‘Some of us have wounds that have never healed. We have
lived with them so long that we don’t even know they are
there any more. But pain reminds us.’
– ‘Tuck’ in The Best of Me
After back pain, there is a whole host of other chronic pain-related conditions that cause widespread misery, place a strain on health services and have such a profound effect on sufferers’ lives that in some cases they are unable to hold down a job or maintain a relationship. If you are a sufferer of fibromyalgia, chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS) or migraine, then you have doubtless spent years, decades even, pursuing relief to no avail. You have almost certainly become cynical about promises of a cure – and enraged by those practitioners who tell you ‘It’s all in the mind.’
Don’t worry: I’m not going to hold out false hope. Nor am I going to promise you can think yourself better. Instead, I hope to show you that underlying those symptoms as distinct as blinding headaches, painful joints or exhaustion, there are some uniting factors at work. And if we understand those, then relief is possible. I am also going to introduce you to hypermobility, which commonly intertwines with the roots of these chronic conditions.
As I said in Chapter 1, the current biomedical model of medicine is not comfortable around conditions that are not explained by a tangible, identifiable underlying disease, i.e. that do not fall within the realms of biology, surgery or pharmacology alone. As a result, medicine tends to mistrust the patient’s story if it does not match the clinical findings. The patient gets filed under neurotic or ‘malingerer’.
But, either way, stating baldly that ‘there is currently no known cure’, as the NHS website does for fibromyalgia, is depressing and completely self-defeating.70 A more helpful approach would be: ‘We have given a set of symptoms and a pain syndrome an official Latin name but don’t know how to treat it within the confines of our knowledge because it falls into a grey area and we don’t like grey areas.’
First, let’s take a look at fibromyalgia. If we accept that what I have presented so far in this book is the mode by which pain, fatigue and related depression can develop, then fibromyalgia is not difficult to understand. It is characterised by persistent widespread musculoskeletal pain, a phenomenon called allodynia (increased pain sensitivity), and trigger points in defined areas of the body, one of which must present with a score of 11 out of 18 to qualify for diagnosis. It affects significantly more women than men and sufferers often complain of insomnia, fatigue, anxiety, depression, gastrointestinal symptoms and headaches, as well as ‘fibro-fog’, an unpleasant loss of mental functioning and acuity that manifests as memory loss and slower recall of names and places.
At the heart of fibromyalgia lies the world of central sensitisation, which we covered in Chapter 2, but which I will recap and summarise for you again here. This is when the brain, through repeated failure to come to terms with whatever threat or lack of safety it perceives, gets trapped in a vicious cycle of arousal, the sources of which are due partly to childhood experiences and partly to current environmental circumstances (our lives, basically). As a result, three things happen physiologically:
1. The firing threshold of the nervous system lowers and smaller stimuli cause pain.
2. The after-effect of pain lingers; and episodes merge and become constant.
3. Previously harmless input from the tissues to the brain is interpreted as harmful or noxious.
CFS, IBS and migraine often co-exist with fibromyalgia, and they all have the same causation or origin. They are effectively all pain syndromes, and muscle is the common denominator in all three.
IBS or irritable bowel syndrome afflicts around 15 per cent of the industrialised world and it is the most common reason that patients are referred to gastroenterologists.71
It is a set of unpleasant and debilitating symptoms (not a disease) which can include abdominal cramps, bloating, diarrhoea, constipation, or both intermittently. Its associated symptoms are tiredness, nausea, heartburn and indigestion, needing to pass urine frequently, backache, muscle pains, headaches, anxiety and depression. Quite a mix, and that’s the interesting bit. Because, although the primary symptoms manifest in the bowel, the syndrome overlaps into several other systems.
If we take ‘backache’, which we associate with coming from the tissues and muscles of the spine (the musculoskeletal system), this may seem unrelated, as a symptom, to the bowel. But it is not. The backache occurs through a reflex we call a ‘visceral reflex’. The part of the bowel which becomes irritated refers the pain back through the nerve which supplies it, to the level of the spine (the low back area) from which the nerve takes its origin. This nerve becomes hyper-aroused and ‘switches on’ along its whole length – to such an extent or threshold that the brain registers pain in all of the regions the nerve supplies. In the same way, the pain of a menstrual period is often not only felt in the lower abdomen but also sets off backache.
Although a large proportion of IBS patients present to tummy specialists, many who have the condition are never seen by doctors, so figures for the prevalence of this condition are probably conservative to say the least. When fMRI brain scans are carried out on these patients,72 it is common to find that an unusual part of the brain lights up in them when the abdominal pain is felt. This region is known as the prefrontal cortex and is associated with the storage of emotional memories. Therefore, we can reasonably conclude that some event of emotional importance is occurring because of, and at the same time as, the pain being felt, which is a result of the automatic firing of nerve pathways formed and sensitised long ago. How can we account for the formation of these pathways? There is a strong association in these cases of abusive or unhappy childhoods, as well as chronic stress in adult life.73
Just as fibromyalgia is characterised by global bodily muscular pain and sensitive trigger points in the muscles, the pain of IBS is stimulated by tension within the muscles of the bowel wall. As the bowel contracts (a movement known as peristalsis), pain is felt, and activation of the skeletal muscles hurts on movement. At the same time, because stress responses cause the vagus nerve (the principal nerve of our ‘rest-and-digest’ system) to shut down, bowel movements also shut down partially and become disordered in their rhythm. The receptors within them become sensitised and volatile. Digestion is interrupted and the bowel wall becomes ischaemic, which means it does not receive enough oxygen and so metabolic waste products build up. This is painful and can cause inflammation in the bowel wall. After a while, these changes also interfere with the absorption of nutrients from the food being digested, resulting in variable bowel movements, from constipation to diarrhoea.
We would be wrong, however, to think that IBS is a disease of muscle. Rather, it is due to the hyper-aroused state of the nervous system and the way it is communicating with the gut, through the pathways that I have described in previous chapters. Remember that the gut does a lot more than digest food. It is also an important sensory organ that we switch on when we are stressed in order to better assess threat from external environmental elements. In fact, there are more nerves running from the gut to the brain than from the brain to the gut – hence what we nonchalantly call ‘gut feeling’, which is actually a real and rather fascinating phenomenon.
Most of the time we recognise a gut feeling as a message that something is ‘up’. That ‘something’ could range from an excited stirring of the loins to a revolted response at something we have just seen or even the harbinger of impending doom. Whichever emotion it represents, it is a warning to prepare, be ready or protect. As we have already discussed, the bowel, including the stomach, despite our perception that it is within us, is in fact a portal through which infections or toxins can invade from outside. It directly interacts with our environment. So the brain has, by necessity, to place a high level of vigilance around its entire length as a monitoring system for threat. Through a branch of the PNI system (see page 88) the brain and gut have a constant conversation.
It is if that stress response goes on for too long that changes occur in the gut and it remains in a ‘fight or flight’ status. Like any sensory organ, it can become sensitised and fire pain at the slightest stimulus, which ordinarily would be ignored. The brain relates to the gut its own emotional interpretation of the world. Similar events in the gut reinforce that emotional interpretation. Where the two meet there is pain. The messages sent back to the brain give rise to conscious ‘gut feelings’. So, IBS is effectively gut feeling gone mad.
CFS (aka post-viral fatigue) rarely occurs without some of the symptoms of the other conditions we have looked at, such as muscle pain and bowel disturbance. I have learned through experience and research that CFS is just another manifestation of the same thing, so all of the above applies. It is clear to me that fatigue, lethargy and lassitude are simply another way the brain has of protecting itself from danger. It is an emergency defence used to opt out of engaging in things that it perceives to be potentially dangerous or harmful.
Fatigue and pain often go hand in hand as protective mechanisms of alarm and withdrawal. The sufferer adopts fear-avoidance behaviour (‘it hurts – that must be bad, so I won’t do it’ or even ‘it will hurt so I won’t do it’) and they become trapped in the cycle. The wise physician will listen to the story and decide which symptom is most pertinent to treat first, but the basic approach should be the same – find out what the brain has to fear and why, and reverse the strategies it has adopted to protect itself. Then formulate your own bespoke strategy to lead that poor soul out of their suffering.
Before we go further, we need to deal with what I call the ‘viral fallacy’. For many years, patients with the symptoms of CFS and fibromyalgia were submitted to a barrage of medical analyses, mainly blood tests. All too often, antibodies to several common viruses were found to be present, most notably Epstein Barr virus, which causes glandular fever, aka ‘the kissing disease’ (because it was common in teenagers at university), but also shingles (reactivated chickenpox, herpes zoster) and the other herpes strains (cold sores and genital herpes). These viruses were often blamed for the chronic symptoms that recurred. But if you cast your mind back to what I explained about the psychoneuroendocrine-immunology (PNI) system, you can see why this is misguided. These viruses exist in most of us naturally and sit dormant in the nervous system, waiting for an opportunity to pounce when the host’s immune system is depleted or distracted by another infection. Herpes sits in the sensory nerves themselves, where it is prevented from propagating and getting established as an infection by our very efficient immune system until such time as our immune system is suppressed for some reason. In the case of herpes zoster, this will take the form of a shingles outbreak. In most people, it will usually be because of the stress/cortisol effect, in which the circulating cortisol inhibits the immune system. Certainly, our immunity has to mount a response once the virus is active, and in the case of an already fatigued and reduced system, this might be the straw that breaks the camel’s back, producing long-term symptoms, such as CFS or fibromyalgia. But it is not the virus itself that causes this; it is the depleted state of the PNI system.
Similarly, auto-antibodies (antibodies against the ‘self’ that can set up friendly fire) will be found in the blood of people who seem to produce a lot of inflammation in their joints and tissues, but they are also present in many of the population who do not have symptoms.
In the case of students (drinking too much, late nights and working to deadlines) and yuppies (stressful jobs and high-performing, competitive lives), it is hardly surprising that they are susceptible to outbreaks of viruses like glandular fever, herpes and shingles. And, sadly, in an increasingly pressured world, we are seeing younger and younger people falling victim to these conditions. Patients frequently adopt the false premise that they are being attacked by some nasty bug. But the bottom line is, it was the state the patient had got into, caused by all the stressors we have discussed before the virus reactivated, that is relevant, not the virus itself.
Migraine, a condition that co-exists in up to 50 per cent of fibromyalgia patients, has a similar origin to these other chronic conditions. It starts as increased sensitivity in the primitive brain stem, due to continued fear responses, and spreads as a wave of excitation across the higher cortical centres. As it passes over the key regions of the brain, it produces all sorts of associated visual and auditory symptoms (e.g. scintillations, blind spots and ringing in the ears), as well as nausea and vomiting. For most, the pain is so incapacitating that they shut down and take to their beds. The anxiety that is induced, particularly over the sinister nature of the symptoms and the lack of apparent cure, fuels the vicious cycle.
Once one understands this phenomenon, then the classic distribution of a migraine is predictable. All the parts of the brain involved have a sensory function. Migraine is mediated through the trigeminal nerve, an important cranial nerve that supplies sensation to the face and head. Along with our eyes and ears, it gathers sensory information from our environment around the evolutionarily most important part of the body, the head (after all, it houses the brain). When under attack, the head, neck and face were the most important structures for detecting, sighting and escaping predators. The nerves from them are all hyper-sensitised by the brain, and the state of physiological arousal that is established in ‘migraineurs’ is constantly raised.
Interestingly, the trigeminal nerve has a very long nucleus, which extends down into the neck section of the spinal cord. From the muscles and joints of the top of the neck, it receives sensory information about where we are in space, and forms an important part of our body-positioning system. This is why atypical migraine can often manifest as pain in the neck rather than in the head and why the visual and auditory symptoms do not occur. Some of my patients ask me why, if migraine is stress-related, they so often get it at the weekend. Migraine experts will tell you that migraine doesn’t like change. So, if you are stressed, stay stressed, and if you are not, don’t get stressed. This makes sense, because if you are in a constant state of vigilance it is changes in the environment that represent danger. We learn this through our orienting reflex, a clever process by which the brain notices what is different about our world. To an already vigilant and primed migraineur, change is bad.
Another curious fact is that many migraineurs get the symptoms in childhood but it manifests as abdominal migraine (recurrent tummy ache). For some unexplained reason, it converts to headache in their early teens. This is speculation on my part, but I suspect it is because our teens represent the time when we leave the safety of our parents’ home and become less vigilant regarding our nurturing and more focused on our new-found need to protect ourselves. Our heads became more important than our stomachs.
What all these conditions have in common is a state of physiological hypervigilance, caused by long-term evolutionary exposure to a multitude of biological, sociological and psychological stressors, to which we have had to adapt and respond. Therefore, to address these conditions, we need to tackle the root causes of our own hypervigilance, as well as our perception of them. Some of the causes we can resolve immediately, as they exist within our current life and lifestyle, for example:
• Lack of education about the problem
• Poor therapeutic relationship with medical team
• Opiate overuse
• Overweight
• Dietary no-nos (e.g. stimulants and sugar)
• Low Vitamin D and B12 levels
• Lack of exercise (the right kind)
• Bad design of working environment
• Poor flexibility and balance
• Relationship issues (friends, partners and marriage)
• Isolation, loneliness
• Poor job/bad boss
• Repetitive habitual behaviour, both physical and psychological
• Poor sleep patterns (e.g. apnoea)
• Overuse of social media
Some contributing factors are more subtle and potentially more difficult to broach, as they relate to issues from the past, for example early life and upbringing. However, they must still be examined:
• Loss of a parent
• Alcoholism or substance abuse in a parent
• Living with or caring for a sick family member
• Parental catastrophising over health issues
• Single or absent parents
• Emotional detachment from parents
• Narcissistic/manipulative parent
• Rigid religious or cultural upbringing
• High-performing upbringing
• Helicopter parenting
• Early separation a from parent
• Unreconciled adoption
• Post-traumatic stress disorder (can be of subtle origin)
Many of these issues will be beyond the scope of practitioners other than psychiatrists or psychologists. But I’ve found that helping a patient to recognise the relevance of them and the influence they have on causing and maintaining the problem is a good start. I’m fortunate enough to have good colleagues within the psychological specialties to whom I can refer patients.
Lastly, we have to mention sleep. Fibromyalgia, IBS and migraine sufferers frequently report poor sleep. I have taken it upon myself to read at least five of the best books on sleep for you and have listed them at the back of this book. The only things that none of them seem to go into much depth on as a source of sleep disturbance are stress and anxiety. While I agree that good sleep hygiene (top tips in Chapter 9 later) is vital, because when it is poor it can cause all sorts of problems, I feel it is of little use unless you get to the bottom of what ails the patient in the first place.
Remember: no one has a single answer for all pains, and each person’s pain is unique.
You need to find the right team to formulate the right treatment programme for you.
The problem for patients is that if they are not lucky enough to find that team, they can end up in what Dr Heidi Prather, head of rehabilitation at Washington University School of Medicine, calls the ‘specialty fish pond’. Patients are swimming in a pond of pain and get fished out by one specialty at a time. Each one realises that they can’t help so the patient is thrown back, only to be fished out by another specialist, and so on and so on.
In an ideal world, any good pain programme must include a team that can provide physical therapy based on early direct manual techniques to relieve pain as well as gradual physical strengthening to achieve proper body biomechanics and cardiovascular training. Group therapy sessions are also helpful, for help with stress management, sleep hygiene, breathing training and biofeedback. Sometimes cognitive behavioural therapy can help as well.
In the case of fibromyalgia, the right type of exercise, properly graded and paced, is crucial, backed up by good manual therapy. Hydrotherapy in warm water has been proven to be helpful, as has a mixture of aerobic exercise and resistance work. T’ai chi and qi gong are also beneficial and I have many of my patients doing it. Good education releases the fear of pain and allows patients to forge through it. Understand yourself, know yourself and your condition, and move… a lot.
One of the most comprehensive and successful programmes I have observed is at the Cleveland Clinic in the US. Edward Covington, the programme director, said in an online interview: ‘The most powerful psychotherapy that the patients receive is in the gym. It is there that they learn to recapture the power of their own bodies, recreate the endurance they lost, and learn to see themselves not as helpless and powerless to deal with their situations but as having the ability to cope physically.’ 74
As far as possible, on Covington’s programme, all patients are weaned off their medication. ‘The patient comes in cognitively soggy and leaves much clearer,’ as one of the team, Judith Sheman, says. ‘There are a lot of Kleenex around as patients are made to talk about family dynamics, their fear and miseducation about their pain, as well as their elation over not being told once more, “We can’t help you’’.’
The clinic believes it is essential to help the patient find a new identity beyond that of ‘sufferer’.
Sadly, as far as I know, there is nowhere in the UK with a unit that utilises this approach on such a comprehensive level. And yet we estimate that 43 per cent of the population have a pain problem.
In several of the case histories in this book, I have mentioned hypermobility, a condition that is not usually an illness in itself but often causes persistent pain and overlaps with fibromyalgia, CFS and IBS.
More research is necessary to obtain better data, but it seems that about one third of fibromyalgia patients will also be hypermobile. Similarly, a subset of hypermobile patients will develop fibromyalgia, particularly children. It is not always easy to discern which symptoms are from the fibromyalgia and which from the hypermobility, but I will try and give you some pointers
Hypermobility is a spectrum disorder, which means you can range from being mildly double-jointed to resembling Elastigirl or Stretch Armstrong (that shows my age). At the extreme end of the spectrum are two main conditions, Ehlers-Danlos syndrome (EDS) and Marfan syndrome. Like me, you can have Marfanoid traits without having the ‘full-monty’ condition. Unfortunately, EDS comes with some other nasty problems, which most hypermobile people will never have to worry about.
If you suspect hypermobility is at the root of your pain issues, then I would recommend you visit hypermobility. org. It is the website of one of the world’s leading experts on the subject, Professor Rodney Grahame, at University College London Hospital.
If I had my way, all children would be routinely checked for hypermobility, to provide parents with the right advice and information to help prevent pain in the future. The clinical checks are quick and easy to do and are painless and non-invasive. Even if children are diagnosed, it does not mean they are disabled or unable to lead a full and active life.
Hypermobile joints just have an unusually large range of movement in them. Sometimes, patients describe themselves as very ‘bendy’, ‘loose’ or ‘double-jointed’. They also notice that they have unusually stretchy skin, as well as stretch marks. Hypermobility is an inherited condition, due to the absence of a gene that produces particular types of collagen in the soft tissues. Collagen is found almost everywhere, especially in the skin, ligaments, muscles, tendons, heart, blood vessels and eyes. Collagen is basically a supportive protein and stiffening agent that helps to hold all our musculoskeletal system together. As they don’t have much of it, hypermobile people have to activate their muscles to work harder to help fight against the burden of gravity while also carrying out the usual movements of daily life.
Hypermobility is also commonly associated with lower resting tone in the muscles, and people with it notice they cannot get the same tone and definition in their muscles that other people have, often despite regular exercise. As in fibromyalgia, hypermobile patients tend to produce trigger points in their muscles, which is another reason why the two conditions can overlap or be confused. These trigger points can develop early in life and pre-sensitise them to pain.
The combination of low muscle tone and looser ligaments means that at rest the joints and limbs are poorly supported. This makes you feel stiff because your muscles have to work harder to support the joints. This in turn causes the joints to settle and the joint capsules (the membranes around the joints) to stretch, which ultimately produces pain. As a result, hypermobile children get uncomfortable sitting or standing still for too long and have to shift position. They fidget constantly and jiggle their legs and feet, which adults can find irritating. As I tell patients, they have to move to think. I am a big fan of asking schools to allow hypermobile students to sit at the back and get up and walk around when appropriate, making it clear, of course, that it is not a punishment. In an ideal world, I would give them all standing desks, as children sit too long anyway. There is great evidence that children learn better and are more creative when they can move.
Hypermobile adults also need to get up and move around more often. They are more prone to repetitive-strain-type injuries, and so need to take regular rests from certain tasks.
They also have a tendency to be clumsy; this is not the same as being dyspraxic, which involves poor hand–eye coordination. They are very often flat-footed or get lazy muscles in their feet due to the wrong footwear, particularly shoes that have too much cushioning and not enough support in the uppers. A lace-up is better and should be flexible. They love swimming as it is gravity-free, and the increased extension they have in their knees and shoulders gives them a better stroke. They are also naturally drawn to dancing and gymnastics as they are naturally flexible, and these are the types of exercise that give them the strength and tone they need. So if your child is hypermobile, encourage physical activity early, particularly climbing, balancing and crawling, even if they don’t think they are good at it. Martial arts are great, too.
Hypermobile people often complain of pins and needles, numbness and tingling in their limbs. This is because they are more prone to nerves being compressed within the soft tissues under their body weight. Also, there is a significant amount of ligament along nerves, which supports them and protects them from being overstretched. If the ligaments lack collagen, as is the case in hypermobility, they, and the nerves they support, can be stretched more easily.
Low tone in the blood vessels (due to lack of collagen) means that hypermobile people tend to have low blood pressure. Generally, this is a good thing. However, sometimes it makes the vessels respond more slowly to changes in pressure (for example when going from sitting to standing), and people may take longer to adapt to it. This can make them feel faint or dizzy. Occasionally, it is accompanied by harmless palpitations. Hypermobile people are more prone to IBS-type symptoms because the bowel has poor motility and can get inflamed. Girls in particular can get a nervy bladder syndrome, making them feel they need to go more often or more urgently. I am afraid natural childbirth can also permanently stretch the pelvic floor to the extent that even exercises won’t help.
Many of my hypermobile patients report that they often feel light-headed in the heat. This is because in hot weather the body tries to cool itself by opening up the blood vessels in the periphery (arms, legs and skin). However, this tends to reduce their blood pressure, which is already quite low, producing a spaced-out feeling. It is harmless but disconcerting.
Weirdly, hypermobile people are more likely to be resistant to the effects of local anaesthetics, such as the ones used in dentistry. They also tend to be vitamin D-deficient and bruise more easily.
What does all this mean? They hurt!
Many people between the ages of 20 and 40 ask me: ‘Why have I got all my symptoms now?’ My answer is that, unfortunately, hypermobility hates inactivity. It hates sitting and it hates habit. When we are fit and well-toned and strong in our teens and early 20s, we do a lot more exercise and are generally more active. Work, on the other hand, tends to involve long hours of sitting and doing the same actions – usually typing on a computer. We just move much less. As a result, our muscles weaken and we slump onto our ligaments, which in the case of hypermobility are weak anyway. The result: sensitisation and pain.
In general terms, the best hypermobility patients are the young, fit, exercising, lean and well-motivated who present with postural problems, muscle strains, tension headaches and occasionally shoulder and knee dislocations. The most difficult to treat are middle-aged, unfit, overweight and deconditioned. But, equally, they are the ones I love to see in clinic because we can mobilise so many different strategies to help them, and when they turn the corner it is very gratifying for all concerned.
As with the other conditions we have looked at in this chapter, explanation and education are paramount to relieve the inevitable anxiety over the distressing symptoms of hypermobility. Many of my hypermobile patients have been relieved and grateful just to have their symptoms linked, diagnosed and explained, so that they can stop being a sufferer and learn to thrive. It immediately empowers them to take the steps to get well and reduce their pain.
The right kind of graded and mixed exercise treats almost all the symptoms, including the cardiovascular ones. Most of my patients start with stretches to specific shortened muscles. These are isometric, postural and balance-based exercises to stabilise their joints in three planes of movement, which are kept simple but should be done daily. The pacing and loading of the exercises is core to their prescription. This is backed up by t’ai chi or qi gong and specific Feldenkrais moves; I rarely advise yoga as people tend to overstretch and we are trying to make them stronger and more stable, not more flexible. After that, they advance quite quickly to more strenuous stuff, with resistance work forming the majority of the programme. As David Butler and Lorimer Moseley, pioneers of pain education, say in Explain Pain: ‘If you have issues in the tissues, motion is lotion.’ 75
I factor in a series of self-treatment strategies, such as breathing training, body brushing and trigger point release with my Bakpro tools, to relieve inflammation and the contributing peripheral ‘feeders’ to the pain that lie in the tissues (this calms nociception and changes the type of over-sensitive receptors to less twitchy ones).76 I am not averse to the use of medication in bad cases, to obtain a window of pain reduction so that patients can get going, but the aim is that they will be completely medication-free by the end of the treatment.
Releasing trigger points – the tender points in muscles that are characteristic of painful musculoskeletal syndromes – with breathing retraining is key. Correct breathing helps to reduce the fear response of the pain and regulate the sensitivity of the points. I also advise my patients to keep well hydrated, eat regularly and not miss breakfast.
Perhaps most importantly, I hold their hands in the early stages but then, once they are ready and can self-manage, I positively reinforce that, in the nicest possible way, I never want to see them darken my door again.
They do occasionally return, because either they have got slack and let things slip, or had a mini-crisis and need to touch base. We reset them and release them once more. As I always tell them, if they need to keep seeing me, I’m not getting them better!
A talented and articulate woman in her 40s, Nathalie is in great demand on televised discussions and as an expert commentator. Her husband is a wealthy businessman and they have three lovely children, the first conceived by IVF. So far, so blessed. But when Nathalie came to see me, she was at the end of her tether. A fibromyalgia sufferer since her 20s, she had suffered wearying pain for two decades which had now led to grave problems in her marriage. The episodes of migraine that had her bed-ridden once a month wreaked havoc with her schedule, and there were mumblings at work.
Her husband travels constantly, pursuing business projects, and the strain of managing her own work portfolio and the demands of her children, while keeping up a constant battle against the pain, had led Nathalie to take a leave of absence from all employment for six months. She told me in tears that she was fairly sure her husband was seeing other women, who could provide him with light-hearted companionship. She felt anger and guilt over it because, although he was being unfaithful, she somehow understood, as her libido had gone through the floor and they almost never made love. Facing the loss of her marriage and her job, Nathalie was understandably distraught. During our first meeting, she sighed 15 times and held her breath repeatedly.
From shaking her hand on arrival and watching her standing posture, and then noticing her constantly fidget in her seat, with a leg crossed around and inside the other, I realised she was very hypermobile. Although she looked a normal size on television, which famously adds pounds, she was actually painfully thin and poorly muscled from following a wheat-, dairy- and sugar-free diet, which she believed would help control her symptoms. She also tried to avoid red meat, and the protein content in her diet was low.
I listened to her story. Nathalie’s father walked out on the family when she was three years old. This memory exacerbated her fears that her own husband would now do likewise: after all, isn’t that what men do? She had always sought the affirmation of her father because he was clever and successful. As a child, she had thrown herself into her schoolwork and dance classes and for a time considered professional ballet training. I pricked my ears up at this. Women with hypermobility often excel at ballet. Eventually, though, she had decided on academia because she kept pulling muscles. She remains very active, having swapped ballet for daily yoga and swimming. More clues.
I asked if her mother had ever mentioned whether she crawled as a baby. ‘Ha,’ she responded. ‘"Clever Nathalie always does things first" is our family motto.’ It was as much family legend that she had walked at 10 months without bothering to crawl as that she was the first in the family to go to university, where she gained a first – obviously!
Nathalie was intrigued when I mentioned hypermobility. It was as if a light switched on when I explained and linked all her symptoms. She resisted, at first, when I told her to give up yoga and swimming and replace them with a specifically targeted, graded regime of weight-training and t'ai chi. I also suggested she reduce her stress response by learning to breathe from her diaphragm and use my tools to release her trigger points and take control of them. I told her she should eat a balanced diet and factor in more protein, otherwise the training would only make her sore, not stronger, and observe a new sleep pattern. Finally, I advised her to work with a good therapist on understanding the impact her father’s abandonment of her and the family was still having on her, and possibly why she had serially bad relationships with men.
Always the diligent student, Nathalie threw herself into the new regime, occasionally overdoing it and with the odd wobble in her belief that she could get better but, as a team, we were always there to help her regroup and forge on. By the time her six-month leave of absence from work came to an end, the pain was largely under control. She understood where it was coming from and how to control it if it niggled at her. She was feeling more relaxed and positive than she had for years. The headaches had gone. At our last session, she gave me some surprising news. Still not sure about whether her husband was having affairs, she had, in any case, decided to file for divorce. Her fear of loss of companionship and support no longer outweighed her humiliation at having been cheated. ‘What was I thinking? He never supported me anyway.’