How can patients and practitioners treat Chronic Pain?  My approach is to first try to understand what we are dealing with.  Chronic pain, by its very nature, is a slippery phenomenon.  Without a clear cause, there is no clear protocol to fit a client who comes in with pain that doesn't go away and can even morph into pain in different areas, of different intensities, durations and onset.  Therefore, I am attempting a series of blogs to get clearer about how to deal with a problem that just won't quit.

Chronic Pain is different from acute pain.  Acute pain has an obvious cause that heals and the pain goes away, while the onset of Chronic Pain usually cannot be traced to a single cause and the pain is not going away.  These two important distinctions set chronic pain apart and can invite anxiety, depression, difficulty sleeping, and a deep sense of seperation from a world that is not allowing the pain and its cause to heal.

First of all, let us distinguish some changes that happen to the nervous system in chronic pain.

• Sensations are more intense.  Nerve receptors are activated at a lower threshold. and more nerve receptors are recruited when a person has Chronic Pain.
• A stimulus that feels like pressure to an average person, feels like pain to someone with Chronic pain.  The nerve receptors called free nerve endings have the capacity to be stimulated by both pressure and pain stimuli. Even a light touch can be noxious to someone who is having a flare of chronic pain.
• A stimulus that feels like heat or cold to an average person, feels like pain to someone with Chronic pain. Nocioceptors (pain receptors) can learn to fire in response to less intense stimuli.. Nocioceptors called free nerve endings react to pain and also respond to temperature changes. But in chronic pain free nerve endings translate both temperature and pain stimuli as Pain.
  

Now let's talk about positive feedback loops that speed up and accentuate the devastating effects of Pain.

• Pain -> Stress -> Pain.  When you are in pain, that leads to more stress. Perhaps you are stressed about the effects of the pain on your ability to perform your job, or maintain your relationships.  Increased stress and tension in the body sensitizes you to tighten up and feel more Pain.
  
• Pain -> Decreased Sleep -> Pain. When you are in pain, it is hard to get comfortable enough to sleep.  Sometimes when you finally get to sleep, the pain wakes you out of it.  Without sleep the body cannot rest and renew and pain gets worse.
  
• Pain -> Increased Depression and Anxiety -> Pain.  When I hurt and the pain won't go away, it makes me anxious and depressed about my future.  I don't see how I can have any control over making the pain go away and I dread or fear the resurgence of pain.  My increased depression and anxiety makes me susceptible to increased tension, which my body now has learned to interpret as Pain.
  

Why does Chronic pain seem to start out of the blue?
Adults rely on movement patterns that were learned long ago as toddlers.  These old ways of moving through life have gotten us where we are today. However, toddler movement patterns are probably not the most efficient ways to use an older body.  This may not surface as a problem for many years, but unfelt wear and tear accumulates. 

Inefficient movement patterns  expend energy that does not translate into movement.  The excess energy that is not being used to move turns into heat and inflammation.  This irritation slowly wears down cushiony tissue, ligaments, and spinal discs in your body.  Eventually bones are left rubbing on bones.  When the tipping point is finally reached, a simple action can cause a nerve ending to be irritated and chronic pain begins. 

So what can you do? 
The solutions I have learned to rely on involve re-learning how to move and feel more efficiently and pain-free. Sometimes entraining the body into ease needs to be demonstrated to the body passively, with bodywork, since the nervous system gets so confused that it cannot untangle what increases pain sensations and everything hurts.  At a certain point in a patient's recovery, active movement can be taught (through mindful movement such as Qigong, yoga, MELT method, Yamuna balls, Feldenkrais, Trager, and other easy movements) to reinforce retraining the nervous system. Awareness of how what I do, think and experience affects my pain can also be incredibly helpful.

The best bodywork to retrain the nervous system involves some back and forth communication with the patient so that they know what makes them feel better, even a little and what makes the pain worse.  I especially like Myofascial bodywork for this reason.  I also like Lymphatic Detox and Craniosacral techniques because they address the inflammation and heightened sensitivity that results from Chronic Pain directly.  I will talk more about bodywork, active and awareness techniques and tackle how to cope with complicating factors of chronic pain in future blogs.  Stay tuned.  Meanwhile check out my services page to learn more about my Myofascial, Lymphatic and Craniosacral bodywork and Qigong active movement classes, introduced in this post.

For many years, more than 10 years, in fact, since I've been struggling with chronic pain,  I've been wanting to write about all the things I have learned to do for myself to reduce pain and suffering.  Techniques that I rely on come from the 3 M's mostly - massage, movement and meditation.  These are the practices central to my career as a massage therapist, qigong and tai chi instructor, and health educator and in my personal life. Each self help post is conceived to be kind of a reminder, a record of simple ways to turn toward yourself and utilize inner knowledge in times of trauma, stress and pain.  So here goes number one in my hoped to be emerging series - about acupressure self help points in the ear. 

I'm going to start by talking about the ear and specifically three points on the ear that can help immensely with any sort of trauma, Shenmen, Kidney and Liver points (see chart above from NIDA https://theory.yinyanghouse.com/theory/auricular/nada_detox_protocol)

How do ear points (acupressure) work?
Ear acupressure can help you reduce symptoms and stay strong. Similar to how foot or hand reflexology targets points on the feet or hands that correspond to areas of your body, Traditional Chinese medicine has mapped out a reflex of the entire body on the ear. Strategic pressure on specific ear points can address everything from stress reduction, soothing digestion, to easing joint and muscle pains. It's done by placing tiny press balls, small magnets, or seeds (radish or mustard seeds, for instance) at specific areas of the ears. You can even massage ear points using a pencil eraser.

Where are the points to press on? What do they do?
1. You can find Shenmen ("spirit gate") by pulling up on the very top of the ear cartilage and it will create a triangular shape (known as the triangular fossa) just beneath. Put the seed into the middle of the triangle to calm and ground yourself.  It is used to open your spirit to something higher to counteract disturbances on the earthly plane.

2. Kidney point is located directly below Shenmen in the next division/fold of the ear.  Place the seed pushing up to the top of the fold. You can think of this point tor bring the body’s energy back in balance. From a TCM perspective, Kidneys govern fear, so it can help with an overabundance of that emotion.  Also Kidney point is the foundation or root of all yin (nurturing) energy. The will to persist and move ahead in the face of difficulty is rooted in the kidneys. this point can revive a low sex drive, calm insomnia and revitalize low energy. 

3. Liver point is located underneath Kidney point .  Follow a horizontal fold of the ear back to where it hits the big arc of the ear.  there might even be a little red dot. When the kidney organs are deficient in TCM, liver suffers. When your liver fire rises, in TCM, it is associated with anger, frustration. Can be out of balance with sexual abuse, and all kinds of trauma.  Liver controls the flow of blood and menstrual cycles.  Lack of nourishment to the liver can result in nausea, headaches, and bouts of emotional outbursts. 

Once you've got your ear seeds in, press on them a few times a day, whenever you feel in distress.  Place your thumb behind the ear and your index finger in front and apply firm, gentle pressure. Ear seeds can stay in place for a few days to a week.  Remove them whenever they become uncomfortable. Often, seeds fall out on their own during showering or hair brushing.

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Along a hellish journey through chronic pain, I've encountered many health providers - western medicine doctors, headshrinkers, alternative practitioners, healing/pain teachers.  Following the advice of professionals, I braved many questionable and harmful procedures, addictive medications, pompous speeches, power trips, and expensive snake oil cures. And on the way, I learned a thing or two about healing with health professionals. 

Every new provider means new intake forms, rehashing medical history, maladies, complaints, - it can be traumatic to dredge this stuff up again.  Why even bother?   Those of us with complex issues are searching for clues about what is going on in our bodies and how to make them feel better. Think of every health provider as a stepping stone to better health. The one you've got may provide a clue or a lead to other professionals who are more and more suited to our needs.

Any health care provider worth seeing will fall into one of three camps.  The first camp holds excellent diagnosticians, the second are fine technicians, and the third group encompasses providers with a healing presence.  A patient who finds a practitioner with even one of these characteristics is lucky.  You may be on to a miracle when you meet someone with a healing presence or technical expertise AND the ability to name what you are dealing with in a way that you can grasp.

Excellent diagnosticians draw on one of two propensities.  A brilliant physician KNOWS what’s in the medical books. She’s memorized the facts and figures.  You provide an inventory of symptoms, and their brilliant brain sifts through it all to churn out useful knowledge. This propensity is developed through years of clinical experience - seeing a bunch of patients and recognizing patterns.

On the other hand, you may not be working with a brilliant provider, but a talented one. A talented medical professional knows when to pop open a medical text and where to find the information s/he needs.  For getting well, talent can just be as useful as brilliance, although hardly as spectacular.  I have heard that the doctor who can help you is the one who synthesizes the information that you provide and spits it back to you in a way that allows you to absorb it into your being.

Once you have a diagnosis, you still need the skillful technician for improvement.  This could be the massage therapist whose knows how to touch someone who hurts, or the acupuncturist who can insert a needle precisely and without a twitch.

Technicians specialize in different modalities. Promising modalities can be identified for different treatment goals. For example, within the field of massage, craniosacral therapy is known calming for the nervous system and used for headaches or pain along the spine, myofascial release eases connective tissue surrounding muscles and is especially helpful in cases of chronic inflammation and pain, lymphatic drainage moves lymph, detoxifying the immune system and is preferred to eliminate toxins and reduce swelling from surgery, trauma and illnesses.  Visceral therapy affects the organs .  Because all of these modalities are so powerful, contraindications must be observed - this is why you want safe administration by the skillful technician. A good listener (with hands, ears and eyes) can palpate minute tensions and follow as they unwind. Like deciphering a puzzle or peeling an onion.

However, a treatment where you lie flat on the table cannot give the body all the information it needs to sustain permanent change. Active, purposeful movements teach the body where is up, where is down, how to stand or move so that the body doesn’t have to fight just to hold itself up.  Mindful exercise leads to alignment, where the joints need to be to function in a position of strength. Yoga can show where the body is resistant and needs to flow. Pilates exercises are focused on the core – especially all things related to the iliopsoas muscle.   A good qigong class helps cultivate your inner strength and muscular endurance while you move in a state of ease.

As for healing presence - now what is that?!  When you find someone with a real healing presence, you know it.  When you get near that practitioner’s body, symptoms just seem to fly away.  You feel good in her office. You want to stay in her presence.

No matter how excellent the provider, your participation in the healing process is vital.  Even with the most brilliant diagnostician, you still have to give guidance about where to poke and prod.  The master technician needs to hear what works and what doesn’t.  Even the healer with a curing presence needs you to recognize when you feel better.  You have to help the talented and brilliant practitioners locate the information they need to run through their memory banks or healing hands before they can spit out a finding, not to mention a cure.  As one healing teachers likes to say, “We are revolutionaries in the making, creating a new model for healthcare. No one besides “us” can take on the mission of “taking care of us”.

Dear Friends and Readers.  I appreciate when you read my thoughts on the blog and it is a gift every time one of you reaches out to connect with me

This post is dedicated to John T. Clark III, a wonderful man, a respected judge, someone who maintained a loving marriage for 48 years, a man who lovingly adopted and raised two strong sons who now have families of their own.  He embodied what we from the Jewish persuasion would call a "mensch".  Johnnie was someoneI am proud to have known and loved as my guardian.

Born in Baltimore, Maryland, September 15, 1943 Died Centreville, Maryland February 2, 2014  After I hung up the phone from a long distance hypnotherapy call on Groundhog day, I looked down to see the light flashing a voicemail message.  It was my guardian's wife, Sally, with news that Johnnie had died around 3:20 in the morning.  To those who know me, you must have heard me talking about Johnnie - he was a force in my life and a surrogate father to me, albeit a very young one.  (He would have been 11 years old when I was born.)  Johnnie gave me away at my wedding and drove to another state to rescue me when I totaled the car that my mother left me in her will. Johnnie and Sally welcomed me into their home every holiday and almost every other weekend when I came home to the Eastern Shore from St. John's College .John Clark III was also a beloved (known as fair but sometimes feared) judge in the Queen Anne's County District Court.  His funeral was so packed with people who loved and admired him that the crowd overflowed onto the street.

From the day he took on the job of "legal guardian", I always knew Johnnie was always there for me.  And that connection continued to the day he left this earth. Even though I haven't physically been in Johnnie's presence or breathed air in the same room since 2005.  Even though he hasn't been able to speak to me in a few years. (His progressing Parkinson's eventually made it impossible for him to talk on the phone.)  And even though chronic pain kept me from traveling back to the East Coast to see him in the flesh. 

His wife, Sally, I also dearly love, (She was my matron of honor and a part of all the other stuff Johnnie was privy to in my life).
She told me in her message, not to be sad, they had many good years, and he was suffering so much in the end.  Sally said she was going to remember all the good times and try to forget the last two years which were hell for him and for her (watching him suffer ).  They have had such a rich and full life together - their fullness and love spilled over as they adopted two sons (one is my godson) both grown now with happy families. Their love also embraced two sisters from Spain during their high school years abroad.  I never met Carmen and Soledad Berbegal but from hearing about them from Sally and John,  I know that they experienced the same love and generosity that I did and were shown the same care and kindnesses that I enjoyed.  I am so grateful to Johnnie and Sally that they took me wholeheartedly into their already full lives and always made me feel like one of their own.  They included me on yearly car trips to Sally's mom and dad in Memphis, Tennessee where we got bored and lost in the fog just like a regular family does.

Carmen wrote a beautiful letter memorializing Johnnie in which she said, "When I think of you, I imagine your big smile, your curious eyes behind your glasses, your aura of youth, your charming way of walking, your belly, a book in hand, a mug in the other... I admire you so much, your generosity, your personality, charisma, and your big heart.  I remember you saying 'Hey girl' when you spoke to me... your sense of humor and sarcasm. John, I cannot thank you and Sally enough for having me in your house and getting to know you.."  all that she wrote goes for me too.

The most recent kindness of the Clark family was that they included me in the obituary as one of the survivors - "John T. Clark is survived by his wife, Sally, their sons, David and Johnathan and families, brother Billy, sister Carol, niece Stacey... and Marian Wolfe Dixon of Portland, OR."   Me. I love John and Sally like a father and mother, sister and brother, and they have been the best friends that ever could be.

thanks for listening

Recently I spent a delightful afternoon exchanging information about temporomandibular joint disorders (TMD) with my colleague Bruce Austin, DMD, LMT, a dentist and massage therapist from Corvallis Oregon.  He wanted to meet with me because in 2002 I developed a massage protocol for research on temporomandibular joint disorders in conjunction with Oregon School of Massage (OSM) and Kaiser Permanente's Center for Health Research (CHR).  To prepare for this task, I had to learn about TMD and what experts in physical medicine recommended for it and other dental pain, then synthesize and test a basic protocol which I still use for clients today and teach to advanced massage practitioners at OSM.  Here are some facts about TMD.

The Temporomandibular Joints (TMJ) are the two joints that connect the jaw to the skull -- the only bilateral joint in the body.  They slide and rotate in front of your ears, and if there is a problem on one side, it will most likely affect the other.

Temporomandibular Disorder (TMD) is any problem that prevents this complex system of muscles, bones, and joints from working together in harmony. “TMJ” or “TMD” refers to a broad range of symptoms.  TMD patients may experience several of these symptoms or only one. 
Symptoms most commonly associated with temporomandibular disorders include:

• Stiffness, tiredness, and/or pain in the jaw
• Chronic, recurring headaches
• Clicking, popping or grating sounds in the jaw 
• Earaches, which may actually be pain in the jaw 
• Pain in the jaw when chewing or opening wide
• Restricted jaw opening, catching or locking
• Difficulty or pain when closing the teeth together comfortably in a normal bite 
• A bite that feels off
• Sensitivity to touch and temperature.
  

The National Institute of Dental Research, part of the National Institutes of Health, recognizes three categories of TMD:

• myofascial pain - the most common form of TMD, which is discomfort or pain in the muscles that control jaw function and the neck and shoulder muscles.
• internal derangement of the joint - meaning a dislocated jaw or displaced disc, or injury to the rounded edges of the jaw.
• degenerative joint disease - such as osteoporosis or rheumatoid arthritis in the jaw joint.

Brief Anatomy of a Healthy Jaw
A healthy jaw is made up of teeth and gums, with a temporomandibular joint on each side and its attaching muscles. In the entire human body, there is no other joint system that has such a complex interplay of functional components.  The jaw functions optimally when the joints are healthy, when the teeth come together in a way that supports and protects the joints, and when the muscles are able to function in a relaxed manner.

Each TMJ (one on each side of the head) is made up of two bones, the mandible (jawbone) and the temporal bone (located at the side of the skull - your ear goes through here).  These two bones are attached to one another by ligaments and are surrounded by small muscles which control the position and movements of the jaw..  A small fibrous pad known as the disc acts as a friction absorber, preventing these bones from rubbing on each other, thus allowing an easy and smooth function. Nearby muscles of the neck and shoulders can indirectly affect the jaw are and/or can become tense and painful as a result of TMD.

Problems in the Jaw System
30-40% of the general population has clicking, popping or other sounds in the jaw joints during jaw movement. Joint sounds indicate a structural change that may predispose the person to developing pain and other difficulties. As long as this continues to be no more than uncomplicated clicking or popping, without pain or catching in the joints, there may be no reason to be concerned. However a dental evaluation at this point can prevent a problem from progressing and becoming more difficult to treat.

It is a myth that something called “TMJ” is a single discrete disorder.  The term “TMJ” (or more appropriately, “TMD”) is a broad, term, covering a wide variation of musculoskeletal disorders of the masticatory system and may include relatively minor, easily treated conditions that involve only the muscles of mastication. However, at the other extreme, are conditions that involve teeth, muscles and the temporomandibular joints which may require complex treatment strategies. The origin of TMD can even be remote to the head/neck, such as pelvis or sacroiliac mal-alignment or even leg and feet issues.

TMD can be brought on by a variety of traumas such as traumatic injury to the jaw or neck, whiplash, arthritis of the temporomandibular joint, and uneven bite (malocclusion) or poor postural habits.

Muscles of Mastication
Jaw problems  are most commonly seen first in stiff, tight muscles and perhaps in difficulty opening or being able to hold the mouth open.. This may gradually lead to painful jaw muscles that can appear as headaches or as an aching or tired feeling in the jaw.

The muscles of the jaw will adapt and accommodate to a bad bite to some degree if they can.  However, this is a little like taking a hike with a rock in your shoe. With each step, certain muscles are now used to “compensate” to avoid stepping on the rock over and over.  After a while, the result can be sore muscles in the leg or hip. In this way, jaw muscle pain can develop over time from muscles having to function in a “compensated” manner.

When pain does develop in the jaw, surrounding muscles tighten further to protect the painful joints. This chronic, prolonged tightening, referred to as “splinting”, can also result in more jaw pain. Clenching and grinding the teeth also contributes to excessive use of the muscles. Very often a combination of these factors, occurring at once, cause muscle pain or headaches.

Dental Role in Treating Temporomandibular Disorders
In the TMJ, the fit of the teeth dominates; i.e. people always close their mouth where the teeth fit together best. The TMJ is unique in that there is no other joint system in the human body that has a structure comparable to the teeth that can so profoundly affect structure and function.. If the masticatory system was like other joint systems of the human body, massage and other manual therapy would be entirely capable of managing TMD without help.

With orofacial pain that is not from TMD, the underlying cause of the pain frequently cannot be directly addressed and, thus, treatment of the pain (reduction of symptoms) is the best that can be hoped for. An example of this would be neuropathic pain,  frequently treated with medications or massage and hydrotherapy.

But for most TMJ disorders, knowledgeable TMJ dentists can address underlying causes of the pain and  reduce chronic exacerbations by means of a properly designed and appropriately adjusted intraoral occlusal appliance (splint).  The splint provides an environment in which all of the affected components of the system can achieve a return of normal function, or as near to that as is possible. Two Portland dentists who specialize in TMJ treatment are Arthur L. Parker, DMD  and Samuel J. Higdon, DDS.

The significance of appropriate and effective dental therapy combined with well-executed physical medicine must not be overlooked for the vast majority of TMD patients  The first objective of treatment of a jaw problem is to eliminate the pain. Patients with relatively mild and TMD symptoms that have not become chronic may experience symptomatic relief from several approaches to treatment, including massage, medications, rest of the joint, and home exercises.  The chronic or otherwise difficult patient is more likely to require a coordinated interdisciplinary approach to achieve significant and lasting results.

Manual Therapists who focus on TMD management should be knowledgeable about the dental role and develop a working relationship with at least one dentist who is knowledgeable, skilled, and experienced in non-surgical TMD management.

Massage Therapy's Role
Gentle mobilization inside the mouth can be very helpful in relieving pain and discomfort that can accompany TMD. Relaxation of the neck and low back is correlated with less severity in TMD symptoms as well.  However, the unique anatomy of the TMJ and the widely varying types of dysfunctions that can occur in this joint system make aggressive manual manipulation contraindicated in most cases due to the potential for compounding the condition.

Furthermore, if a therapist lacks
1)    Knowledge of the anatomy of the TMJ  and the wide variation of potential dysfunctional
2)    Familiarity with the effect of the dental occlusion on joint position and function, and
3)    Confidence of the specific diagnosis in a patient
aggressive manual manipulation is definitely contraindicated.  As not all massage therapists are trained in intraoral techniques or have a sense of the complexity and vulnerability of the TMJ, it is best to find professional bodyworkers who have specifically been trained in a TMD class like the one I offer at Oregon School of Massage.  Of course, TMD /intraoral massage is one of my specialties and you click here to contact me.

Massage will relax the muscles around the joint, thereby changing the bite so that some dentists want manual therapists to perform massage with the patient wearing their occlusal appliance (splint).  Dentists may also want to modify the appliance immediately following the manipulation to assure proper support for the joint in the corrected position.

In summary, an ongoing working relationship, involving regular communication and good rapport between a dentist and your  massage therapist is essential to treat the complexity of disorders collectively known as TMD.

When I receive bodywork - most notably acupuncture and massage, my therapists  remark on how loudly my body speaks.  They say that it almost seems like my body is yelling sometimes - "I want you to focus here! I want you do do that!"  And when they check in about what they think the bossy body is saying, it's almost always something I am thinking while I'm on the treatment table.   The health providers that I trust and stick with for the long term,  joke about my very "bossy" body. These excellent practitioners are not intimidated by the prolific non-verbal and sometimes out-loud verbal directions that help them focus better on helping me. And vice versa, when they say my body is "bossy",  I take it as a compliment - a bossy body is one that knows what it likes and needs.

My acupuncturist, Polly, often finds herself in the middle of a session puzzling why she is putting in so many needles or why she is leaving them to "cook" for so long or so deep, then she realizes - "oh its Marian" and she can relax.  She remembers that my body happens to like all that focused sensation and takes it's sweet time to process it.

And last time I went to my bodyworker, Katharine, she started telling me how "they" were telling her not to push so hard on my belly to give it relief.  At first I thought she was talking about her spirit guides -  she has told me that she talks intuitively to a bunch of exotic healing entities. But when I asked her point blank who she was talking to in regards to my body, she admitted she was conversing with my intestines.

Its not just nonverbal, mystical, intuitive messages that make up the way my body communicates, I can also use my mouth to flat out say what I want.  It is not uncommon for me to request, "Could you apply kneading or jostling so that my pain has somewhere to go, instead of pushing down on it?  I don't like the way that I feel with static force.  It feels like that kind of pressure traps the pain in my body."   (I have been teaching, writing about and applying massage for so long that I can be very specific in my requests.) Good health practitioners are grateful for my specificity.  They realize that my bossiness actually makes their job easier. They don't have to wonder what is the right thing to do. They don't have to pretend that they can intuit what I want when I am right there clarifying everything for them. They don't get caught up in their own ego.

I love my bossy body.  I revel in its voice.  For many years that voice was muted by confusion over my medically unexplained chronic pain and the prescriptions that I poured into my system to drown out the intractable hurt.  I didn't understand at all at any level, conscious or not, what could help me climb out of that morass.  I was at the mercy of therapists who didn't care how I wanted to be treated and who proclaimed conflicting diagnoses and treatments.  Heck, one local PT known around town for her "intuitive" bodywork met me and then arranged my body on the table like Jesus up on the cross.  She then started yelling at me "There, there!! you are a martyr!".  (Needless to say, the dramatics didn't help me and I didn't return.) Over years of dealing with personalities and agendas in alternative health that tried to boss me around just because I was sick, I learned that developing my own bossy body is a good thing.

So now I am so grateful for my beautiful mixed up crazy "bossy body" and any help it wants to share..

Calibration
A good health provider can model caring by the way they calibrate the modality that they practice.  Here are examples of how a therapist can hone your self-care, drawn from two of the modalities that I most rely on: Massage Therapy and Qigong/Tai chi.

Massage
    Massage therapists use touch to shine a spotlight on places of dis-ease, but more importantly, to shine the light of awareness on places of “ease” in your body. After a series of sessions your ability to feel and take refuge in places that feel good increases. Those body regions of refuge expand after repeated sessions, while areas of discomfort become less intense and smaller as they diffuse and are absorbed into healthier tissues. The most effective massage therapists will never make you grimace through painful pressure. They know that you are far more likely to experience longer lasting and quicker acting results when they massage right up to the edge of tension without forcing past. This technique establishes awareness and the possibility of release without increasing tension, strain and pain. After experiencing the ease with a professional, you may find that you can get in touch with your body in a new way using your own hands. You may even be able to feel the knots melting underneath your hands, or your own energy pulsing beneath your fingers, as it releases. And you may want to reinforce this knowledge by having your therapist give you a good working over. Let this become your once-a-month, twice-a-month or weekly treat to take care of yourself.

Qigong/Tai chi
    Qigong/Tai chi is a movement meditation enhanced with imagery. At its most basic level, Qigong is a practice of following  the continuously changing sense of life force energy as it moves through you. Self-practice reinforced with weekly or biweekly group practice/classes are ideal to build Qi (energy) and one’s connection with self, others, and nature. A good Qigong coach teaches and encourages you with this loving practice.
    The word master, as in “Qigong Master” is somewhat intimidating – it implies a lineage that has been passed down and teachings that cannot be adjusted in any way. However, Qigong literally means “energy work” (Qi = energy and gong = work, so we’re actually learn to “gong our Qi”). This energy work is an iterative process, and naturally changes over time by the people who put it in to practice. The best Qigong coaches or tai chi instructors encourage students to develop a solo practice that meets their individual needs.
    For example, when I practice the pose “Carry tiger to the mountain” and feel the incredible release in my body as my hands reach up to release my burden/the tiger’s spirit into the sky, that body sensation is how I understand the form.  The pose “Holding up two mountains” is honed to my exact needs when I feel just how much to extend my arms in order to express “right place, right time”.
    I am not the first to adapt Chinese movement forms for personal needs. The Yang family adapted Tai chi to reflect a health generating form from the twisting, powerful Tai Chi movements expressed by the Chen family. Qigong and Tai chi were the original Chinese medicines, before acupuncture, before herbs. Movement practice doesn’t depend on any outside substance or procedures– just an increasing trust of one's own body and how it wants to move.

Compassion
Once you have chosen therapeutic modalities to support your unique needs, what else does taking care mean? In colloquial language, “take care” is often used to mean “WATCH OUT!!!” Sometimes when you leave on an airplane, friends and family cry out: “Take care!” They really mean: “Take care not to get killed on the airplane! Take care not to get hijacked!” However, taking care is so much more than a warning. Taking care can be like the soft brush of a mother’s hand on your cheek. Say to yourself: “There, there, I know it hurts, but I am here for you.” You can be your own best friend on the journey towards wellness.

Most of us are nicer to everyone else than we are to ourselves. When we practice accompanying ourselves with love and kindness throughout the day, whether things go well or not, it can translate into all sorts of benefits, some tangible, some not. This loving practice can build a resiliency to carry us through to the next thing in our lives.

Taking care of yourself compassionately can be the intentional path to try the next step proposed by a practitioner even if it seems scary or strange. Taking care can involve following through on exercises or lifestyle changes that support the healthier you. And taking care can be giving yourself a break when you are sick of only eating rice and vegetables every day and decide to splurge on a piece of chocolate for a special occasion!

Communication
Taking care is not blindly letting a therapist dictate significant lifestyle changes. Patients are not empowered when a doctor simply hands out a bunch of pills, although sometimes medications can be a necessary jump start towards wellness. Similarly, people don’t feel stronger when handed out a bunch of prescriptions of what they have to do – for example, lots of exercises or food restrictions without consideration of how to implement the lifestyle changes in real life. No one can live on kale salad and mushrooms alone or 3-6 hard hours of cardio every day—unless it gives them joy.

In my mind, dogged adherence to rules is little better than downing a bunch of drugs. Asking hard questions of my practitioners about how I can do what I am asked to do makes me feel stronger. Communication is empowering.

Choice
Last but not least, taking care involves exercising choice. The power of expectation and choice is illustrated by one of my favorite research studies, ever. Kalauokalani, D. et. al. (1) studied 135 patients randomized to receive either massage or acupuncture as treatment for low back pain. Before being assigned to either group, participants were asked to describe their expectations regarding the helpfulness of each treatment on a 1 to 10 scale. Patients who expected that massage would help more than acupuncture were more likely to feel better with massage, and vice versa. General expectations about getting well did not effect how well patients recovered. This study demonstrates the importance of selecting how you care for yourself.

In summary, taking care involves lots of “ vitamin C's" :

• Calibration or fine-tuning knowledge about your body,
• Compassion and self-kindness,
• Communication,
• Choice

The last "C" is for Continue.  Continue to apply any and all Competencies you gain.

(1) Lessons from a Trial of Acupuncture and Massage for Low Back Pain, Kalauokalani, D., Cherkin, D.C., Sherman, K.J., Koepsell, T.D. and Deyo, R.A. SPINE volume 26, Number 13, pp. 1418-1424 (2001)