What Influence Our Nervous System Can Have on Our Well-being – Interview with Annika Cost

In today’s interview, we engage in a conversation with our physiotherapist, Annika Cost, exploring the impact of our nervous system on overall well-being. Additionally, we delve into its potential connection with endometriosis and examine the role played by the vagus nerve in these dynamics.

Dr. Nadine Rohloff: Welcome back, everyone. Today, I am joined once again by Annika, our dedicated physical therapist. For those who may have missed our last interview, would you mind reintroducing yourself?

Annika Cost: Absolutely, Nadine. It has been over a year since our last conversation, so a reintroduction seems fitting. I am Annika, a physiotherapist based in Frankfurt am Main. My focus lies exclusively in the realm of women’s health, with a particular passion for endometriosis and its treatment. I find great joy in this specialization and actively contribute to an app, where I develop content centered around pelvic floor health and physiotherapy. Over the past few months, my pursuit of knowledge has led me to acquire new skills, and I constantly find myself immersed in the next three planned training courses.

Dr. Nadine Rohloff: It is crucial to emphasize, as we discussed in our first podcast, that physiotherapy for endometriosis is genuinely justified, even if it tends to be overlooked by doctors and health insurers.

Annika Cost: Absolutely. In today’s discussion, we will delve into the autonomic nervous system—a component controlling various involuntary functions like breathing, heartbeat, blood pressure, and digestion. It operates seamlessly in the background throughout our day. This system can be categorized into three states, each with distinct impacts on our overall well-being, potentially extending to endometriosis. We will explore how we can consciously influence these states. It is a fascinating topic that I believe deserves more attention, so keep listening to gain a more in-depth understanding.

Dr. Nadine Rohloff: Absolutely. That explanation sets the stage quite effectively. So, we are delving into the realm of the nervous system that one may not consciously control initially. Could you provide a brief overview of its components—how it is structured and functions?

Annika Cost: A helpful metaphor is to envision a simple wooden ladder with a few cross struts, divided into thirds. Picture the top, middle, and bottom parts of this ladder representing the states of our nervous system. The top part is the one we all prefer to be in, often described as the “Rest and Digest” state. Imagine someone sitting around a campfire, enjoying good food, perhaps surrounded by friends—it is a state of ease and relaxation where you have time to digest and savor life.

Now, let us move to the middle part, a more dynamic state often associated with “Fight and Flight.” I, personally, encounter this state when biking to work in downtown Frankfurt, where run-ins with assertive drivers are inevitable. It quickly elevates my stress levels, but it is also advantageous because it enhances my reaction time. In the context of evolution, this stress response was crucial for survival when facing threats like lions. The stress moment prompts a rapid reaction, allowing for quick maneuvers and potentially saving one’s life.

Now, descending the ladder to the lowest end and briefly contemplating a few millennia ago, we reach a state where fighting or fleeing makes no sense—it is a moment of “Shutdown” or “Lockdown.” In contemporary terms, you might compare it to a traumatic experience, where one becomes apathetic, perhaps spending a lot of time in bed and struggling to engage with the outside world. This third, lowest state, too, can have its justification for a shorter period. For instance, it might be beneficial to temporarily “shut down” after a particularly distressing experience to process and cope with it.

Dr. Nadine Rohloff: So, this implies that all these states have their purpose, in a sense. Stress is not inherently bad, as you have mentioned; in certain situations—like when we need to swiftly get away—it makes complete sense. Essentially, in a healthy state, the ability to switch is crucial. One cannot lounge around a campfire all their life, yet it is also unsustainable to be in a perpetually stressed state, as one eventually needs to switch gears. However, this proves challenging for some people, particularly, I believe, in navigating between the upper two states, as the lower one naturally comes with some distinctive features.

Annika Cost: I must say, ever since I have become more aware of it, I make a conscious effort to approach things differently. I recall coming home in the evening and recounting to my husband an encounter with a driver from 8 o’clock in the morning that still fueled my anger. Now, I acknowledge that the anger may be justified on its own, as the driving style could genuinely be life-threatening. However, dwelling on it for 12 hours does not benefit me in any way; it lingers in the back of my mind throughout the day, leaving me feeling negative by the end of it, especially when, thankfully, nothing serious happened in the situation. I appreciate that my body safeguards me in the acute moment, allowing me to react appropriately. Yet, I am also grateful for the chance, once the situation has passed and the immediate danger is gone, to take three deep breaths and swiftly climb back up the ladder! The key is to cultivate flexibility that enables swift and effortless transitions up and down the ladder—always adapting to the current situation.

Dr. Nadine Rohloff: Numerous examples illustrate this; for instance, delivering a lecture. It is understandable to feel stressed in the moment, as it holds significance, but being stressed about it three months in advance hinders your ability to calm down and may impact the quality of your presentation. Or perhaps being upset after an argument or frightened while standing on a tall building. However, it is crucial to return to a relaxed state afterward. It sounds simple.

Annika Cost: It would be wonderful if it were that easy. While I am sitting here comfortably on the sofa, saying, “It always works and is easy,” the reality is different. I will be honest – there are moments when it is genuinely challenging to calm down quickly. It takes time. Afterward, you might question whether all the stress and trouble were truly worth it. But it does not always work out that way. I believe this is an area where each of us can improve, and it is okay; such skills can develop over time without the need for added stress.

Dr.  Nadine Rohloff: Before we delve into possible solutions, could you share from a physiotherapeutic perspective what happens to the body when it remains in a prolonged state of stress?

Annika Cost: Essentially, staying in a stress situation longer than necessary can be likened to overloading the body. The sympathetic (middle) state is designed to provide a burst of energy for a short period, directing attention either broadly to identify imminent danger or intensely focusing on visible threats. While we can handle this temporarily, living in this state long-term means exceeding our resources—we consume more than we possess. This can lead to various issues. Speaking of prolonged periods, spanning decades, the risk of cardiovascular problems such as strokes, heart attacks, and arteriosclerosis (cell calcification) increases. This is one contributing factor among many, but it is noteworthy. On a physiotherapeutic level, it results in increased muscle tension. In the sympathetic state, muscle tension rises significantly. This heightened tension is beneficial for Fight or Flight scenarios, as muscles need to be ready for running or fighting, making them more efficient. While advantageous in the short term, prolonged increased muscle tension can lead to pain or restricted movement over time—symptoms often associated with endometriosis. Additionally, in this intermediate state, sensitivity to pain increases. The threshold for touch triggering pain is lowered. This, coupled with elevated muscle tension, creates a challenging cycle to break free from.

Dr. Nadine Rohloff: It is, of course, unfortunate if someone with endometriosis and pelvic floor tensions finds that stress exacerbates these issues. It is important to clarify that experiencing a stressful half-hour will not necessarily have a negative impact on your pelvic floor. We certainly do not want to cause unnecessary concern.

Annika Cost: No, absolutely not! As I mentioned earlier, all states have their validity; none are inherently good or bad. It is about finding balance and being able to transition between these states. The discussion about serious consequences applies to prolonged periods spent in these states, often spanning decades. To paint a clichéd picture, think of highly successful managers who consistently work long hours, pull all-nighters, have limited social lives, maintain suboptimal diets, engage in minimal exercise due to time constraints, and experience compromised sleep quality. Engaging in such a lifestyle over the years may indeed lead to more severe health consequences. Fortunately, serious health issues do not manifest rapidly after a week of stress. If that were the case, our society would likely have faced a considerable crisis by now.

Dr. Nadine Rohloff: Nevertheless, it is essential to utilize stress effectively, especially when muscle tension impacts other areas negatively. I find it intriguing that stress also influences inflammation—meaning the immune system and inflammatory mechanisms react differently. This has long-term implications. Yet, one can also benefit in the medium term by practicing how to relax.

Annika Cost: Absolutely. Inflammation is particularly relevant in the context of endometriosis! We will not delve into the specifics of endometriosis lesions and inflammations, but they directly impact endometriosis-related complaints and issues. However, it is crucial to acknowledge that a chronic disease like endometriosis can quickly push someone into a sympathetic low. There is often considerable stress associated, especially in cases where societal understanding is lacking, work is constrained, and support from colleagues, employers, or family might be insufficient. Dealing with constant pain adds to the burden. These factors can hasten the descent into a stressed state. Hence, it is essential to remain realistic, strive for balance, and not set the unrealistic goal of eliminating all stress. Instead, perhaps aim for increased flexibility and the ability to exit stressful situations more swiftly. Being mindful of the situation alone has proven helpful for me and many of my patients, fostering awareness without an immediate need to overhaul everything.

Dr. Nadine Rohloff: Absolutely! We have established that being in Fight or Flight mode intensifies pain sensation, muscle tension, and inflammation. When I realize I am stressed, what methods can I employ, aside from the conventional relaxation techniques that come to mind?

Annika Cost: One useful trick, especially when you are feeling overwhelmed, is to step outside for five minutes and move around. The goal is to get moving and ascend the ladder. You can directly translate that concept and ask yourself, “How can I get moving? What is the smallest step I can take in this situation?” Movement genuinely helps. A simple stroll around the block for five minutes is a quick and easy step that requires no special equipment. Therapeutically, I employ various techniques. An essential nerve in this context is the tenth cranial nerve, the vagus nerve. It plays a role in various points across these three states, particularly in the uppermost state where we aim to be or return to quickly. Manual therapy techniques, such as working with the ears, can activate and stimulate the vagus nerve. I use a vibrating pen in my practice, and while the sensation may feel unusual initially, it proves to be very beneficial. I, personally, love it and use it during breaks for its pleasant effects. If you want to try something directly, you can grasp both ears, pull the earlobes down, and then outward away from the head. Create a fluid movement, like making a small circle, and repeat this five to six times. Please do not cause yourself pain during this process! Depending on the number and size of earrings, you might need to remove them temporarily for better efficacy. Many find this very pleasant. Another option is to stroke behind the ears, which is also soothing, especially given the tension from wearing masks all day. These are practical tips and tricks that can be easily implemented into daily life. As for vibration, humming is another technique. Humming induces vibrations throughout the chest, involving the larynx and nerve fibers that stimulate the vagus nerve. These are insights from my practice, and while some are tied to my hands, you can certainly try these at home.

Dr. Nadine Rohloff: Fascinating! Is there a specific pitch when humming, or does it not matter at all? Can you do it however you like?

Annika Cost: Essentially, you can start with any pitch you prefer. The key is to hum, and it is better than not humming at all. I do not want to complicate it unnecessarily—just hum away. In my practice, I sometimes combine humming with exercises for the pelvic floor, while simultaneously focusing on relaxing the muscles throughout the body. I occasionally give my patients the task of humming something to me. I always join in because most people feel a bit hesitant to hum in front of me if I do not participate. Honestly, I usually start with “All my ducklings”—it is a familiar tune, everyone knows it, and you do not have to think too much about it. Ideally, I would suggest humming in the middle range, not too low, but definitely not too high—somewhere in the “lower middle” range. But, as I mentioned, if you do not resonate with that advice, just hum in a way that feels good to you. I do not want to turn it into a science. The exact pitch that is pleasant can vary from person to person. The goal is to find relaxation in a way that suits you. You have the freedom to choose.

Dr. Nadine Rohloff: There are also yoga exercises where you make a humming sound when you exhale.

Annika Cost: Additionally, acoustic stimuli can be beneficial. While it is not yet a prominent aspect of my practice, it is something that spontaneously comes to mind. The muscles in the middle ear can assume different states of tension. Going back millions of years, in a sympathetic stress state during a life-or-death situation, it becomes crucial to perceive very high and very low tones, as they often signal danger—high-pitched screams or a low growl from a bear. The ear is attuned to pick up these extremes particularly well, but not so much the middle tones. Many of my patients, including myself, experience this as “auditory hypersensitivity,” to give it a more elegant name. For instance, I may find it bothersome when dining in a restaurant, attempting to have a relaxed meal with friends, yet hear loud clanking of dishes from the kitchen, even if I am not seated nearby. Or, after a stressful day, I may be intolerant of any form of music at home. Depending on what my husband is listening to, it might end abruptly—not always entirely to his delight, understandably. Being overly attuned to high and low tones throughout the day, which are fortunately no longer life-threatening in our world, can add stress. Steven Porges has developed a music protocol addressing this three-step process. While I am still exploring it, I might offer it in the future. In this protocol, familiar songs are processed through an algorithm on the computer, filtering out the high and low notes. The songs may sound peculiar afterward, but they serve to re-tune our ears to focus on those middle tones. Engaging more with middle tones, like we are in our current relaxed conversation, can positively impact balance and well-being.

Dr. Nadine Rohloff: Is there a song that perhaps has plenty of middle tones?

Annika Cost: I have not discovered that yet. I recently had a conversation with a group, and they mentioned they do not provide individual pieces. It is recommended to undertake this with a trained therapist, especially initially, as defensive reactions may occur. They advise against doing it alone. I am considering trying it myself, and I can provide detailed feedback later. I find it intriguing because many people can relate to this sensitivity to noise in everyday life.

Dr. Nadine Rohloff: You can perhaps classify it as a self-kindness step—just turning off music you do not feel like listening to at the moment. The vagus nerve, housing many fibers that promote relaxation, is also somewhat sensitive to temperature. Is there anything beneficial you can do in that regard?

Annika Cost: Yes, one effective method is a cold face wash, although it does not directly involve the nerve but works through a neighboring one. However, neighboring nerves often influence each other. It struck me how much of these practices we already do intuitively. Washing your face with cold water when stressed is not uncommon. Many people do it to find a moment of relaxation. I found it fascinating to discover the scientific explanation for why it works and is good for us. One practice I often recommend to my patients, but now view from this perspective, is the cold abdominal wash in the morning. When you wake up, cozy in bed, take a minute to get up, keep the covers closed to maintain warmth, head to the bathroom, grab a washcloth, and perform a cool abdominal wash. It does not have to be freezing cold; it should be sensitive, especially when getting out of a warm bed. Return to bed—creating a warm-cold-warm sequence—stimulating blood flow. As the vagus nerve innervates almost all our digestive organs, it naturally stimulates the nerve. I have generally looked at this from a local-muscular perspective. Increased blood flow in the abdomen also leads to the relaxation of fascia and muscles. Simultaneously, it has a clear impact on stimulating the vagus nerve and promoting overall relaxation.

Dr. Nadine Rohloff: Fascinating! I will give it a try tomorrow!

Annika Cost: Go ahead. It involves a brief moment of overcoming, but it is quite pleasant.

Dr. Nadine Rohloff: So, we have many things here that you can do—humming, ear exercises if you are not alone or during an exam. There are numerous options, and you probably need to experiment a bit to find what works best for you.

Annika Cost: Absolutely. There is no one-size-fits-all magic solution. I searched for it for a long time, but I have not found it yet. I no longer believe it exists. But if someone discovers it, give me a call! I would like to have it too! No, you really have to say—as with all other things—you should try it for yourself. One method might work better for some, and it is great that we have such a broad selection. Everyone will likely find something that makes them say, “Hey, that feels good to me somehow; that feels nice.”

Dr. Nadine Rohloff: Thank you very much! For everyone listening, feel free to ask your questions or leave a comment. We will address them later as well. Oh yes, you have attended quite a few courses recently. Is there anything you are planning in the near future that people can sign up for?

Annika Cost: There is one event with a concrete date: On the first weekend in April, I am hosting a two-part workshop with a menstrual cycle consultant. It is about getting to know your cycle better, adapting aspects like pelvic floor health, lifestyle, diet, and exercise, so you can optimize your energy. We live in a world designed more for men, who benefit from relatively stable energy levels and hormone balances. Women, on the other hand, have a highly fluctuating cycle. But that does not have to be a drawback; we just need to be aware of it. By doing so, we can figure out how to leverage it for our benefit and make the most of our days. We will delve into this topic over the weekend, as it is too much for one day. Saturday and Sunday mornings, each session lasting two to three hours. Keep an eye out for timely updates on Instagram and my website. We are finalizing the details, and once everything is set, we will announce it.

Dr. Nadine Rohloff: Excellent! If people want to stay updated on your activities, they can follow you on Instagram.

Annika Cost: Absolutely. There will definitely be another chronic pain course this year, a self-paced one. But that is all a bit tentative. I will share more details in due course. For now, mark your calendars for the first weekend in April!

Dr. Nadine Rohloff: Excellent! Thank you again! Until next time!

Annika Cost: Thank you for having me! See you next time!

Weitere Infos zur Physiotherapie bei Endometriose findest du übrigens in unserem Symptom Explorer.

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