging

Various things support nervous system regulation including understanding it, along with  trauma-informed, compassionate, and somatic approaches – to support shifting out of survival mode and into a state where healing, connection, and thriving become possible.

We are social beings, nervous system regulation enables us to co-regulate—to be present, steady and attuned with others, both in our work and with the children and loved ones in our lives.   It’s especially important with children as initially they can’t regulate themselves initially and then they learn to self-regulate from co-regulation.

The Nervous System Regulation Tools and Models I Use

The tools I use are grounded in compassionate trauma-informed care, compassion and mindfulness-based practices, somatic and embodiment practices, and clear frameworks that help to understand and support the nervous system with compassion and clarity in sustainable ways.  The main frameworks I use are:

Window of Tolerance

This was developed by Dr. Dan Siegel, this model describes the optimal nervous system state (the Window of Tolerance) which is sometimes referred to as the optimal zone of arousal, where we are settled/safe, alert and engaged, and the two dysregulated states either side of it (hyperarousal and hypoarousal).  Hyperarousal is the fight or flight response and hypoarousal is dorsal vagal in Polyvagal Theory – the parasympatehtic nervous system without the vagal brake and without the mobilisation of the SNS that we need to function day to day (this is not the same as the fight or flight responses of the SNS, which of course we also need!).  The aim isn’t to be within our window all of the time, instead to know how to stay there as much as possible and keep gently expanding the window over time.  The edges of the optimal zone are our stretch zone, here we can learn and grow.

There is a Window of Tolerance infographic I created below and a few links to more information on this model.

A helpful short video about the Window of Tolerance by Lewis Psychology https://m.youtube.com/watch?v=TNVlppGz0zM

A helpful Window of Tolerance blog by Dr Sarah Davies https://www.drsarahdavies.com/post/what-is-window-of-tolerance-emotional-regulation-model-explained

Polyvagal Theory

Developed by Dr. Stephen Porges, this theory explains how the autonomic nervous system moves between:

•  Ventral vagal (safety, connection & social engagement)
•  Sympathetic (fight/flight, mobilisation)
•  Dorsal vagal (shutdown, immobilisation)

Understanding and mapping these states helps us better understand our nervous system and gently support return to regulation.  The three main states are shown in the first infographic below and the two blended ventral vagal ones are shown in the second infographic (please feel free to share these infographics, kindly ensure the credit is visible).

A helpful blog about what Polyvagal theory is by the Polyvagal Theory institute https://www.polyvagalinstitute.org/whatispolyvagaltheory

A useful video on Polyvagal Theory by Lewis Psychology https://m.youtube.com/watch?v=SlhFrBoEnxU

The Three Circles Model (The Three Emotional Systems Model)

This is part of Compassion Focused Therapy and was developed by Professor Paul Gilbert.  The three emotional systems in this model are:

• • Threat (protection and safety seeking system, activating/inhibiting)
  • Drive (incentive/resourced focused system, pursuing and achieving, activating)
  • Soothing (connection, safeness & care, non-wanting/affiliative)

No one of these systems is good or bad, we need them all, the aim is for them to be in balance.  Many people I work with have overactive threat systems and underactive soothing systems, which is a very common pattern partly due to the way our society is in general.  One of the ways I use this model is to support people in growing the green (the soothing system) with practices and strategies that feel safe, nourishing and sustainable.

Trauma-Sensitive Mindfulness (TSM)

TSM was developed by David Treleaven, and I have completed his Advanced Trauma-Sensitive Practitioner training.   It’s grounded in the 4R’s of trauma informed practice:

• Realising the widespread impact of trauma
• Recognising the signs and symptoms of trauma
• Responding with informed, supportive practices
• Resisting (or avoiding) Retraumatisation

You can read more about the 4 R’s on my Trauma Informed Practice page: https://unityphysio.co.uk/services/trauma-informed-practice/

Mindfulness can be a powerful tool for nervous system regulation—when it’s offered safely. I use mindfulness in a trauma-sensitive way: the practices are choice-based, gentle, and paced to meet each person’s needs.  Regulation, choice, and empowerment are central to this approach.

My Framework: A Compassionate Path to Regulation

In both my workshops and 1:1 sessions, I use a visual framework that I developed to support regulation through compassionate awareness and curiosity.  It’s non-linear – each element is interconnected, and many experiences may sit in more than one circle at a time.

The process usually begins with noticing your internal state through compassionate awareness with a gentle curiosity.  From there, you might explore settling, grounding, letting go, or receiving what feels nurturing and supportive.  Each part of the framework reinforces the others, helping you reconnect with safety, presence, compassion and self-trust at your own pace.  Over time, this helps build your capacity for regulation, connection, and thriving.

There’s no one right way to move through this—it’s a path of compassionate awareness and curiosity that you can return to again and again.

Summary

Nervous system regulation is a vital, ongoing process of gently returning balance for us all, and is especially important with chronic health conditions, or healing from chronic stress or trauma.  It isn’t about fixing ourselves (we are all already whole)—it’s about gently understanding our bodies, restoring balance, and reconnecting with a felt sense of safety and compassion towards ourselves, others, and the world around us.

Understanding protective responses and using compassionate, trauma-informed frameworks, supports us in reconnecting with safety, regulating and building nervous system capacity, and moving from surviving towards thriving.  This journey is unique for each of us, and it’s important that it’s grounded in curiosity, patience, compassion and kindness toward ourselves and others.

Would You Like to Explore More?

If you would like to explore nervous system regulation more take a look at:

Nervous System Regulation https://unityphysio.co.uk/services/nervous-system-regulation/

You can also book a free 15 minute discovery call to see if this work feels like a good fit for you 1:1, alternatively you are invited to take a look at my 4-week nervous system regulation workshop series on:

The Awakening The Body’s Wisdom: A Somatic Workshop Series https://unityphysio.co.uk/services/awakening-the-bodys-wisdom-somatic-workshops/

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Stress often gets a bad press, which is because it negatively affects our health and wellbeing when it’s certain types of stress, prolonged and repetitive.   Stress is part of our daily life in many ways and some of it we need for adapting including the stress from exercise.  Chronic, or ongoing stress, also impacts chronic health conditions, it amplifies pain, fatigue, gut issues, anxiety and other symptoms.

Many things contribute to stress, including health inequalities, which I’m not going to go into in this blog.  There is also often a negative perception of stress and a stigma associated with it which isn’t needed or helpful.  I’m not going to go into this because it would be a whole other blog, however it’s important to mention that being stressed isn’t a weakness and recognising it and taking action is a strength. 

We cannot change stress if we aren’t aware of feeling stressed, or we don’t notice when stress is increasing and/or are not aware of the factors that we can influence.  The rest of this blog will focus on my compassionate mindful 5 steps stress awareness and management model which can support stress awareness and management, and optimising health & wellbeing, alongside lifestyle factors, including: exercise/movement, diet, sleep, time outside, and connecting with others and nature.

The 5 steps stress awareness & management model

 1. Slow down & pause 

2. Awareness – Notice what’s present in the body (somatic check-in) with compassion & curiosity 

3. Let Be –  allow what’s present as it is without judgement as best you can, noting how things ebb & flow

4. Let go – let go of what does not serve 

5 Let in – choose what’s helpful, what you would like to invite more of.  Connect to what’s nurturing & supportive, and focus on this.

Using this model we start by slowing down and pausing, perhaps noticing the feet on the floor and the position of the body (eg sitting or standing).  It can also be helpful to connect to an intention to notice how we are and what’s present with a compassion and curiosity.  

Step 2 is noticing what’s present in the body (a somatic check-in), this includes how the external environment is impacting our physiology, for example the nervous system state.  Doing a somatic check in creates an embodied awareness of what’s present.   A somatic check-in can include noticing what sensations are present where, what the breath is like, what energy levels are like, what thoughts & feelings are present and how they show up in the body. 

Step 3 is letting what’s present be, allowing it to be as it is as best you can with compassion and curiosity, and also noticing how things ebb and flow.   Acceptance of what is present is part of this, there are many misconceptions about acceptance, it doesn’t mean liking or wanting something, nor does it mean something won’t change, and it’s not a one off thing (it’s an ongoing relational process).  Alongside allowing and accepting we can also notice how what we are paying attention to changes moment by moment, everything’s always changing.   To be with what’s present and allow it we need to have a wide enough window of tolerance, this could be seen as nervous system capacity to maintain some regulation with the impact of stressors, this is something that we can expand over time.  We also need to know what helps us keep a foot or at least a toe in some regulation whilst we are being with what’s present when it includes suffering or things that are challenging.  If our window of tolerance is narrow and we don’t know what anchors us in regulation, what supports us to stay settled and grounded enough (regulated enough) we will become too dysregulated to be with what’s present, mixed with previous experiences, and can become overwhelmed.  We need a number of things to support being with suffering especially compassion, courage, nervous system regulation and a sense of safety in the body.  The being with what’s present and listening to the body often holds much wisdom, this can guide us towards what’s helpful. 

Step 4 is letting go of what does not serve us.  This is not always an easy process and can take some time, it’s not necessarily a one off in the moment thing, nor a do one practice and we have magically let go of something, although sometimes it can be like this (usually when there has been prior work with something).  Letting go can be related to a variety of things including worry, self-criticism, impatience, unhelpful beliefs, unsupportive/unhealthy habits and excess tension in the body.  Things that support letting go include the wisdom from within the letting be step, embodied movement, other somatic and embodiment practices, breath practices, compassion practices, compassionate phrases/mantras, meditations, visualisations, and other things like journalling.  As well as needing some nervous system regulation to be with and let go of what does not serve us the process of letting go usually creates more nervous system regulation.  We can also purposely use practices to support regulation as part of letting go which can support the process.  

Step 5 is letting in what supports our health & wellbeing and being able to thrive.  Letting in what’s nurturing or supportive can include many things, for example: noticing a sense of ease, spaciousness, or freedom from letting go of tension in the body, or through connecting to a slow soft smooth breath; noticing a sense of being cared for/loved; recalling a sense of being appreciated; noticing kindness and being kind to others; connecting to a sense of what you can do being enough; and moments of joy.  In this step we aim to take in the nurturing moments as they happen and/or recall them, letting them soak in and noticing how this impacts us, for example a change in breathing or nervous system state.  This is what Dr Rick Hanson calls ‘Taking in the good.’  One of the things you can do here is consider what you would like to invite more of into your life, for example more connection, more kindness, or more strength.  We can choose to embody what’s helpful here, for example self-compassion, a gentle strength, a sense of ease, or feeling cared for.  With regular practice of letting in what’s nurturing and supportive, letting in the ‘good’, it changes our whole being.  It impacts our physiology, how we relate to ourselves, others and the world and we are training our brain to take in what’s helpful, positive and nurturing.  This supports our health and wellbeing, whilst not pushing things away or ignoring them (the noticing and allowing steps) – there’s much wisdom held within these steps.  This letting in step could also including letting in the changes that with repetition become helpful habits. 

This 5 steps mindful compassion based stress awareness and management model is really about connecting to the body, awareness, compassion, being with, letting go and letting in/bringing in what’s helpful/supportive/positive.  Compassionate awareness is foundational to this, and I think in many things if not in all things.  If we pay attention to what’s present with self-criticism, blame, or frustration it increases the stress, one of many reasons why compassion and awareness are like two wings of a bird, we need both to fly.  The model isn’t 1-5 steps that we rigidity stick to, we move back and forth between different stages, there’s a flow and flexibility within it.  For example, we might be working with letting go and then go back to noticing and letting be before going back to letting go again, or we might be working with letting in and go back to awareness and noticing and even more letting go, and there might not be a clear distinction between the steps always.

As mentioned at the start of this blog there are various lifestyle factors which support optimising our health and wellbeing and stress management.  Developing helpful habits by focusing one habit and one step at a time can be a helpful starting point, over time habits become a way of being.  You could also use this model to support developing habits that support health and wellbeing, I could write how but then this blog would be even longer!  Do let me know if you would like a blog with some tips for this.

If you would like to learn more about these steps in relation to the frame of compassion and compassionate mind training check out the ‘Compassion Focused Approach to Stress Management’ blog which I wrote for Balanced Minds https://balancedminds.com/a-compassion-focused-approach-to-stress-management/

Letting be, letting go and letting in has been a practice for me for some time, it will always be ongoing as part of a way of living and being, and I use it in my work.  I’m not sure if I developed this practice fully myself or if it’s something I picked up and from Dr Ricki Hanson’s work and modified in my own way based on all my learning and personal practices.  I always acknowledge other people’s work and where I get ideas from, in this instance I’m unclear if one of Dr Rick Hanson’s books or attending one of his workshops inspired this model and my work with ‘Let Be, Let Go, Let In’ so I’m mentioning it in case it did.

What do you think? Could this be a helpful model/practice for you for you? Maybe something like this is a practice, or part of a way of being for you already.   

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The festive period commonly brings with it a lot of stress, a variety of feelings and emotions, decreased routine and lack of sleep and other things.  These are are things that can turn up the dial on pain and fatigue.  Strategies/tools/practices that help to manage pain & fatigue in general, to manage stress and regulate our nervous system can be helpful.  Practices/tools that can support stress management and nervous system regulation include:

• Breath practices
• Mindfulness & Meditation
• Self-compassion practices
• Being mindful of our language & reframing it (watch out for the ‘shoulds’, more on this a little later)
• Gentle yoga or other mindful movement practices
• Somatic practices
• Time connecting with nature

Commonly over the festive periods routines get thrown out of the window, people try and fit way more in than usual and more than they have capacity for, this is another reason symptoms increase.  There are different contributors to this including feeling pressure to do things a certain way, to do more & make everything ‘perfect ‘ at Christmas.   There’s no such thing as a perfect Christmas or a perfect anything for that matter, one of my wise sisters once said to me ‘it’s the imperfections that make us perfect.’  Christmas has become very over commercialised and there is quite a lot of unhelpful messaging that can make people feel they aren’t good enough unless the Christmas they have matches all the adverts and social media posts.  It can be helpful to remember that it’s only one day of the year and we can choose what we want to do on that day, it doesn’t have to be a certain way.

When managing any condition associated with pain and fatigue there needs to be flexible routine and pacing of activities.  By flexible routine I mean doing the things that support us each day though not in a fixed or prescriptive way.  For example, maintaining a sleep routine, eating food that supports health & wellbeing, pacing activities, using breath practices and other practices to support nervous system regulation, maintaining our boundaries, connecting with others and nature, and used in a way that meets what’s needed each day.   

Sticking to your daily routine as best you can in terms of using the resources/practices that support you in managing the condition you’re living with is important, as well as setting some compassionate boundaries over the festive period.  Creating a flexible plan each day, prioritising and planning what you need and want to do, considering what’s realistic, what supports you, what’s meaningful to you, and consideration of what’s in the week ahead can all help with pain and fatigue management at anytime of year and is especially important with events like Christmas. 

It can be helpful to explore our beliefs, expectations & our language, for example, noticing when we are we telling ourselves that we must do something, that we have to do something, that we should do more/should do something a certain way.  It’s quite likely that if you tend to overdo things that this language is appearing quite a bit, commonly there are a lot of shoulds (this comes from our threat system).  When you catch this language ask yourself where these come from & explore reframing the language.  For example, maybe reframing something from I have to do ‘x’ to I get to do ‘x’ and I’m going to ask for some help to make it easier.  Are your beliefs about Christmas supportive of your wellbeing & values?  It’s not always easy to reframe unsupportive beliefs, expectations and language sometimes support is needed to do this, especially when there is a history of trauma.

It’s important to know your toolbox of resources, knowing your resources and nervous system well can help you to choose which tools/practices are supportive each day, as well as bringing in additional practices to support you over the festive period as needed. It’s helpful to know what your energy nurturers are, what is restful for you and what regulates your nervous system so that these things can be included each day.  We all need rest and when living with a long-term health condition we need extra rest and more so if experiencing an increase in symptoms (often referred to as a flare-up).  The winter time is also the time we need more rest and the busyness that has now become a ‘norm’ of Christmas pulls us out of our natural rhythm with nature and our time for rest and restoration.

Things I see as foundational, are using mindfulness, self-compassion & listening to your body’s wisdom to guide management of pain & fatigue.  Mindfulness simply means being aware of the present moment, or being aware of our experience as we our experiencing it.  If we aren’t aware of what’s happening and how we are then how can we take helpful action?  The way in which we pay attention matters too, it is important that we are aiming to be compassionate and non-judgemental.  Turning a loving awareness towards ourselves is most supportive and it takes ongoing practice.  Being mindful of what’s present in our body in a compassionate way means that we can hear our body’s wisdom and we can use this to guide our choices. 

Here is a summary of tips (there are more than I have written about above, the blog would have got rather long if I wrote a bit about each tip!):

• Have a flexible daily plan
• Have a flare up plan (what supports settling systems down)
• Pace things in a way that supports you (5P’s to remember planning, prioritising, play & purpose, problems solving.  My blog on pacing for pain is linked at the end of this blog)
• Take regular rest breaks
• Check-in with your body regularly
• Listen to your body’s wisdom
• Practice self-compassion
• Be kind to yourself
• Remind yourself what you can do is enough
• Include what’s meaningful each day
• Connect to a sense of playfulness
• Set compassionate boundaries (it’s ok to say no)
• Communicate what’s possible
• Ask for help when needed (asking for help is a strength not a weakness)
• Use daily practices that support you
• Use nervous system regulation practices (for example breath practices, meditation, mindfulness, yoga, somatic & embodiment practices, self-compassion practices, singing/humming)
• Prioritise sleep, rest & restoration
• Manage stress
• Communicate with family & friends
• Reach out for support
• Connect with others & nature
• Spend a little time outdoors each day if you can, or look out of the window & see what you can notice
• Remind yourself Christmas doesn’t have to look or be a certain way
• Explore beliefs & expectations, reframe them if it’s helpful & possible
• Watch out for ‘I should…’, ‘I have to…’, ‘I must…’
• Connect to a sense of joy, wonder, vitality and other nurturing feelings each day

The tips with this post can be helpful for us all and are especially important when living with persistent pain & other conditions.  You don’t need to do them all, trying to change too much at once often has the opposite impact, instead pick one or a few things that feel helpful for you and take action on them.  Maybe you have some tips you would add, I would love to hear them if you do.

It’s important for us all to remember there is no such things as a perfect Christmas & whatever we choose to do is ok and whatever we can do is enough.

Here’s the link to the pacing for persistent pain blog mentioned in this blog (a lot of what is in the blog applies to ME/CFS and long covid too, though pacing for these is slightly different): https://unityphysio.co.uk/what-is-pacing-how-can-it-help-with-persistent-chronic-pain/

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Some people like to use end of year journalling as part of reflecting on the year as it draws to a close.  Journalling can be helpful as part of reflecting on the year and see what’s gone well, what’s not been easy or challenging and what helped navigate these times, what’s been meaningful and other aspects too.   Some people like to reflect on the year and journal and others don’t, either way is ok.

As we reflect it is important that we notice what has been helpful, supportive or ‘positive’ as well as the more tricky and challenging times.  Our brains have a ‘negativity’ bias, this means that we will naturally remember the challenges and focus here if we don’t intentionally explore the ‘positives’ too.

This time of year is often a reflective time and when we align with nature seasons it’s a time for slowing down.  Our society and the commercialisation around Christmas tends to make people busier which can take us away for our natural need to slow down, turn a little inward, to rest and restore.

Before we look at different types of journaling and some tips I feel that it’s important to mention a few things:

• We all struggle and suffer sometimes and these will be part of everyone’s years to varying degrees, this is part of being human.  There will also be joy, connection, love, wonder and other nurturing emotions and feelings to varying degrees too
• There isn’t a right or wrong way to reflect or journal
• It can feel too much to reflect on the year, this is normal and it’s ok not to do it.  We can reflect and journal if it feels ok to do so and like it might be helpful for us and if not we don’t have to do it.

Types of Journalling

There are many types of journalling I have listed some of them below along with examples of how they can be used as part of end of year reflections:

• Free flow journalling/stream of consciousness journalling – this basically means writing whatever comes into your head even if it doesn’t seem to make sense.  Instead of choosing one focus like gratitude or feelings as journal prompts free flow journalling doesn’t have a focus and it is writing without editing
• Gratitude journalling – this is basically noticing and focusing on what you are grateful for.   For end of year journalling you could notice a few things that you are grateful for each month of the year as you explore the year that’s gone by and simply list them and/or use one, or a few of them as journalling prompts
• Art journalling – this type of journalling uses visual representations of things like your thoughts and feelings.  You could draw or find illustrations/visuals that you feel reflect your year as you review it
• Nature journalling – this type of journalling relates to what you are noticing in nature.  It can be combined with other types of journalling like art journaling.  One way this can be used is to gather nature pictures that you have from throughout the year and then journal with what arises through connecting with the picture memories, this may also lead into other types of journalling like what you are grateful for within the year
• Yoga journalling – this type of journalling is where people write in their journal after a yoga practice.  An example for end of year reflections could be to hold the intention to reflect and review the year, take this onto the yoga mat and then journal with any thoughts, feelings and insights that may have come up
• Strength based journalling – this journalling focuses on your strengths and exploring these through journalling.  For example, see if you can notice something that has helped you to thrive and/or manage the challenges this year and journal about this
• Values based journalling – this uses your values as a prompt for your writing.  One way to do this is to note down your core values and then journal with each value and how you brought it to life this year.  If you’re unsure of your values do a values exploration exercise first, there are some in my book, linked at the end of this blog
• Bullet journalling – this can be any sort of bullet point list.  For an end of year review you could list the things that you are grateful for, the values in your year, the strengths that helped you navigate challenges and helped you to thrive, and/or inspirational quotes that reflect your year.

There are many more types and you can blend different ones together and of course create your own journalling style

Questions for journalling:

 Questions can be used as journal prompts, some examples for end of year reflections/journalling:

• What has gone well the last month/last few months/this year and why?
• What are 1-5 things that I am most proud of this year and why?
• What has been tricky or challenging & what have I learnt from this/what am I taking from it?
• What helped me navigate the challenges?
• What strengths helped me this year?
• What’s been supportive for me this year?
• What 1-5 things am I grateful for right now/over the last few months/this year?
• Did I set boundaries, did I stick to them and were they helpful?
• What’s created some balance, some ease, some stability this year?
• How have I related to myself most often this year? (For example, with self-criticism or self-compassion)
• Is my daily routine supportive of my wellbeing?
• What 1-2 things could I keep doing or start doing regularly that would make a difference to my wellbeing?
• What are my core values (3-5 values) and how have they been part of this year?
• What is most important to me & why?
• What do I want to take into the new year?  What feels welcome to have more of? (This ties in with word of the year if you do this)
• What would I like to explore more of, what qualities do I want to embody next year?
• What could it be helpful to let go of?

Journalling tips

Some people like to reflect prior to journalling and then deepen the reflection through journalling and other people prefer to journal first and then reflect more in some way, for example through a yoga or other somatic movement practice, and others prefer to do something like a yoga practice first and then journal.  There isn’t a right or a wrong with journalling or reflecting, it is simply what feels ok for you and what’s helpful.

Before starting reflection and/or journalling I suggest people do a somatic (body) check-in and notice how they are.  The way I guide a somatic check-in is by encouraging connection to the body with compassion and curiosity to notice what’s present, for example noticing sensations, energy levels, the breath (if it’s ok to notice this), what thoughts are present and how they show up in the body.  I also encourage people to reflect and journal in a somatic way, this basically means noticing the bodies reactions, the body’s wisdom as you reflect, for example, what sensations do you notice, what’s your breath like, is there a temperature change, how are you feeling, what do you notice where in your body?  Without doing this we are only reflecting on a head level and this means we are missing important information and the body’s wisdom.   It is important to slow down and pause regularly, this can help us to notice what’s present in the body and increases our awareness and understanding

I encourage people to journal and reflect with compassion and curiosity, holding the intention to be curious and compassionate can be part of this.  As well as holding this intention you can connect to your compassionate self to support with journalling in a compassionate way, there are various exercise available that can guide with this.  There are a few in my book and there are some audios freely available like this one by Dr Shelley Kerr: https://on.soundcloud.com/kSyVQUZu923v9HYz7

It can also be helpful to use soothing rhythm breathing from compassionate mind training, this can be used as part of connecting to your compassionate self or simply to connect to your body, settle and slow down.  I have an audio freely available for this here: https://on.soundcloud.com/kqJdxtjerKGMUHBq6  There are a number of other soothing rhythm breathing practices freely available, you can find a few of them here: https://www.compassionatemind.co.uk/resource/audio

If reflecting on the whole year feels overwhelming consider what feels ok, perhaps exploring the last month or last few months, or something else that feels better to you.  If nothing feels ok and it feels too much don’t do it and perhaps reach out for some support instead.

One way you can reflect using end of year journalling is by reflecting back on the year by moving back through time from now and noticing what events/memories come to mind and what is present in your body, noting feelings or something else down in your journal.  Once you have reviewed the whole year you could choose a common feeling to journal with, or use some things that you are grateful for that have come to mind.  If journalling on the whole year feels too much you can split it into chunks, maybe quarters.

When you have finished your reflection one of the things you may wish to explore may be what would it be helpful to have more of in the following year, what would support you and what may you wish to let go of.   You can journal with these as prompts as well.  What you wish to have more of can be used as a word of the year (or words) for the following year, something I see as a kind of gentle guide.

Summary

• There are many types of journalling and you can blend different types together
• You don’t have to use a specific journalling type you can create your own approach 
• You can review the whole year working backwards from now or split it into chunks, for example review each quarter
• Do a somatic check-in before beginning and during the journalling 
• Slow down, this helps you to notice what’s present in the body
• Go at your own pace and take breaks as needed
• Use the body’s wisdom along with the minds understanding in your journalling
• Hold the intention to be curious and compassionate
• Connect to your compassionate self and use soothing rhythm breathing if these feel helpful for you
• Journalling can be combined with yoga and other somatic practices
• You could explore what it would be helpful to invite more of in the following year, what would build on your strengths & resources and support your wellbeing 
• There isn’t a right or wrong way to journal or reflect.

In this blog I mentioned that there are some values exercises in my book you can find the book here: https://www.amazon.co.uk/Dancing-through-Life-Guide-Living/ dp/B08P1CFDNW/ref=mp_s_a_1_4? crid=3EHSYPASVND90&keywords=ann+parkinson+book&gid=1671047573&sprefix=ann+patkinson+ %2Caps%2C65&sr=8-4

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There isn’t an agreed definition of pacing, I would define it as flexible way of structuring your day in a way that supports both function and wellbeing.  Pacing essentially means breaking down tasks and activities into manageable chunks with consideration of the different types of activities, including enough short rest breaks in your day and flexibly adjusting things each day/throughout the day as needed.  Pacing needs consideration of different activity types, for example what activities are more physical/cognitive/emotional and how they impact you.  It needs a number of things which I will touch on in this blog, especially awareness, compassion, noticing what’s present in our experience within our body (what’s embodied), flexibility, knowing our values & what’s most meaningful, and exploration.

Pacing is helpful for us all and more so when living with persistent pain and/or other health conditions.  A quick note here, pacing for persistent pain is similar and different to pacing for ME/CFS and long covid (where post exertional malaise is present), this blog is focusing on pacing when living with persistent pain.

The way I suggest exploring pacing with the people I work with includes discussing what pacing is and is not, there are some examples of what pacing isn’t below, perhaps the commonest misconception is that it means doing less.  I also encourage an understanding of nervous system regulation through a cognitive understanding and an embodied understanding (body based).  Part of this includes developing a toolbox of strategies and practices that support compassionate awareness & nervous system regulation, both I see as key aspects of pacing.   I often use the window of tolerance model by Dan Siegel, polyvagal theory by Stephen Porges and the three circles model from compassion focused therapy by Paul Gilbert as part of exploring understanding nervous system regulation in an embodied way.  I explore what’s meaningful with people and what their values are for a number of reasons, including because it helps people make choices about which activities to prioritise and engage in.

As already mentioned pacing can be misunderstood (and often is), here are some of the things pacing is not:

• A rigid/restrictive daily plan
• Doing less
• It’s not another thing to be ‘done’
• Only being able to do certain things a certain way
• Only doing things that don’t cause a pain flare

Pacing is not a rigid daily plan, it’s a way of flexibly adjusting our day as we move through it.  It is helpful for us to bring a non-judgemental compassionate awareness to how we are relating to our world (both the internal and the external), which is changing moment by moment.  From a place of being the compassionate observer we can take conscious wise action, where it’s possible to meet what’s needed (part of pacing).  A quick note here, there isn’t really any division between our internal world and the external world (not something we are exploring in this blog).

Avoiding doing things that tend to increase pain because of worry of a pain flare is not pacing and doing this over time this increases threat system activation, decreases our tolerance levels for the activity being avoided and often also tolerance for different activities.  It increases sympathetic nervous system activation (fight-flight), essentially there is more threat in systems and a sense of safety is lacking or has significantly decreased (pain is part of our threat system).  Tolerance levels decrease for a number of reasons, mainly due to an increase in sensitivity levels to different stimuli and a decrease in fitness levels.  Stimuli that gets overreacted to (we become more sensitive to it) often includes sitting and standing still and moving a certain way.  When systems are super sensitive all movements can trigger a protection response, doing certain activities and even thinking about doing a particular activity can create a pain response.  A quick note here about cause and pain, rarely does one specific thing cause pain or an increase in it, it’s complex and there are many variables that we don’t see.

Another thing that pacing doesn’t mean is ignoring pain and pushing on regardless, this tends to ramp up the protection responses and sensitises systems more.  This is the opposite of avoiding activities, it is sometimes referred to as the boom-bust cycle (not a term I use unless someone is using it and relates to it in a helpful way).  Both avoidance and regularly exceeding tolerance levels by too much are both problematic.  A quick note here, choosing not to do something that doesn’t come from a place of threat may well not be avoidance.  Doing a lot more than tolerance levels tends to result in having to do less for a few days, or even longer, it increases sensitivity and the threat in systems.  Doing a lot less also increases sensitivity and threat in systems too, along with tending to decrease strength and fitness as well.  However, doing a little more with a sense of safety, understanding your nervous system and using practices that help regulate your nervous system can help to gently nudge tolerance levels over time.

Pacing is not another thing to be ‘done’, it’s a way of flexibility adjusting to how we are and what feels needed throughout our day.  The way I see it is that pacing becomes a way of being that supports both effective function and our wellbeing.  For example, compassionately relating to ourselves and others, taking regular pauses in the day (these are needed for everyone, whether living with pain or not) and having nurturing daily practices that are part of a way of being and living, these could be seen as helpful habits.

(Image: my Grandad when he was 90 doing a meaningful activity – time in nature with one of his grandchildren – made possible by having something to sit on & only walking a very short distance)

How Can Pacing Help With Persistent Pain?

Pacing encourages people to work around their normal tolerance levels, this means knowing your baseline for different activities and where your soft limit/soft edge/soft boundary is.  This means knowing what level of different activities is generally ok (the baseline) and also having an embodied knowing (an awareness from what’s present in your body related to your whole experience).  Knowing your soft boundary includes knowing the whispers from your body that indicate you are near this point and indicate that taking a rest break or changing tasks would be helpful.  I have found it helpful over the years, with myself and working with others, to combine the cognitive understanding of a variable baseline with an embodied knowing of the signs we are near our soft boundary or soft limit.  One reason combining these is helpful is because our baselines are always changing and are impacted by many factors/variables, for example lack of stress and increased stress, and our body will reflect dysregulation consistently – we can come to deeply know it’s whispers when we listen compassionately.

Pacing can help in many ways, here are some of the ways it can help with managing and changing pain:

•  People living with pain can often more consistently do what needs to be done and what’s meaningful to them by breaking things down into more manageable chunks of activity interspaced with rest
• As well as taking short rest breaks changing to a different activity, for example changing more of a physical task for more of a cognitive one can be helpful
• With a pain flare-up things may need to be broken down into smaller amounts with more rest breaks to help systems to calm down
• Pacing can help people to engage more often and more fully in what’s meaningful along with using the strategies & practices that help them to manage pain
• It can help to modulate pain, for example taking a break and doing a breath practice helps to regulate the nervous system – down regulating the threat system can potentially modulate pain
• Pacing can help with both nervous system regulation and retraining the nervous system.  So, it can be part of both managing and changing pain over time
• It can help to decrease sensitivity to different stimuli, increase tolerance & fitness over time along with other things

Pacing Tips

It can be helpful to have an understanding of why pain doesn’t necessarily equal harm, knowing that we are safe to do things even with pain.  Having an understanding around this is one thing that can help people to pace activities and create a sense of safety.

I use 5 P’s with people for pacing, if they find this helpful, these are planning, prioritising, play, purpose & problem solving.  I have a pacing handout, that includes these that I offer to the people I work with who are struggling with persistent pain, to support their exploration of pacing.

As already mentioned listening to the body and integrating enough rest, along with having daily practices that help to regulate the nervous system is important.  Many things can help to regulate the nervous system and help with pacing when living with pain, for example, breath practices, meditation, gentle yoga or other mindful movement, singing/humming, time in nature.  Including a variety of activities, including exercise, in pacing is important, finding what’s helpful for you needs exploration.  There is a link to an exercise and persistent pain blog that I wrote in the resources at the end of this blog.

It is important to explore what is restful for you and the sort of rest that certain activities/tasks offer, there are a number of different forms of rest which I am not going to go into in this blog.  The picture below is child’s pose, this is often referred to as a pose of rest in yoga and is known to be calming, grounding, restful and restorative.  It is important to remember just because something is said to be calming and restful it doesn’t mean it will be for you, this highlights again the importance of embodied awareness (what is showing up in the body).  Understanding what is showing up in your body and how your nervous system is responding is part of developing an embodied awareness.  I encourage the people who attend my 8 week Creating A Healing Path workshops for people with pain/fatigue/anxiety, and my 4 week nervous system regulation workshop series to do this.  Even though we didn’t specifically cover pacing in my Creating A Healing Path workshops people reported pacing better and being more able to engage in what was meaningful to them.  You can find the link for more information on these workshops at the end of this blog.

As already mentioned pacing is not rigid, it needs flexibility as everything is changing moment by moment.  Our internal and external environments are constantly changing, our tolerance levels and nervous system state are in a constant state of flux (with everything else), it another reason why having an embodied awareness matters.  We need a cognitive understanding combined with an embodied awareness of what practices and strategies are helpful when, along with the different ways that we can adapt them.  Without a body based understanding (embodied awareness) we will be running on cognitive understanding alone and missing out on what our nervous system is communicating and the wisdom of our body.

Here is a common example of how our tolerance levels and nervous system state are always changing, imagine that you haven’t been sleeping well for a few nights and you keep on doing things in the usual way.  There are some common impacts of this, including: increased fatigue, increased stress, making poorer food choices, getting hooked in unhelpful thoughts, and increased pain which may also stop you sleeping (one of the many cycles in pain).   Lack of sleep in itself sensitises systems, increases threat system activation, increases the perception of pain, our baselines and soft boundary change, and it impacts our concentration and focus.  So, rather than keeping doing things in the usual way we need to explore what’s helpful and adapt what we are doing.  This might look like breaking things down into smaller chunks than usual, having more rest breaks during the day, including more meditation, or having a few minutes outside a few times during the day, and doing less exercise than normal (the body responds differently to exercise with lack of sleep and it responds differently with persistent pain too).  Making these adjustments like these are examples of pacing.

When there is something that’s important for you to do and you know it’s over your tolerance levels one way to manage this is to engage in what gives more safety messages to your body for a few days before the event, during it if possible, and again for a few days after.    Factoring in more rest afterwards and even before the activity/day can be helpful.

Remember what is helpful on one day, or in one moment won’t be exactly the same as what’s needed in another.  This is why we need an embodied awareness (body awareness) and a toolkit of practices and strategies that we have explored and used regularly.  This helps us to select what feels most helpful and then notice how our nervous system and body are responding, adapting what we are doing from this as needed.

Here’s a list of some more examples that can be part of pacing with a flare-up of pain:

Modulate your usual activities, like with the example above

Use additional helpful strategies from your toolkit if needed, a few examples are mentioned above

Do what helps to regulate your nervous system more frequently during the day

  Practice self-compassion, an example would be reframing your language (the self-critic can get loud when things during a pain flare-up)

For some activities where you are doing less than you normally would due to a flare-up remember to ensure that you have a plan to build things back up gradually as things start to settle (something which can be forgotten).

Some questions you can ask yourself:

•  Do you pace your activities in a way that’s supportive for your wellbeing
• Do you make adjustments to your day for factors like lack of sleep and increased stress?
• Do you know your baselines for activities and do you the know the signs of your soft limit/soft edge/soft boundary?
• Do you do what’s important to you or do you avoid doing it out of fear of making the pain worse?
• Do you push on regardless?
•  Do you incorporate the helpful strategies/practices into your day or just when the pain is worse?
• Do you know what helps give you a sense of safety with doing different things?
• What daily practices/strategies support you?

In Summary

This blog has covered what I see as the basic principles of pacing when living with persistent pain, these are:

• Planning & prorating tasks
• Problem solving 
• Breaking things down into manageable chunks
• Understanding different activities (physical/cognitive/emotional) and your tolerance levels for them
• Integrating enough rest (with consideration of different forms of rest)
• Changing activities for a break is helpful (alongside having rest breaks)
• Having a cognitive understanding and an embodied awareness (body based understanding/knowing)
• Knowing the whispers from your body that you are near or at your soft limit/soft edge/soft boundary
• Using the practices and strategies that support you and help to regulate your nervous system and manage pain
• Remember there isn’t a right or wrong with pacing and it needs flexibility.  There isn’t a perfect way to pace!
• We need to be able to flexibly adjust during the day, this needs an embodied compassionate awareness & ongoing practice

No-one paces the same way, no-one walks in the same shoes, yet we create similar footprints.  This means that we can learn from each other and use the principles of things like pacing and different practices and adapt them to meet what’s needed.  There are common tools/practices/strategies that can help regulate the nervous system, manage and modulate pain, support wellbeing and effective function, these need adjusting for each person.  This is something I explore with people as part of 1:1 work and it is part of my workshops  With regular practice people understand the many ways they can adapt practices to meet their needs and as part of exploration and regular practice they create their own toolkit of resources to manage and change pain.

Learning how to pace and manage pain is a journey of exploration that takes many directions, there isn’t a destination/an end point with pacing, instead pacing supports pain management and engaging with what matters each day.  I would say that understanding nervous system regulation, noticing how we are relating to ourselves and practicing embodiment (noticing what’s present in our body) are all key parts of pacing.

I have written this blog from my understanding of working as a pain specialist physiotherapist & integrative somatic practitioner as well as lived experience of persistent pain, ME/CFS & PoTS.  If you would like to learn more about pacing and/or would like help with management of persistent pain in general get in touch to book your free 15 minute call to see how I can help.

If you would like to find out more about the 8 week online Creating A Healing Path workshop series for people with any condition associated with pain/fatigue/anxiety, or the 4 week nervous system regulation workshop series click the links below:

https://unityphysio.co.uk/services/ahealingpath/

https://unityphysio.co.uk/services/listening-to-our-inner-wisdom-workshops/

Pacing Resources

There are a number of resources specifically for pacing for persistent pain and related topics, here are a few:

There is a little about nervous system regulation in part one of my healing blog https://unityphysio.co.uk/healing-within-connectedness-love-part-one/

This is a blog that I wrote on exercising with persistent pain and can help with pacing of exercise/physical activities https://unityphysio.co.uk/exercising-with-persistent-pain/

A blog written about pacing in the context of neuropathic pain http://livingwellpain.net/persistent-pain-pacing

A short pacing video https://www.paintoolkit.org/pain-tools

Q&A: Pacing & Chronic Illness http://natashalipman.com/qa-pacing-chronic-lllness-resting-pain-fatigue/

(Images in this blog: icon with heart in hands and man walking are authors own, childs pose image is from Shutterstock by Rasterbird, time for change image is from Shutterstock by Trueffelpix)

The post What is Pacing & How Can it Help with Persistent/Chronic Pain? appeared first on Unity Physiotherapy and Wellbeing.

Aligning mind, body & heart

Terms like aligning mind, body and heart can seem a bit abstract so I’m going to define this in the way I see it before we explore connectedness more.  To me aligning mind, body and heart means living in a loving and embodied way aligned with our purpose and what’s meaningful, living from a place of love, compassion & connectedness.  By living in a loving and embodied way I mean noticing how, for example, our thoughts and feelings, are showing up in the body in a compassionate and non-judgemental way.  Part of healing is awakening our senses and being able to fully be in the present moment in an embodied and loving way.  We can’t do this if we are stuck in hyperarousal or hypoarousal, where we are stuck in our heads or rushing around all the time, disconnected from ourselves and the world around us, and not feeling safe/settled and secure.  Aligning body, mind and heart helps us regulate our nervous system, awaken to a deeper way of being and reconnect to the connectedness of everything.

Living in an embodied and open hearted way can also help us see that the obstacles and challenges that appear as part of life can help us awaken and grow.  We can ask questions that support with this like how can this help me grow? How can this help me serve myself and others?  How might this help serve my heartfelt intentions or aspirations?  Sometimes things are overwhelming, these times we won’t know the answers to these questions and we will struggle to connect to our bodies, these times we may need to find a suitable therapist to support us.

Love & connectedness in healing 

One of the things that is really important in healing is that our suffering is witnessed and acknowledged in a compassionate and non-judgemental way.  Suffering that is not witnessed and acknowledged, or done so in a critical way, often causes more trauma.   Love, compassion & connection are needed here because when we aren’t fully present and connected we can’t truly notice our suffering, or that of another, and without love and compassion there is judgement and criticism.

Acceptance is important in healing, it isn’t a one off thing, instead it’s ongoing and it can be said to be a moment by moment process.   Acceptance isn’t passive, it doesn’t mean putting up with something, or that things won’t change (things are always changing right down to each moment).  A great strength or courage is needed to be able to let go and trust in our inner wisdom and the process.  With curiosity, openness, courage and a compassionate loving presence (a heartfelt presence) we can notice and allow what’s present in the moment to be exactly as it is, even if it’s not how we would ideally choose it to be.  Being present with love & compassion helps us accept and allow what’s present to be without, for example, self-blame or self-criticism, and when these do appear they can be met with compassion and love too.   Allowing what’s present to be needs a sense of safety, or feeling safe enough in the present moment.  This means that we need the nervous system to be balanced or close to balance (where we are within our window of tolerance/ventral vagal system).

From a place of noticing what’s present in the body we can increase our understanding, connect to our inner wisdom and discern what’s supportive for us.  Any action comes from our inner wisdom rather than from a threat based reaction, for example a pushing away, trying to get rid of something, or avoiding.  It’s important for us to stop over controlling and resisting, this is part of being in a regulated nervous system (resistance & over control are part of our threat system and protection mechanisms), as it calms our nervous system and allows new possibilities to begin to surface.  Allowing what’s present to be with an acceptance or openness is a place where fear softens and we can start to see what’s resting underneath.  Holding whatever is present, in love compassion isn’t always easy and this is part of the practice and the healing.  Things can reappear that we thought we had dealt with once, that we had healed, new layers surface for healing, here again we practice acceptance and compassion.

We need trust to allow the healing process to unfold in its own time without wanting it to be a certain way or create a certain outcome, without pushing or resisting, easier said than done I know (that’s part of the practice too).  We naturally push away or resist what causes suffering and grasp what creates joy and the things we want more of.  Part of suffering is in the pushing away and grasping, we can learn to allow things to flow through (an ever ongoing practice).  We can, for example, notice that pain is present and allow it to be in the background as best we can, rather than trying to get rid of it and getting frustrated, angry or self-critical when nothing works.  This doesn’t mean we don’t take action to try and alleviate the suffering, instead it comes from a different place and we take wise action.  This may be no action sometimes, or something simple like after noticing what’s present and allowing it to be, offering ourselves some soothing words or soothing touch (this could be part of Tara Brach’s R.A.I.N practice or Kritsin Neff’s self-compassion break, for example).  We also need to learn to hold the outcome lightly, we cannot control this as there are many variable (some we don’t see) we can influence the outcome and control how we relate to it.

Often when we are suffering we lose trust in ourselves, I have seen this time and time again working with people with persistent pain, other long-term conditions and felt it myself.  The decreased trust, or the loss of trust, brings an opportunity to connect more deeply to it and develop more of a kind of unshakeable trust.  Part of trust is trusting that we have the skills, knowledge, resources/practices to manage, or if we don’t then believing that with support we can develop them.  Learning to trust the healing process is important and it means we need to trust in uncertainty too.  Trusting in uncertainty isn’t easy, it’s important because so much is uncertain in life, this means we need to let go of over control.  Being safely grounded in compassion and love links with trust in holding us steady enough within the uncertainty, within what feels like a vulnerable place.

Reconnecting to our inner wisdom is so important in healing, it supports and guides us.  Terms like inner wisdom and our true nature or essence, can seem a bit abstract, they aren’t tangible things we can see.  Our inner wisdom and true nature both hold love & compassion and connecting to them is important in healing.  Connecting to our inner wisdom through our body guides us in many ways, for example it can guide us when to explore something to deepen understanding and when to allow something to be in the background for the time being.  Sometimes we need help to access our inner wisdom especially if there is unprocessed trauma, the light of compassion and love can be hidden under layers.

Feeling the connectedness to love, nature and the wider whole is also important in healing and our overall wellbeing.  Research is showing us that it is not necessarily the amount of time that we spend in nature that is significant for our wellbeing, except in terms of physical wellbeing, there needs to be a sense of connectedness too (physical wellbeing needs this too, so again it’s not just the time in nature that’s important).  Sometimes we have disconnected from the interconnectedness of nature, reconnecting to this is part of our healing and it’s needed for natures healing.  Nature’s wisdom combines with our inner wisdom and can guide us when we listen.  If we haven’t lost the connection to the connectedness with nature then the sense of connectedness with this tends to deepen as part of healing.  Nature is part of us and we are part of nature, our wellbeing and natures wellbeing are inextricably interlinked, connecting to this helps our healing and also the healing that nature is desperately calling out for.

The interconnectedness with nature and something bigger than us may resonate with you or it may not, either way is ok.  If these things are of interest one of the books that I would recommend is called ‘Reconnection: Fixing Our Broken Relationship With Nature’ by Miles Richardson.

Common Humanity & Healing

As human beings we all experience joys and sorrows, love and loss, easier times and tough times, suffering and healing.  This is the common humanity we all share, we share many things as part of being human and connecting to this is important in healing.  Connection to others is important in healing, we are social animals.  We self-regulate and we co-regulate, our nervous system talks to other nervous systems.

Adapting to and processing many losses is part of being human and is often part of healing too  This can be for many reason, for example, from the multiple losses related to living with a chronic health condition, from life being different from the way you wished it to be, and/or from the loss of a loved one.  There isn’t a right or wrong way to grieve.  I wrote a grief and loss in persistent pain & other long term health conditions blog which you can find this here:

Part one https://unityphysio.co.uk/grief-loss-in-persistent-pain-other-health-conditions-part-one/

Part two https://unityphysio.co.uk/grief-loss-in-persistent-pain-other-health-conditions-part-two/

It is the tough times that we learn the most from and these times that we need a toolbox of practices to draw on, these can also be referred to as strategies or resources.  The tough times strengthen our heart and allow our heart to open more fully, to be present with love, compassion and courage, connect to the depth of our strength and to connect more deeply to the connectedness of everything with a sense of spaciousness.  We cannot heal until we learn what supports our nervous system regulation and have some resources/practices to support this and healing, we create more resources along our healing journey too.

What supports healing?

There are many things that can support us each day, that can become part of a way of being and part of healing, including: embodied self-awareness practices (awareness in the body), meditation, mindfulness, breath practices, self-compassion, yoga, exercise and movement, walking, time in nature, journaling, distraction (sometimes this is needed, for example when things are over whelming) and many more things.

When I had a really tough couple of years due to some health conditions I leaned deeply into my yoga and compassion practices and drew on many other resources that I had, my gratitude for these deepened and I developed many more resources through this time too.  I also reached out for additional support, remember we can’t heal on our own.

What practices and resources/strategies do you use to support you day to day?

Summary

To heal we need many things including: to restore balance and retrain our nervous system, a sense of safety and trust, an embodied loving awareness, acceptance, a variety of resources/practices along with a daily commitment to practice, belongingness, support of others, connection and connectedness, and of course compassion and love.  Healing takes time and a toolbox of strategies and practices, it’s not one thing that helps us heal it’s many things.  We can’t heal on our own, we need the co-regulation and support of others which can take many forms.  Sometimes support needs to be in the form of a therapist, other times it could be a coach or mentor, friends, or a wider community group that we are part of.

As we heal the confusion that we had in our suffering evolves into clarity and we awaken a little more to our true selves and the interconnectedness in everything too.  There are times that we think we have healed and everything is going smoothly and then something happens that opens up new layers that are ready to be healed.   Healing is something I have come to see as being ongoing, maybe you can relate to this too.  I don’t think there is a destination unless it is to return to our true selves and wholeness, to the alignment of mind body and heart and live from this place, and return again and again.  Each time there is a challenge or an obstacle it gives us an opportunity to grow and connect to our true selves, our inner wisdom, and more deeply to the connectedness within and around us.

We all already have what’s needed for healing within us, to access and nurture this we need to be able to safely connect to our bodies and we often need to change how we are relating to ourselves, from being critical, for example, to being more compassionate.  Sometimes we need help from a psychologist, or another psychological clinician to do this, for example when there is unresolved or unprocessed trauma.  We all have within us a core essence of compassion and love, this light never goes out, sometimes it’s under layers and we need help to be able to start to see it, and the more we connect to this place the more brightly it shines.

Healing has many aspects and perhaps we could see it as being rooted in connectedness and love, and aligning mind, body and heart.  I have come to understand that our healing rests within the love that is within and around us all and the connection to the interconnectedness of everything.  Healing is a place where enougness, okness, compassion, love, trust and freedom all rest.  Connecting to the wisdom of our body, heart, inner trust, compassion and love over and over again helps us to heal & develop an unshakeable inner core, or at least a less shakeable one.  The inner wisdom that is within us all, our core of love and compassion, is a place that we can come to know more deeply with time and once we have an embodied knowing (a felt sense in our body) we can return again and again to our true selves and a balanced state (our ventral vagal system/window of tolerance) that supports healing.  As we heal we can live more fully in an open hearted presence, developing a new way to be, relating to ourselves in a more loving and compassionate way and extending this love and compassion to others and the world around us.

To finish this blog I’m sharing a poem that I wrote called ‘Healing Within’:

Many things were unknown

Couldn’t be seen

In the darkness there was always some light

Flickering gently

Leading the way

Slowly, step by step

Pauses scattered through

Compassionate awareness enveloping

Body wisdom guiding to explore

What’s resting inside, to be seen, accepted and loved

Slowly, never to be rushed

Each footstep exploring

Heart trusting

A loving presence guiding

Exploring and listening

Natures wisdom shining

Deepening a knowing

Harmony evolving

Learning a new way to be

Compassion, love and trust united

Deeply embedded within

Shining brightly

Holding the steadiness

Resting in aliveness

Connected to the unity

Being & healing

You may also like to check out the poem I wrote called The Body Remembers The Trust

https://m.youtube.com/watch?v=2pgR3COJLPk

I would love to hear your thoughts on healing and this blog, do drop me an email if you would like to (info@unityphysio.co.uk) or share some thoughts in the comments on social media where I’ve shared this blog.

The post Healing Within Connectedness & Love (part two) appeared first on Unity Physiotherapy and Wellbeing.

I’ve especially been considering healing in relation to trauma, persistent pain, ME/CFS, long covid, PoTS and other long-term conditions, which is probably because these are the areas I work within and have lived experience of some too.   Many people are healing from trauma and/or a long-term health conditions in our modern world.  Last week I read in a new report by The Health Foundation it has suggested that 9.1 million people in England are expected to live with a major illness by 2040 and that a significant proportion of this will be related to certain conditions, including anxiety, depression, chronic pain and diabetes.   In my opinion there are many factors that need consideration here including healing and the innate connectedness that we need to reconnect to and nurture.

What does healing mean?

There is no agreed definition of healing, healing in acute terms means repairing damaged tissues, or fixing an injury, for example.  Things get complex when it’s not a simple acute injury and there isn’t a specific time frame to heal or repair the wound/injury.  When there are, for example, layers of trauma, or many symptoms from fibromyalgia, or someone is living with persistent pain healing becomes trickier to define.

Before reading on I invite you to consider what healing means to you?

I think we could say that healing is always an individual experience that involves reducing or transforming suffering.   However, if we were to say healing is only a change in suffering this would be a simplistic view, especially as suffering is complex and it is always changing, everything is always changing, and because healing is about more than the suffering or struggle that is part of the picture.

Another thing to consider with what healing means is that it may or may not mean full resolution of pain, anxiety, or other symptoms.  Often people have shared with me themes around alignment with their heart and what’s meaningful, connectedness and wholeness as part of what healing means to them, and these are things I can relate to from my own healing journey too.   Some people may say that not feeling whole implies that something is broken and needs fixing.  I don’t see it this way and instead see it as a disconnection from our true selves, disconnection from nature and a disconnection from the wider whole/universe (there are different terms for this, it can essentially be seen as something bigger than ourselves).  Although we may at times feel broken we never really are, our true self is like the sky in that it is always there and can never be broken and the weathers come and go.

A journey to wholeness is something I see as a heart based connection, a connection to meaning and purpose, to a sense of belonging, and to the love, trust and compassion that’s within us all.  We could maybe say that healing is a coming home to ourselves, reconnecting to our inner wisdom and connecting to the interconnectedness of everything.  I would say healing is also an alignment of mind, body and heart, a place where we can live fully connected from an open hearted presence with a gentle strength and love.  We will explore this a little more in part two of the blog.

I think that it is helpful to consider what nervous system regulation means in the context of healing, especially because we can’t heal with a nervous system that is dysregulated too often/too much.

What is nervous system regulation?

Nervous system regulation includes the whole nervous system and is often discussed in terms of the autonomic nervous system.  Everyone’s nervous system dysregulates many times a day and then re-regulates, the problems come when the nervous system is dysregulating too often or too much relative to the context and not re-regulating well.  A well regulated nervous systems helps us to feel safe or safe enough to be fully present and to engage with others and the world in general, and it helps all of our systems to function optimally.

There isn’t an agreed definition of nervous system regulation, this is one that I created for my Creating A Healing Path workshop series:

‘Nervous system regulation can be thought of as when our nervous system is flexibly able to move between different states in response to stressors & the level of arousal matches the context/what you are required to do.  It is where it is working in a balanced way that supports optimal function & healing.’

A quick summary of the autonomic nervous system (ANS) could be helpful here.  The ANS unconsciously controls and regulates our organs and unconscious body functions, including heart rate, breathing (which we also have conscious control over), blood pressure, and temperature.  It is split into two branches, the sympathetic nervous system (SNS), fight or flight, and the parasympathetic nervous system (PNS), rest and digest.  These work together to maintain a state of balance in the body (homeostasis) and we need both branches of the ANS, neither is good or bad.  The levels of activation of the SNS and PNS are always fluctuating, our central nervous system CNS) and autonomic nervous system are constantly adjusting, along with all other systems, to try and maintain homeostasis.  Our ANS and the CNS (mainly the amygdala and hypothalamus in the limbic system in the brain) are constantly monitoring for threat/danger or safety.  The ANS and CNS are constantly surveying our internal environment (information from all systems), along with our immediate and wider external environment, including how the interactions with others feel.  Our nervous system takes a better safe than sorry approach and our previous experiences and modern society mean it is often dysregulated by things that aren’t actual threats.  Once the threat, or potential threat, has gone we need to be able to return to regulation to function optimally and feel safe and settled again.  When this doesn’t happen automatically or takes sometime we can assist this process and there are many ways in which we can do this, this is part of healing.

It is important to mention that changes in ANS activation are associated with different chemical messengers which of course impact all of our systems.  Our thoughts feelings and emotions are also in themselves associated with different chemical messengers, they are part of our biology too.

There are different models that can help us to understand the ANS and nervous system regulation, the ones I use most often are Dan Siegel’s window of tolerance and Stephen Porge’s polyvagal theory, combined with the 3 circles model by Paul Gilbert (part of Compassion Focused Therapy).  For this blog I’m going to touch on the window of tolerance model and polyvagal theory.

The window of tolerance model was developed by Dan Siegel to describe the optimal level of arousal, it has three parts:

• Hyperarousal (too much SNS – fight or flight)
• Window of tolerance – optimal zone of arousal (balanced ANS)
• Hypoarousal (not enough SNS & PNS without the vagal brake)

In this model a dysregulated nervous system is one that is too often, or too much for the context, in hyperarousal or hypoarousal, and/or takes longer to regulate from these states back to regulation, and sometimes gets stuck for a while in one of these threat/protection based states.  When the nervous system is dysregulated in the direction of hyperarousal a variety of things associated with this can be present including: fear, panic, initial freeze (deer in headlights) emotional overwhelm, anxiety, irritability, anger, over-activity, lack of clarity, worry, gut issues, increased muscle tension, pain, insomnia, a tired and wired feeling.  When the nervous system is dysregulated in the direction of hypoarousal a variety of things associated with this can be present including: disconnection, dissociation, low mood, depression, decreased muscle tone, shame, guilt, feeling numb, fatigue, shut down.

(infographic by Dr Sarah Davies, the link to the blog that this is in is below)

Through the lens of the polyvagal theory by Stephen Porges we see the ANS protection responses as:

• SNS (fight or flight, includes the initial freeze response)
• Shut down or collapse (PNS minus vagal brake, termed dorsal vagal in this model)

Porges suggests that there are three pathways in the ANS, being the sympathetic nervous system (SNS) (mobilised/activated, protect/survival mode, unsafe), the ventral vagal circuit (safe, regulated, sympathetic and parasympathetic activity balanced with the vagal brake, and able to be socially engaged) and the dorsal vagal circuit (unsafe, protect/survival mode, shut down).   These three systems/states are also included on the above infographic).  The SNS part is where there is increased SNS activation (hyperarousal in window of tolerance).  The initial freeze response (deer in headlight type response) is SNS dominant, this is where we freeze whilst a decision is automatically made as to whether we can fight or flee, if neither are possible and this response continues eventually the SNS is overwhelmed by the PNS (we lose the ventral vagal regulation, the vagal brake – the rest and digest part of the PNS).  Here we go into a primitive survival response of shutdown or collapse, this is termed dorsal vagal in this model (it’s where there is increased hypoarousal in the window of tolerance model).  The ventral vagal system is where we are said to be safely activated, in other words the SNS is balanced by the PNS with the vagal brake.  Here all systems can function optimally, the ANS is in balance, the limbic system in the brain is settled and the frontal lobe is online.  When we are in the ventral vagal system we feel safe and secure, this supports social connection and full engagement in a heartfelt presence with ourselves and the world.

The wider our window of tolerance, the more frequently we can be in the ventral vagal system and the more easily we can return to this place again and again.  This helps systems function optimally and we can, for example, find ease within challenges.  Being in our ventral vagal system or window of tolerance helps create the conditions that support healing.  Also with a wider window of tolerance we can more often be in a full heart felt presence and have a greater tolerance to be with our own and others suffering, along with being able to access the wisdom to discern what may be helpful in alleviating or decreasing the suffering.

There is a lot of information on the window of tolerance model and polyvagal theory available, like this blog on the window of tolerance model:

https://www.drsarahdavies.com/post/what-is-window-of-tolerance-emotional-regulation-model-explained

You can find a free beginners guide to polyvagal theory on Deb Dana’s website here:

https://www.rhythmofregulation.com/resources

Considering nervous system regulation alone would be a reductionist way of looking at things, it needs to be considered as part of the whole picture.  This includes considering all systems, what is happening in our body, the thoughts and memories that are present, our behaviour, previous experiences, essentially the whole of our experience and the connectedness of everything.

Summary

Healing doesn’t have an agreed definition except in acute injury.  Healing involves changing or transforming suffering and creates a new way of being through reconnection to our true self and living aligned with our mind, body and heart.

When our nervous system is not well regulated, we don’t feel safe, we can’t see the bigger picture and are disconnected from ourselves, others and the wider whole, and we can’t heal from this place.  It is important we remember that we don’t control any of our nervous systems threat/protection responses (hyperarousal/hypoarousal), they are quickly automatically activated when protection is deemed as needed.  When we are within our window of tolerance or ventral vagal system enough (a regulated and balanced nervous system state) we are safely able to fully connect to ourselves and others, have a more expansive view, and conditions are optimised for healing.  A healing state is one that rests in safety and connection, a place where strength & gentleness are balanced, a place where the seeds of change can be planted, begin to grow and later flourish and these are all part of having a well-balanced regulated nervous system.

Perhaps we could see healing as a return to wholeness, or an alignment of mind, body & heart.  An alignment and wholeness that means that we can live a life full of meaning, with a sense of purpose, fully connected to ourselves, others & to something bigger than ourselves (the wider whole) in an open hearted and grounded way.  These will be explored a little in  part two of this blog.

What do you think, does this way of seeing healing resonate with you?

Link to part two of the blog https://unityphysio.co.uk/healing-within-connectedness-love-part-two/

(brain in hands image with this blog is from Shutterstock by Sergey Nivens, all others are owned by Ann Parkinson at Unity Physiotherapy & Wellbeing)

The post Healing Within Connectedness & Love (part one) appeared first on Unity Physiotherapy and Wellbeing.

What is PoTS?

Postural orthostatic tachycardia syndrome (PoTS) is a form of dysautonomia (autonomic dysfunction) and is characterised by an abnormal increase in heart rate within 10 minutes of sitting from laying down or with standing, this is referred to as orthostatic intolerance.  For people with PoTS upright posture (sitting or standing) is limited to varying degrees.  Alongside the main diagnosis of PoTS, which we could call classic PoTS, there are different subtypes: neuropathic PoTS, hypovolaemic PoTS & hyperadrenergic PoTS.

PoTS diagnostic criteria is a sustained increased in heart rate (HR) for over 3 months of 30bpm within 10 minutes of standing in adults, or reaches 120bpm or more in this time, and in children an increase of at least 40bpm.  A tilt table test is used for diagnosis and/or the active stand test or NASA lean test.  It is also important that other conditions are ruled out and tests should include blood tests and an ECG.  If people don’t meet the diagnostic criteria and other things have been ruled out they most likely have orthostatic intolerance (which is one end of the PoTS spectrum before it reaches a level classed as PoTS).

There are a whole range of associated symptoms including:

• Increased heart rate
• Alteration in blood pressure
• Palpitations
• Light headedness/dizziness
• Shortness of breath
• Chest pain
• Fatigue
• Brain fog
• Sweating
• Shakiness or tremulousness
• Fainting/blackouts (in a fairly low percentage of people)
• Sleep issues
• Headaches/migraines
• Anxiety
• Nausea
• Gut & bladder issues (IBS is common)
• Visual problems
• Purple hands and feet (pooling of blood in extremities due to sitting and standing for varying amounts of time)

I would like to highlight that people are often misdiagnosed with anxiety when it’s actually PoTS, PoTS itself creates feelings associated with anxiety & increased sympathetic nervous system (SNS) activation.  Living with PoTS can of course also cause anxiety, or anxiety may be pre-exisiting as well.

Many things can make symptoms worse including excess heat, a big meal or certain foods, decreased fluids or dehydration, hormones, stress, standing up too quickly, not getting enough rest, exercise (doing too much or certain types like HITT – HITT is never a place to start but may be possible with rehab), time of day (generally worse in the morning) and alcohol.

PoTS can occur as a primary problem or secondary (associated with another condition), including: fibromyalgia, ME/CFS, Elhers-Danlos syndrome (EDS), Parkinsons disease, lupus, rheumatoid arthritis, lyme disease & others.  Mast cell activation syndrome (MCAS) can be present as well, it is not clear if this is a primary or secondary issue, there is also a triad of EDS, PoTS & MCAS.  PoTS is also associated with long covid/post covid syndrome and is fairly common with this.  In my experience PoTS rarely exists in isolation.

PoTS is something I screen for as part of an autonomic screen with all the people I work with including those with persistent pain & fibromyalgia.  It’s not widely enough known about and screened for so is not always picked up and can be misdiagnosed as anxiety.  Some level of autonomic dysfunction is common in all the conditions I work with.

There are many things that can cause PoTS or contribute to it, which I am not going to cover in this blog.  You can find more information on PoTS here:

PoTS U.K website: https://www.potsuk.org

Information on the Long Covid Physio: https://longcovid.physio/dysautonomia-pots

How Can Physiotherapy Help With PoTS?

PoTS often needs to be managed by a multidisciplinary team (with a specialism or good experience in managing the condition).  Ideally a cardiologist with an a specialism or special interest in PoTS, a specialist physiotherapist, an occupational therapist when needed, a psychologist when needed, and a dietician may be needed with dietary adjustments especially if there is MCAS.   Psychological therapy can help in a number of ways, including with managing the distress of living with PoTS and some treatments, like EMDR, can help to regulate the ANS.  Other specialists may need to be involved, for example a sleep specialist.

A specialist physiotherapist can help to reduce symptoms and improve function, this needs to be alongside other factors like medication (when needed), hydration, increased salt (when not contraindicated), diet, compression stockings/garments, stress management & pacing of activities.   Some of the ways in which a physio can help are mentioned below.

Education & lifestyle modification: A physio can help people understand the condition and give advice on the lifestyle changes that help with management, along with supporting exploration of these.  There are a variety of lifestyle factors that can help, some of the main ones are mentioned above.

A tailored exercise programme:  A specialist physiotherapist can tailor an exercise programme, although this isn’t a place to start when PoTS is severe and great care is needed when there is PEM.  It is crucial that PEM is screened for as it completely changes how things are done.  Depending on severity of PoTS and other factors, including other conditions and exercise tolerance, recumbent exercises may be the starting point.  Exercise has been shown to be helpful in the management of PoTS, any exercise programme needs to bear in mind many factors.  To begin with it needs to be of a low intensity and progressed very slowly and it needs to be combined with other factors, including regulating & retraining of the ANS.

Pacing:  A physiotherapist can help people explore pacing of activities and different strategies that help with managing functional activities.  Pacing is not a set or fixed way of doing things, there isn’t a right or wrong, it needs to be individualised and it’s something we need to hold lightly otherwise we step into over control which ramps up the threat system and impacts our flexibility in interacting with life.  Pacing needs to be flexible and come from a foundation of compassionate awareness and understanding in my opinion.  People understanding their baselines for activities and what rest is for them is part of pacing, for people with PoTS rest may need to be laying down.

Breathing exercises:  Some people have a breathing pattern disorder alongside PoTS due to the prolonged over activation of the sympathetic nervous system, increased heart rate & shortness of breath (a breathing pattern disorder also contributes to these symptoms, and other reasons, it becomes a bit of a vicious cycle).  A physio can assess for this and give exercises to help retrain normal breathing and regulate the ANS, if needed people can be referred onto a respiratory specialist physiotherapist.

Management of multiple conditions:  People may well have other issues alongside PoTS including persistent/chronic pain, a specialist physiotherapist can tailor things bearing in mind the other conditions someone is living with as well as PoTS.  People may also have ME/CFS or long covid, I have an interest in both of these conditions along with PoTS, a graded exercise programme is not recommended with ME/CFS and this would also apply to long covid when PEM is present.  I have worked many years as a persistent pain specialist physio & so am well placed to help with this.

Regulating & retraining the autonomic nervous system:  This is important with PoTS, a physiotherapist can help people explore what helps them with nervous system regulation and retraining.  This like other aspects of care needs to be individualised, there is not a set guide and instead more of a flexible framework.  Part of this includes using measures like monitoring heart rate and heart rate variability (HRV), these are also helpful as part of guiding exercise progression.

Self-Compassion:  This isn’t something that is part of physiotherapy as such, it is however part of my approach to whole person care. Self-compassion can help to regulate the nervous system and the research shows us it helps in many ways (not specific PoTS research) including with decreasing self-criticism, increasing resilience and overall wellbeing.

About Me 

I work as a Pain & Fatigue Specialist Physiotherapist & Integrative Somatic Therapist.  Alongside working in the specialist area of persistent/chronic pain I also have a special interest in ME/CFS, long covid & PoTS, chronic stress & anxiety.   I also have lived experience of PoTS, ME/CFS, persistent pain & anxiety.   All of my offerings are trauma informed and I have a compassionate, integrative, person-centred approach to care.  You can find out more about me by clicking the link below

https://unityphysio.co.uk/about-ann-physiotherapist-in-lincoln/

I can work with anyone in the UK virtually and locally can offer in person appointments or a combination of remote and in person.  I offer a free 15 minute call for anyone before they decide if they would like to book an appointment.

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