#4 Balancing the autonomic nervous system with Dr Boon Lim (Part 2)

[Music] Welcome to Make Visible, the podcast shining a light on complex chronic illness. I am your host Emily Kate Stevens and I've been living with an energy limiting condition since 2020. Here I will speak to the world's leading experts to bring you the latest science research and insights into invisible illnesses, including MCFS, EDS, fibromyalgia, pots, long COVID and more. This week we are bringing you the second part of my conversation with Dr. Boon Lim, cardiologist and electrophysiologist, who was on the show in episode two. Many of you fell back and said you wanted to hear the rest of this conversation as soon as possible, which takes a broader look at some of the holistic approaches that we might take to alleviate symptoms in conditions such as long COVID. In this episode we discussed breathing and adjusting our mental load and state to try and find that homeostasis. We respect that everyone's illness and path through improvement takes different forms and caveat each of our interviews with the knowledge that this is that experts opinion, research or experience and it's not intended as direct medical advice tailored to your condition. So it's for you to adopt or ignore as appropriate. It's particularly pertinent in these conditions to carefully consider whether ideas presented either by our guests or indeed from any healthcare provider could induce post-exertional malaise or exacerbate your symptoms set. As ever, please do comment, review and write to us letting us know whether what Dr. Lim says resonates with you. We're interested to hear your experience and learn what has worked for you. Before talking about some of the root of what has actually driven this autonomic dysfunction, whilst we are talking about therapeutics, water, salt, movement, I would really, really like to talk to you about two of the other things that you really, really advocate for for your patients and this sort of go together mental stress management and breathing. Are seem to be two of your biggest things in your toolbox. Yeah. Can you indulge me with like five minutes of a qualifying statement before we go there? Absolutely. And I think it's very important to know that we are in this era living the parable of the six blind men of indistan. And I don't know if you've heard of this parable, but the six blind men of indistan, John Gottfried Sacks, Google it. It's a beautiful poem that describes blind men who are asked to describe an elephant. And the person who approaches its tusks says the elephant is like a spear. The one who touches its tail says the elephant is a rope and the one who touches the side says the elephant is a wall and so on and so forth. Now the point I'm trying to make here is that when you see anologist who is generally a very, very blind specialist, including me, what you're asking is, is there a problem with my heart? And theologist might do a whole host of tests and eventually find yeah, you're you're a bit tachycardic, you're blood pressure slow. But then you go and see a gastroenterologist. It's a problem with my gut because you know I've got reflux. I've got a lot of gas and it's not just going a lot. It's conservation alternating with diarrhea. And the gastroenterologist does a whole host of tests and he says, nothing really raw I can see, but have some probiotics. And then you can see rheumatologist, oh my god, my joints, they come so tight all the time and they'll do a lot of tests and say, you've got some post-exession delays, but right. All your antibodies, some of them are mildly positive, not sure. You see a dermatologist, you see a woman specialist and we're all blind because we don't see the. You're listing all the people that I've seen. No, sure, but you know, because I see this all the time. And none of these people really, including me, they don't really get it because they don't see the elephant. And the second analogy to bring into the equation is that if you don't see somebody who can see a holistic view or this see your illness as a whole and see marveled in a true like beauty of the elephant rather than the elephant parts, you'll never really, truly get to source. And when I think about it a different way and using the example of let's say we go down the anticoagulation root or we go down the plasma aphoresis root, we think of a factory up top upstream, right? Which is producing lots of gunk adrenaline, inflammation, cortisol, spike protein, lack of clearance, viral debris and it's all coming downstream. And then it branches into its tributaries, including the heart system, the heart tributary which gives you popitations. So you might ostensibly as a cardiologist, it's not really knowing very much about autonomic dysfunction. You say, ah, popitations get beta blockers. But beta blockers are awful for those patients with low blood pressures because they lower the blood pressure further. And the patient thinks, oh, this cardiologist knows that I've got a tachycardia, the tachycardia is a problem. But it's not a tachycardia, the tachycardia is a response to something upstream. So treatment of the tachycardia with a drug may not be the right thing to do. Just like treatment to try and push a net out to catch all the toxins or the stuff that are coming down this tributary, which is the immune tributary, like spitting your blood and taking stuff out. Means that fine, for that tributary, you get rid of the blood, the toxins or the crap that are coming from the factory. But if you don't stop the factory, what's going to happen in two weeks and six months? Same again. Same again. So the question is not how do I treat my tachycardia doctor or how do I treat my IBS or my boating? The question is how do I identify what the source of all these things are? And here is where I come back to the question you asked me, like the value of breathing and the mental state. Those are only two components. But if we go back to the factory, it's got a major switch. And the way I sometimes now start to draw it is that I draw Yin Yang symbol, which is the the black and white with an S in the middle. And what I say to patients that you once upon a time would have been born with a fully balanced Yin and Yang. That means in a day time, you shift more towards Yang or masculine or energetic or doing. And then in a night time, you need to rest and normalize that Yin. So you have a sense of general balance which balances your immunity, balances your heart rate, balances your response to infection so that you don't get repeated infections again and again. Is that sympathetic and parasympathetic nervous systems? Yeah. The side of the Yang Yang. Yeah. So Yang is sympathetic, adrenaline, Yin is Vegas or recindigest at rejuvenate. And what I find is if you put it in this context and you say what are the determinants of Yin Yang balance? That's when you get more to the root cause. Now some listing will be quite agitated by the narrative because they'll say I was in balance until I got this damn COVID. And COVID was the disruptor of my Yin Yang. So you must fix COVID or you must fix whatever viral debris because the fixation is on something a trigger that caused their imbalance. But in my experience, there are like millions of people who get COVID. There's a fraction of them who have long COVID and there is a phenotype or there is a type of patients who it's more susceptible to getting long COVID than others. Tell me what they are. Tell you what they are. So this is a generalization and quite broad. But the typical person I see as you've identified are more women than men. Okay. More women who are juggling a few things and we often don't say it or see it enough but I love you mom because of everything you've done. And as a mother with two or three kids juggling school house and actually if those parents also need to work to kind of sustain the household income, that is a mother with three jobs because recovering from an illness is a job in itself. So kids household chores job or two or three is what shifts your autonomic nervous system state into a predominant Yang state. And if you think about now a third analogy and I'd like to bring this all together with this last analogy, this is not your proverbial gazelle grazing in a savannah line comes out of long grass and then form your maximizing your adrenaline, your papillary dilatation is maximum your heart is beating very fast and you're breathing quickly so you can maximize oxygen, consumption and flow of blood to your organs, your muscles so you can run for your life. And this is not that. But in that situation where you have an acute stress, you shut down digestion. You shut down reproduction, who'd want to reproduce? And when you're running for your life, this is not that. This is the analogy of a gazelle whose sister was just killed by a lion a week ago in a radius of long grass, let's say 20 meters, and you're rooted in the middle and you don't know when the lion's going to get hungry again. You occasionally see a swish of a tail and the north-south east of west. You can't travel and you can't run because you don't know where the lion is. This unknown roots you in a state of chronic yang or adrenaline. And in that chronic state ground down, why would any one prepare for reproduction? Why would anyone have normal physiology? The men says, go, hey, why are some people get periode or advanced or have perimenopal symptoms, which are not in keeping with the age? People don't sleep well. People have brain fog and fatigue because you're constantly on high, just like if you were studying for exams and you didn't sleep for three nights on the trot. This is not resting. Maybe you sleep, but you don't rest because the lion is in long grass. What are the lines? The lines are your financial future, your career, on the line, when I'm going to go back to work, Dr Lim. Tell me, is it three months? Is it two weeks? I need to plan. I need to plan. My kids, I'm not spending enough time with my kids because I'm recovering. I feel guilty because I can't bring them to school. I can't teach them. These are the preceding factors in my mind that perpetuate the factory. And the factory switch, actually, the on switch is this state of perpetual blackness with the Yin Yang symbol. Yang is black. You're shifted into like three quarters black state chronically. And even when you rest and you wake up in the morning, the first thing you do is you think of all these thoughts that come in, you're already shifted in black. And black or Yang state living or adrenaline state living is a very, very energetically consuming state. So it's essentially creating even more of a spiral as well. It's an absolute spiral and people who actually don't or are unable to or feel unable to change life circumstances. You can't get rid of your kids just because you have COVID, right? You can't let the house be full of dust. You can't stop working. So how does that work? It's an extreme stress, but it's an extreme stress over a chronic period that sets your immunity out. And you know, going back to the gazelle analogy, when you're running acutely, you want your mess cells and your white cells and your NK cells and all your immune cells to be very reactive so that if the line manages a scratch, you can dump platelets to heal that scratch. You can bring in your mess cells to activate histamines to really mobilize your immune system to that spot to heal. But if you're not getting a scratch and you just set down grounded and your immune cells are really, really still waiting for action, but they don't see any. Guess what? Some of them will trickle into an autoimmune state, right? Which explains why there is a high prevalence or high the normal prevalence of any itists that you might find. A gastrointritis, arthritis, a pneumonitis, a myocarditis, all these things that inflame. And you might see a group of patients who have flushing and who have mess cell activation who are helped by anti-istamines. That's part of the being in chronic stress state. And that's like a hyper activation of all of those systems. All of your immunity is very reactive and they become so reactive held in that ready to attack state that your immune system doesn't have the ability to regulate and sleep and rest to become more effective. And over time, immunity's impaired, which is why patients get infections, after infections, after infections is by sleeping in bed or being bedbound all day. It's one of the paradoxes. I'm resting all the time, not doing very much. And yet I'm getting infections, which then set me back so much. So, you know, I think those three examples or the analogies I've given can be very helpful in allowing people to understand what the kind of driving forces are. And the reset which comes most quickly in my view is a physiological and false reset. And of all the elements of autonomic control and you'll be aware that the autonomic nervous system is that bit of the brain that controls all the automatic functions of the body, digestion, parastylsis, dilatation of your pupils, skin dilatation, sweating, tacky cardio, blood pressure regulation, heart rate regulation. Now, of all those things, if I said to you, Emily, can you increase your heart rate by 10 beats a minute now? By thinking you can't. If I say can you make your pupils start late? You can't. But if I say can you control your breathing rate? Ah, you can. So the breath is a unique place. The control of respiration is a very, very unique dual control system. If you are not conscious, it's controlled by your autonomic nervous system. And you see this breath pattern. And I see it straight away. A patient comes to my room and they go, that sighing breath is called a reset breath. If you google Andrew Huberman, the physiological sigh, it's a Stanford neurobiologist. It's interesting. He talks about taking a deep breath in like this and then a next one and then it's a double breath in maximum capacity and then a slow prolonged exhale with a sigh. And we see this all the time during tilt table testing when people are getting dialed up with adrenaline, the oscillations are going like that. They go, they don't do that. They might go, they have this sighing pattern. And the sighing pattern is trying to reset their Yin Yang. It's trying to shift them to Vegas. Now I say why not we use the power of breath to actually regulate upwards because the autonomic nervous system has outputs, which is where we suffer the manifest effects of high adrenaline. But also has inputs so you can regulate it by slowing down the breath. And when you slow down the breath, your heart rate slows down too. And I do demonstrations, I do demos with patients where I put on a monitor on my ear, then I put it on the patient's ear and I get them to breathe in and out and I get them to see the oscillations in their heart rate just with controlling the breath. And overall the reduction in the mean heart rate when they slow and regulate the breathing. And the breathing should really be regular. IE, ideally six seconds in six seconds out. That's the perfect physiological breath as per James Nestor in his excellent book, Breath. Oh, I love that book. That book is amazing. And he takes it back to ancient times where monks would meditate on a rosary and the time it takes to do one revolution of the rosary is six seconds in and six seconds out of five and a half, but you know who's counting half a second. So for me, it's eight seconds. So I like an eight second cadence because it just works for me. But for most patients, you should try and start with a six in six out. It should generally the most important bit about that is the rate of change of oxygen. So it's not. And then you're taking very little at the end. It's a slow through the diaphragm. IE, push your belly out on the breath in and touch your navel to the spine on the breath out. It should be regular. Deep if you can and rhythmic. And those are the key principles of breath work that if you practice 10 minutes when you wake up instead of checking your phone. And don't check your phone. Don't check your email. Don't look at blue light when you wake up. That's another top tip to stop you switching immediately into Yang into that Yin Yang shifting. In fact, start with a breath. If you're prescribed mid-adrened, start with mid-adrened, a glass of water 400 mils and then do your 10 minutes of meditation. Because that sets your mind up in this very, very healthy space because you are in training the Vegas and already shifting your Yin Yang towards more Yin. And with this simple 10 minutes of breath work exercise, you are choosing to alter your physiology to be more conducive to healing on that day. And then if you couple that and this is for extra brownie points, which I recommend everyone do with one gratitude exercise, which is I'm grateful I've got a warm bed or duvet. I'm grateful I've got a kid. I'm grateful I've got family. My mom's looking after me. Whatever it is, you're grateful fall. Instead of saying shit, I can't get to work again today because I feel I can't stand, change it and express gratitude. That is a real shifting state to be in and then express one other thing. What am I good at? Because there is something that you will find that you're able to express a positive about yourself. And if you have one gratitude or two or three pieces of gratitude, you have one or two or three pieces of expressing what you're good at. You're setting yourself up at the beginning of the day and do it three times a day, middle of the day, after lunch before lunch and then once before you sleep, you are really recalibrating this kind of Yin Yang to be more inwards. And so that's a power of breath and intention in my opinion. And mindfulness, which I think possibly one of the big reasons that we've had this huge impact at this point. of the world from Covid is because we are so distracted all of the time and even our recovery from these things is rushed and it's in our phones and it's at a high level of stress and bringing it back to that simple breath and mindfulness and being present and also I think with the the gratitude and water my good at it's coming to some kind of acceptance rather than fighting against it I think is instrumental in the healing. So so acceptance and the phrase which I like to use is an expectation gap management is is are are two phrases that sometimes are difficult for patients to manage and I I consider acceptance as a present present moment exercise because the moment you accept yourself or who you are what's in all it can be it can be a very grounding present moment experience and it's the expectation gap reduces so the expectation gap is when you expect that you're going to be able to do a full day work full day of work in the in the day ahead and then you can't do it and then you feel so anxious about the fact that you haven't been able to do what you expect at yourself to do or expect to be able to go back to work in three months and look I can't do anything now you are actually rooting yourself in the future moment anxiety the future hasn't even arrived and you're stressing about that and all the time you're thinking about that gap you are shifting towards yeah present moment awareness is it's very challenging because you've got all these things you have to do like get the kids to school and the household builds and jaws but whatever it is you do at any one time you just give your time and attention to the task at hand and that is part of the kind of gift of the present moment that you you grow on yourself in the present moment and you're not worried about an anxiety about a future and you don't worry about something that happened in the past and that is a way also to shift into more balanced autonomic nervous system states and sometimes that present moment is not particularly pleasant it's not that you're absorbed in playing with your children of course of course sometimes it's because you're stuck in bed and you're in intense pain and you feel utterly dejected about the world but the presence and acceptance in that is actually hugely freeing because rather than saying oh why am I like this this is such a terrible situation I should be doing x1 z you just let it go and you say this is my situation I'm in pain I'm going to rest now and just be with it I was actually and I'm still am part of a program actually by Imperial which is the Long Coby Clinic at Simmeries they offered for the Long Coby Clinic mindfulness classes and there was I think a lot of people would find that really offensive that's saying you can go and cure this by some kind of mental activity but I say that it's been absolutely instrumental in me I wouldn't ever say that I've recovered but me getting incrementally better has been the mindfulness the meditation and I do a huge amount of breath work and yoga to to try and balance it and so I can say from personal experience they are hugely effective but this acceptance are not constantly fighting the illness fighting the condition it's not a resignation that you're always going to be like this or giving up but it's simply being yeah so there there's a really nice story that Susie Bolt tells on her on her program and it's when I think she she has a bred new kind of water and windproof jacket going she lives in Brighton and so she goes for walk on the beach and it starts raining with horizontal sheets and it's quite chilly and her jeans get completely soaked through and she's dripping into her boots which are freezing and just thinking oh crap like this is so uncomfortable it's so painful I'm so I'm so cold and then something shifts in her mind and she says actually my upper body is completely warm and toasty I'm so grateful I've got this nice warm jacket which keeping me warm and you know the hoodie's keeping my face dry and it's also in shifting focus right and that is where thinking of something you're good at or being grateful for what you have rather than for what you don't have or focusing on what you don't have or the illness or the pain is a very helpful mental shift very helpful and just that shift enables you even in the face of a lot of pain or tension i.e. my lower limbs and my jeans are soaked in icy cold weather it doesn't make the cold less bad but when you shift in your other half of the body which is doing fine or the other aspects of your life which are still good you got a supportive like lovely kids or you know your boss has been very supportive and giving you time off right shifting that perspective is one way to shift towards more autonomic balance as well and you know I always bring it back to autonomic balance and maybe that's not the narrative for the factory let me talk about the factories being out stuff but certainly for me it's the most helpful way that I can think of the off switch and the off switch is actually regulating that Yin Yang symbol and bringing it back to balance that that for me is the off switch because the Yin Yang symbol is so nebulous and it describes or you can understand the multifastored input into Yin Yang that it's no longer offensive to think mindfulness because we know that when you're not mindful in your stress you activate the Yin Yang you also know if you're dehydrated you activate the Yin Yang because when you stand up you have what we call autostatic stress you can't help but have a high amount of adrenaline when you stand up if you're dehydrated you also know when you're in the throes of an infection you will have the stress related to the infection and of course you know if you're in pain you'll have a stress related to the pain so pain relief can be helpful in regulating Yin Yang breathing and mindfulness and controlling infection all these things are off switches right like we can think about it in a more multifastored input setting because I think we understand how it creates outputs the inputs which is the root cause into the Yin Yang imbalance is what we need to really get out there and it may be different for different people that's a fascinating reason it because rather than saying I have to work out what caused it and removed that from my system like you mentioned the viral persistence or maybe it's driven you into auto-immunity or maybe there is damage to the vascular chart or whatever has physically caused it this is a shift for me this idea that perhaps we can alleviate whatever we don't necessarily need to go back and remove that for us to be able to heal for us to be able to fix perhaps the method out is not simply by reversing the method by which we got into it I was hoping you'd see perhaps the method out is to go in because I got because I think there's a lot of that as well to go in and understand what what the triggers are and to work by yourself you know with with guidance but mainly is to heal yourself with the work that you can do for yourself the other aspect which you raise which maybe would sound slightly odd is you know the stolen focus book by you on Harvey yeah it's an excellent book excellent and I would think that part of the collective healing of the world post-long COVID is to really really get a good grounding and have a science of a science into understanding the negative effects of everything that is written in that book the social meter aspects that kind of being glued by your TV or emails and lack of real connectivity human connect service yeah and let's connect to earth again let's connect to each other because when we're disconnected it's another way that we we shift into an autonomic nervous system state and I guess it's a more to high level order viewpoint and this is what I call you know you talk about mind body I like to add in a third component spirit so the spirit healing is kind of a higher level awareness about why we are suffering the the way we do in terms of some of the methods that you employ and that we go into in detail in this episode we talk about things that people might consider to be alternative or not rooted in scientific fact breathwork mindfulness are there any scientific studies for example one of the first randomized controlled trials that was I believe ever done in long COVID was the ENA breath program proving the power of breathwork in recovery in long COVID are there any other references to studies evidence or indeed the impacts that you see in your clinic that lifts what we're talking about from being some kind of theoretical esoteric thing into science-based. I'm a bit more familiar with that ENO work because that was a collaboration between a respiratory physician at St Mary's Hospital who at the initial stages of ENO and ENO for those who don't know is the English national opera and they came up with a program which is fairly well funded at the time to help patients with long COVID through the long COVID symptoms and it's important to note Emily that there were exclusion criteria in that patients who were too unwell were excluded from attending this service. So we're taking people and we're training them not only with breath work but I think that sense of community on a regular basis, the sense of fun, the sense of learning a new skill to try and get into flow and connecting with individuals are I think things that you may not be able to fully separate out in the paper because we know the program work but what specific facets of the program whether it was breath work or community or learning that skill of singing or the fun of it all are all components that could feed in and shift your state. So in terms of other studies I must say that there are hundreds of not thousands of studies now and to be fair Emily I have not kept up to scratch with the studies because I only like you have a finite amount of time. What I do know is that a lot more studies are starting to try and measure HRV properly and HRV stands for heart rate variability and there is a standardized measurement which is said to be the best way that we can measure HRV which is either one or two minutes of pace breathing which means if you take a patient you give them a set breath timer so let's say six seconds for inspiration and six seconds for exploration and you carry that on for two or three minutes at the same fixed time every day or after an intervention you will get fixed results that are churned up by the HRV analysis software and it will tell you your RMSSD which is the most commonly reported marker of HRV but it will also kick out things like the low and high frequency oscillations of your heart rate index and these are ways in which the studies have assessed the impact of for example vagal nerve stimulators or any other intervention like nutrition or sleep on your resting state. How wonderful it would be Emily if the methodology became the treatment because that's what we're talking about. In fact if we got people to practice and I tell my patients to get your 10 minutes of breath work in with a slow regulated rhythmic pattern and instead of asking for the trial that shows you that this breath will work for you feel it yourself before you go to bed feel how breathing in this 10 minute cycle before bedtime increases or decreases your capacity to sleep better and have a more rested night and feel how you feel in the morning if you change your transition from waking up with your alarm checking your emails to just taking some time out to calibrate and set yourself up in the perfect autonomic balance as best you can for single morning and this is what I'm trying to get my patients to do because it's one thing looking at a randomized control trial and to say this vagal nerve stimulator should really work because the trial data says that it should work and you buy the 600 pound device you put it on your triggers which is that little low in front of your ear and you clip it on and you turn the dial up until you feel a little sparking or prickling in your ear and then you dial it down or you can keep it's trickling with the spark for an hour and then you don't feel any benefit or you might or you might not in essence you have to take what works for you and in my mind that the cheapest the simplest option that you could almost always immediately feel a difference because it's such an ancient art is to control your breath yeah absolutely the final thing that I would like to do is I introduced you in the first episode you are a cardiologist dealing with the mechanical and electrical defects of the heart you are in no way saying that these illnesses don't exist or that a virus has not occurred that had a direct insult on people's body but you have certain strategies that enable or encourage people to heal could you just qualify that in terms of your clinical experience what you have seen it's like the classic Lao Siu saying the more I know the less I understand and this is certainly true of medicine especially when something like long COVID hits you as it hit me as it's hit many of my patients because the most striking thing about long COVID in my experience is how bad we've been as a profession in helping patients and I say this across the board not with any disrespect to myself or any of my colleagues but we are completely unprepared for that patient with multifastored complaints which don't all link up in a reductionist way and we talk about this a little bit in talking about the parable of the blind men and the elephant but to take it I guess further on a personal note the way that I teach my registrar so the way I lecture to medics about long COVID is to say to everyone at the end of my lecture that please do feel empowered as a doctor but more so as a human being to make a difference that person in front of you because if you end the conversation saying I don't know I can't help you your echocardiogram and halter is normal and there's nothing else I can do go away time and time again when the patient hears this from one specialist to the next one all or just to the next one blind man trying to describe an elephant but not really getting it quite right the patient then adopts this persona or at least a view that it's all in my head or that I'm sure there's something wrong with my heart all my skin all my gut but I'm told everything is normal so it must be in my head this is very damaging for that patient and they can go I guess one of two ways the the first way is that they get into a despondent state where they get helpless and they feel that if the smart guys can't help me then no one can help me and the second state is one of anger and frustration in both those scenarios the helpless patient or the patient who gets a bit frustrated because no one knows what they're doing there is a bit of a need to come back to their own power of healing and this is probably one of the most difficult things to communicate in medicine which is I would say medicine 2.0 which is where we're at now is very very effective with the latest drugs the vaccines treatment for surgery new implements or catheter ablation techniques which I do as an electrophysologist or coronary stents or angioplasty or surgery these are all highly developed technical skills but medicine 3.0 I think comes back to having a partnership where the doctor does what they can to educate the patient but the patient takes some of that away takes some of the tablets if they are prescribed takes some of the interventions which we know do work but also empowers themselves to change what they can internally because the best pharmacy that we have I would say lives in our brains so antidepressants where you inhibit the breakdown of let's say serotonin or dopamine are simply products that can be produced in your brain when when say you're out in nature and if you for me personally if I'm in a bad mood or very stressed I'd go out in the park by by trees and if there are any birds songs even better I'll just sit down take a few deep breaths and I come back with my mood switch and that is the best antidepressant for me I would say there's a lot of the softer bits of science now who is going to pay unless you're the government of Japan who is going to pay for you to have forest therapy as a trial or Shinrin Yokus it's known in Japan forest bathing which is actually prescribed for stress so the medics in Japan prescribe forest bathing for stress because it's such a well-accepted therapy and trials have been done to show that it works but would a farmer company ever ever support that as a means of treatment you know who makes money from this no one no one but who gets the love to be out in nature who benefits the patience and when you feel this connectedness i.e. more than who you are inside and all your troubles and and you go out those and you see things happening around you and you feel a oneness and connectedness with nature beyond yourself. It is in itself a switch in state that occurs. That switch in state is very subtle and cannot be fully trial or randomized, but you know the feeling, Emily, when you are out doing something you really love going out for a walk going by the sea surfing skiing, whatever it is you're in the mood to do and gets you in flow, sometimes just sometimes that flow engages your energy sensors. And when I say that I don't mean like chakras, but it allows you to wake up and somehow feel more energetic. And there are some times, and I'm sure if a patient is listening and they want to know what that feeling is, imagine the night before your one week holiday to that bucket list destination. You could have had just four hours of sleep packing all night, but you wake up fully excited, refresh full of energy that keeps you going. Now you have that same amount of sleep, but preparing for a week of hell at work, a very busy week at work, and you feel tired and grumpy, but it's the same amount of sleep. In one instance, there are factors beyond what we can express medically that charge you and put you into a flow state so your energy flows. And I think these are concepts that is easiest to explain when I asked the patient in front of me when was the last time you were on holiday and really really switched off. I either was no Wi-Fi or phone to it down. And probably 70% of the time, they'll say, oh yes, my last holiday was whatever three months ago or last summer. And you know what? I felt 50% better just because I had no routine to get back to. My routine was broken and these things that set my energy every day were taken out of the equation. I had somebody catering for me or cooking for me or I was in a nice result or or a hotel. And that is the shifting of states that we're talking about, which is experiential Emily. It's not evidence-based or scientific in a way that you might say this drug can be prescribed in this way. And we should come back to knowing what charges us, what fuels us and do more of those things. And Enobreath is a classic example because the ambitions were to start out something that singers already knew was very helpful for their well-being, which is singing. But singing with that modulated breath and diaphragm control, which comes back to my own bias. I'm strongly biased towards patients learning how to breathe properly. And the Enob program and the publication subsequently demonstrated that you can feel better in so many clinical domains by joining a program like this. And we don't stop there. We have other long COVID for recovery programs like Susie Bolts, 360 Mind Body Soul Program, which so many patients have fed back to me have been a wonderful different way of helping. Does it cure all their symptoms? No. If you are hypotensive, for example, and every time you step up, you feel like passing out and your blood pressure is 85 over 60, then maybe you could benefit from something more like a tablet that boosts your blood pressure together with the fluid, the salt, the compression that we talked about. So it's a more holistic view. And I would say a partnership between a physician who's understanding and a patient who really starts to experience or learn to re-experience joy and energy again in their life by doing the things that allowed them to experience these things. And anecdotally, I had very bad COVID when I was skiing in May 2022. And I was rushed down from the French Alps with the saturations of 82. I thought genuinely I was going to die of a bilateral, poor, embolus because the sets were really quite low. Must be even more terrifying because you actually understand what the set, what the things mean. I was in pain. I was coughing blood. And I thought I'm gone. That my lungs are gone. I would be one of those long COVID sufferers with damaged lungs, not the true autonomic long COVID. But I was so, so afraid. And so when I finally made it down to base cam in a town called Tonon's and went into a hospital and had my CT scan, thankfully it was just, it was just new monitors. It was just a COVID long. It wasn't a PE. And then I could breathe a sigh of relief. But then I sit to myself. I just wrote two emails, one to my NHS, one to my private secretary. And I said, no emails, no questions, nothing. Shut all my clinics. That's it. I need to recover. And in that six weeks that I took off, I never knew I could put down the seven balls that I was juggling. And so my lesson for my experience with COVID was that I could put down balls because I like most patients on my, on my patients. I've got too many things. I've got an academic career. I've got research fellows. I've got my kids who are, you know, have to teach in school. I've got household bills to pay. I've got the usual box standard stressful things in life. And I also have a bit of a type of a personality wanting to achieve more, do more. And I put those balls down. And then I recognize when I came back, I didn't have to pick all seven up. So I pick up maybe four balls and then now five balls. But it's not the same pace. And you know what? My life hasn't suffered. I suddenly haven't been demotored or been given a lousy title or, you know, there's been no, there have been no negative consequences, only positive. And it's a way of the world just knocking at my shoulder and saying slow down. Because the life that you thought needed to be lived in this way, juggling all this ball, sleeping less, coming back late, not having dinner with your family. Now that's, that's what you have to learn. So that spiritual guidance or the listening to your heart and your intuition to recalibrate what is important in your life is something that we don't discuss enough. But I think if we take a deep look at how we were living before COVID, not after, but before, and we think about what balls we can afford to drop to enhance the quality of our life experience. Regardless of illness, an instilling a sense of community, connection, nature, looking after self and coming back to how we're supposed to be breathing. None of us breathe correctly anymore. You just sit on the underground one day and you just look around and you see everyone holding their breath and taking size. Now that I've mentioned it, you will see it. You can't unsee these things. There are very few people, there's some, there are very few people who close their eyes and you know they're listening to a nice, by a norral track and you know they're breathing from the diaphragm and you know they're in a nice state and you can feel it. You just watch them and you know he's in a good state and you can see others who are not in a good state doing the emails, the spreadsheet, breathing like this and you know they're not in a good state. So which one of those two is going to get long COVID if the both of them had COVID because you're coughing them? You can tell just this awareness is amazing. It's allowed me to see people in an entire different frequency. That is a wonderful point to end on because I think it gives people something to reflect on. Thank you for listening to Make Visible. Please do like, follow or subscribe to listen to our next episode where we'll be uncovering more insights into complex chronic illness. 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