Thursday, November 22, 2012

It's in the Details: Using Moist Heat

  I am the type of person who really likes to learn, so after I read Claire Davies' book (The Trigger Point Therapy Workbook), I wanted to read the book where he got his information.  This two-volume set is called, Myofascial Pain and Dysfunction:  The Trigger Point Manual, and is written by Janet G. Travell and David G. Simons, et al.   (Hereafter called the Red books...) It has more detailed information in it and if you have a bit of anatomy background as I have, it is readable.  It also has great illustrations by Barbara D. Cummings. 
  One of the things that was emphasized in the Red books was to apply moist heat to the area after performing trigger point therapy.
  I thought this was a good idea, but I hadn't used it much, mainly because it seemed difficult to do.  I was picturing a fairly complicated scenario, in which I would take a hot bath, or at the very least, get a bucket of very hot water, dip a towel into it, squeeze out the excess water, and then apply to the affected site.  
  I wondered how to apply moist heat without all of the hassle.  Then I remembered:  Rice-filled, microwave-powered heat pads.  They give off moist heat.  I have some of those.  (If you don't have these, they are very easy to make.  Do a search on the Internet, and I'll bet you find some instructions.  If you can't find any, leave a comment here, and I will get some for you.)
  Several days ago, my back "went out,"  I used trigger point therapy on the most likely culprits:  the psoas, my gluts, the muscles surrounding my spine, especially up by the bottom of my ribs.  I would get temporary relief, but everything seemed to seize up again, pretty much immediately.  I decided that I probably had pinched a nerve.  I could not get my abdominal muscles to relax.  The pain would start in my sacrum area (center back around and below the waistline), and I could feel it reach up the sides of my neck and down my thighs.  It is really hard to maintain your cool when you can't get these muscles to relax.
  I called to see if I could get in to the chiropractor, but knew it was not likely.  They put me on the cancellation list, but I never got in.
  Knowing that the long holiday weekend was ahead of me, I knew that I was going to have to tough it out.  It was then that I remembered my rice-filled heating pads.  I took my ibuprofen.  Then I heated up three of my rice heating pads and sat in a comfy easy chair.   I put one heating pad on my back behind my waist, another around one of my hips to help one of the trigger points in the gluts, and the other I put around my shoulders.
  I was amazed at how fast my pain subsided.  I could actually think!  After a while, I was able to get up and do a few things, very carefully and slowly.  Of course, after an hour or so, I began to feel pain again, but I was encouraged; at least I could manage the pain through the Thanksgiving holiday!
  I decided to do an experiment (I am taking a statistics class right now, so I think like this...).  In a few hours, I tried just the ibuprofen after using trigger point therapy, but I used no warm, moist heat.  It lessened my pain somewhat, but it seemed hardly noticeable.  A few hours later, I used just the moist heat after trigger point therapy, with no ibuprofen.  Again, I felt that instant, soothing relief!  Yay!  I found that taking the ibuprofen every four to six hours, and doing the trigger point therapy and moist heat every hour was an ideal prescription for my pain. 
  Over several sessions, I was able to get my back to the point where it did not feel like a pinched nerve anymore, but it still had the residual soreness from the whole traumatic experience.
  My upper back started to feel like it might go out though.  This happens sometimes when one area of the body has been so tight that other areas are tightening to keep the balance.  When the overly tight area finally releases, sometimes the second area seizes.  (Think of the energy involved in a tug-of-war.  Both sides are pulling very hard on the rope.  If one side suddenly lets go, the other side will be exerting too much energy and fall down.  It is a similar idea.) 
  I have been continuing to use trigger point therapy on all of these areas, and I am careful to not overdo my activities.  At least I can walk somewhat smoothly today.  And I can get up and down out of the chair without trouble.
  I was able to get up this morning and roll out my "twisty" rolls for Thanksgiving dinner.  I am so thankful that I was not doing the turkey this year.  I don't think my back is strong enough for that yet.     I will bring my therapy ball (lacrosse ball) and my heating pads to Thanksgiving dinner.  Meanwhile, I am feeling very thankful that my pain has lessened significantly


Wednesday, April 11, 2012

A Word about the Weather

Have you ever heard someone say that they can tell when a front is coming in?  Perhaps you are one of those people.  I am.  For many years now, I have had various symptoms that can range from something as "mild" as an antsy feeling, to feeling like I have a stomach flu, with nausea, muscle aches and headache. I noticed that certain symptoms predict certain types of weather.  For example, if my knees started to ache really bad, that usually happened before a snow storm.

The common factor, though, was that once the front finally arrived, I felt better.  The tension would cease, or the pain would subside, and I would feel tons better.

One theory that I have heard about the joint pain, is that as the pressure changes, the pressure changes in our joints, and that is why there is pain.  This made sense to me, but I found out something interesting.  After I learned about trigger points and started to work them on a fairly regular basis, instead of feeling the pain in the joints when a front came in, I felt pain in the muscles that referred to those joints.  For example, instead of feeling pain in my knees, I felt pain in my thigh muscles.  Instead of feeling pain in my bones of my lower back, I felt pain in the muscles of my buttocks.

This piqued my interest.  I did a lot of research on the Internet, trying to learn about what happens when the weather pressure changes.

I wondered if the changes in the electromagnetic field might have something to do with it.  Years ago, when my husband worked for a large software company, I noticed that I could not visit him at his office for very long because of all of the computers (with CRT monitors).  That environment seemed to suck the energy out of me and I could hardly function by the time I had been there for 15 minutes or so.

I also remembered that once, when a salesperson demonstrated a whole-house air cleaner that when he turned on a particular feature--I think it was an ionizer or de-ionizer, but I honestly can't remember--I got a headache, almost immediately, and that headache went away after he turned it off.

But, I could not find much on electrical fields.  I learned that night and day, and summer and winter have different configurations.  But I could not find a way to measure these differences at home to see if they were having an effect.  And I could not find a website that kept track of this kind of information.

For now, I have had to be satisfied with knowing that changes in my body are associated with changes in the barometric pressure.

To learn more about how this affected me, I first charted a week's worth of symptoms.  Then I went to a website that has information for the past two weeks of weather.  This is Time and Here is the link, if you are interested: (Go to Weather.  Then click on Past Week.  You can put in your specific location, or a location that is near to you.  The barometric pressure information will show up when you click on the Detailed List link.) I compared my symptoms to the weather and noticed a very strong correlation, which was, of course, no surprise.

Next, I kept a record for a few days of how I was feeling at various times and I recorded the barometric pressure at that time.  (We have a portable weather station...)  At this stage, I was interested in noting specifics.  Was I feeling worse at the time that the pressure started to drop after it had been steady?  Was it the absolute value of the pressure, or was it how far and how fast the pressure was dropping that was affecting me?  Were there different symptoms associated with each phase?   I kept a chart by the weather station and marked the information down whenever I was feeling symptomatic.

I am still fine-tuning this understanding, and it may be that there are other factors that determine what type of symptom I have.

Next, I found a really great app for my iPad (It is also available for iPhone, Windows Phone, Android, Blackberry, and WebOS HP Touchpad).  It is called WeatherPro by MeteoGroup. Here is the link if you are interested:   WeatherPro  It costs about $5.00.  It says it has information for over two million locations in the world.  It has four general areas:  Weather, Radar, Satellite, and Maps.  In the weather section, it has an eight-day forecast, with several categories, including barometric pressure.  It is charted in a graph form, and you can see the whole week at a glance.  It is fairly easy to pinpoint about what time during the day the barometric pressure will dip, bottom out, go up, etc.

I have compared it with the actual readings that happen here, and it is very reliable.

The next thing that I have done is to use the forecast as a tool to help me plan what I will do and to give me perspective when I am in a symptomatic period.

For example, if I know that there is going to be a huge drop in the barometric pressure, I will realize that I may not be able to do much of anything, and so perhaps I need to plan some down time, something I can do while lying down with my feet up, if need be.  I can also plan to work trigger points before hand, and, if needed, take ibuprofen to lessen the severity of the symptoms (kind of like taking ibuprofen before going to the dentist).

If I see that the barometric pressure is going to change in the afternoon on a particular day, I might try to get important chores taken care of at the beginning of the day, so that I will not be agonizing over how much I did not get done later.  My rest period will occur at a natural time and will coincide with the time I would not be able to do much anyway.

If it is a moderate drop, I often feel antsy, so I might plan something active to do during that time.  It is not a good time to sit and read.  If I do that, I will find myself constantly going into the kitchen and opening the cupboard, looking for that item that has the perfect combination of chewy and crunchy without being too sweet or too savory.  So, I might plan on vacuuming, exercising, yard work, or anything else that will help to get that restless energy channeled.  (Last time, I made homemade bread and cinnamon rolls... the family liked that.:)

I have noticed that if it is a steeper drop in pressure, I usually have more pain.  I may have to just muddle my way through, taking pain medication and trying to distract myself.  But, for me, it also helps to see that the pressure is going to head back up in an hour or so.  Or, if I know that it going to last longer, I can tell myself that this is the perfect time to watch those shows that I have wanted to watch.

I think it is better to avoid the computer because of the tension that typically builds up when we are on the computer.  If we are typing, our head, neck, shoulders, arms and hands, are continually tense, along with any part of the body that is positioning itself just right for us to balance the laptop (knees) or to reach the floor (feet in tiptoed position).  I find that it is better to do something that is pleasant and distracting, in a position where your entire body is supported comfortably.  You don't want to add any more tension.  But, it might be different for you, so do what relaxes you.

I have noticed that sometimes when the pressure goes quite high, I get migraines.  I am still monitoring that aspect.  My migraines are also very affected by my hormones.  (One thing that I am very happy about, since learning about and using trigger point therapy, when I do get headaches, if I cannot relieve them by using trigger point therapy, I can at least treat most of them now with ibuprofen.  Nothing worked before.)

One thing about these pains is that they eventually go away.  I love having the chart that tells me about when they are heading out. I suppose it makes me feel more in control of my situation.

I am also interested to see how things will change as I continue to work my trigger points.  Right now, I can feel pretty good, and a front will come in and I will feel like I have been attacked.  But, as I mentioned above, the nature of the attack has changed.  It is now in the muscles that refer pain to the bones that I feel it.  I wonder if this pain will lessen over time as I get those trigger points more under control or if it will stay the same.  My hope is that the pain will lessen.  Time will tell.

In the meantime, I am very grateful for the techniques, devices, and medicines that help me over these rough spots and help me to be able to enjoy my journey.

Monday, February 27, 2012

Dealing with Back Pain: Psoas

Back pain can come from a variety of places.  Did you know that back pain can come from muscles in your abdomen?  One of these muscles is called the psoas (pronounced "SO-az").  It actually connects up with another muscle called the iliacus and together they are called the iliopsoas ("Ill-ee-oh-SO-az'").

The psoas can refer pain to the back, anywhere from the shoulder blades to the buttocks area.  Back pain from the psoas is usually on one side of the spine or the other, unless both the psoas muscles have trigger points, in which case, the pain will not feel like it is confined to one side or the other.  Here are some other places that the psoas can refer to:

  • groin 
  • upper thigh 
  • contributes to scoliosis 
  • abdomen 
  • genitals 
  • stiffness in hips or groin in morning when you get up 
  • rotates legs outward 
  • can't stand up straight
  • stooped posture
  • leaning to one side

(Information is from, The Trigger Point Therapy Workbook, by Clair Davies, pp. 151-155.)

The psoas attaches to the bones of the spine, starting at about the height of the last rib. It comes down and forward to attach to the top of the thigh bone.  The iliacus portion of the muscle starts at the front of the hip bones and joins the psoas to attach at the same place on the top of the thigh bone.
Primitive drawing, but it should give you an idea.  The psoas is shown in red, the iliacus in green.  

While the iliacus is a little more accessible, the psoas is buried deep in the abdomen.  But it is possible to work it.

You must use caution.  It is important to stay away from major veins and arteries, so if you feel a pulse when working your psoas, just move over a bit until you do not feel it anymore.

The psoas is actually located under your intestines.  To work it, you need to come in at an angle.  There are a couple of ways to work the psoas.

One is to lie down on your back with your knees bent.  Then let your knees drop to one side.  This will bring the hip opposite your knees up and move your intestines over a little. (Move your knees to the other side to work the other psoas.)

The main trigger points are a couple of inches away from the belly button on either side.  You can start there and look for trigger points about halfway between your belly button and your hip bone.  Bring your hands together with the fingers of each hand on the backs of the fingers of the opposite hand.  Using this tool, push down into your abdomen, searching for trigger points.
Tool for working abdominal trigger points, including the psoas.

You will probably find trigger points in other abdominal muscles, and you can just go ahead and work those while you are at it.  If you want to know for sure if you have located the psoas, you can move your leg up and down.  You should be able to feel the muscle under your fingers as you move it.  Do not work the muscle while moving, however.  Trigger points are much easier to work out when the muscle is relaxed.

A second way to work the psoas, and this is where I am saying use caution, is to use the theracane.  I personally like to do it this way, at least sometimes, because my arms seem to wear out pretty fast when I work my abdomen.  I would advise that you learn how to find the psoas first, using your hands and when you feel like you have a good handle on where it is located, then you can move up to using the theracane.

To work the right psoas, hold the theracane in front of you with the curve on the right, curve facing upward.  Grasp the top of the curve in your right hand and the outermost handle in your left hand.
Holding the theracane.

Let your knees fall to your left side.  Then push the remaining handle into the trigger point.  It is very important to proceed gently and carefully.
Using remaining handle, press into trigger point.  I am standing in this picture to provide a better view how to push in with the theracane, but you would be lying down.  

You can also work the iliacus with a lacrosse ball against the wall or a countertop.  Place the ball just below your hip bone in the front.  You can also work your quadratus lumborum, another contributor to back pain, by placing the ball just above the hip bone.  Working both of these areas will make it easier to work the psoas.

When you work the psoas muscles, be sure to work both of them every time.  And it is a good idea to work your glutes, quads and hamstrings, since they work with the psoas.  If all of the muscles are tight, and you loosen one of them, the others may reflexively tighten even more.  Picture a tug-of-war happening.  As long as both sides are pulling hard on the rope, it stays pretty much in the same place.  But, if one side lets go, the other side will end up falling down because they have still been exerting the same amount of force needed to keep that rope in the same place when the other side is pulling with all of their might.

So, if two muscles (for example) are plagued with trigger points, both muscles will be extremely tight, but that tightness will be tempered by the pull of the other muscle.  When one muscle suddenly has its trigger points released, there is no longer a pull on the other muscle and it is likely to tighten even more, resulting in more pain.  Because of this, it is a good idea to work any muscles that are antagonists (the muscles perform opposite functions) or synergists (the muscles perform a function together) at the same time that you work the original muscle.

Addendum added Oct. 23, 2012: 
I have found another way to work the psoas which I think is easier IF you are able to get down on the floor.  I have been able to get down on the floor lately, and it is easier to access the psoas using this method.

Part 1:
1) I lie face down on the floor with a lacrosse ball placed between me and the floor, about two inches out from my waist.  I take slow, deep, full (abdomen fills also) breaths and let myself fall further into the ball each time I exhale.  After two or three times, I go to step 2. 

2) I lift my head and rest on my elbows and forearms.  At the same time, I pull slightly forward.  I do the same breathing routine.  Then I go to step 3.

3) As I exhale my first deep breath, I lift my leg on the same side the ball is on and I let myself fall into the ball.  I hold my leg in that position until I have done about 3 repetitions.  The leg is lifted from the hip.

Then I repeat on the other side.

Part 2:
Then I turn over onto my back and work two or three trigger points at my bottom rib area and at the top of my pelvis (about waist level).  Using the breathing technique is helpful here also.  I do this on both sides.  Then I roll over gently and get up.

I found this excellent youtube video by tptherapy that shows how to do Part 1:  Trigger Point Weekly Workout #1   There is more on the video, but the part I am referring to is the first few minutes when he shows how to work the psoas with a therapy ball. 

For the second part of what I am describing, check here:  Remove Muscle Knots Yourself (Tennis Ball Release).  This youtube video by Paula Moore is excellent.  She also gives good advice about getting up from working your trigger points.  Don't just sit up.  She will show you how to roll over correctly when getting up.

One more thing:  This video, uploaded by posturedoc, describes a good sleeping position to help prevent back pain. I found it very helpful.  The Best Sleeping Position and How to Get Out of Bed

Hopefully, something here will help you. 

Monday, January 16, 2012

More Trigger Point Tools

Having the right tool can make all the difference. For example, it would not be very effective to use a screwdriver to hammer in a nail, and it would not make much sense to use a hammer on a screw. Sometimes, we can substitute another tool and it will be somewhat effective, like using a knife as a screwdriver, but it will be faster and more efficient to use the right tool. Sometimes, we have tools that are good enough, but a more specialized tool would make it so much easier.

I have introduced you to what I would consider the mainstays of a trigger point tool kit:  the lacrosse ball and the theracane (or backnobber). Today, I will introduce you to a few other tools that can be useful, especially for specific jobs.

Interestingly enough, bouncy balls are great tools for getting to some of the harder to reach muscles. They come in different sizes so you can usually find something that will fit your particular purpose. They are not as durable as lacrosse balls, but they are relatively inexpensive and they will last for quite a while.

Two sizes of bouncy balls and lacrosse ball.  

I have a favorite size that I have been using to massage the muscles in my arm while I am recovering from my elbow injury. There are many narrow muscles in several layers that I am working and this ball is perfect for this. The ball a size up is too big and the ball a size down is too small.  

Using bouncy ball on the outer elbow area.  

Using bouncy ball on inside area of elbow and down the arm.  

 Using the opposite hand, I press and roll the ball into my muscle. I use the heel of my palm to get particularly deep, but I also use the entire palm of my hand, and my four fingers held straight and close together to form one tool. Using this method, I roll the ball around my arm, and as I find trigger points, I work them for a few strokes before continuing on.

Getting in position to use the opposite hand on outer elbow.  The ball is placed between the palm and the opposite elbow. 
I have used a bigger size (the purple and orange ball in the photo above) for my triceps, and it is perfect for that. When I first got off the pain pills and I was starting to venture out into the world again, I went grocery shopping. I took that ball with me, and whenever my elbow started to really ache, I worked my triceps with the ball, and it relieved my pain.  

As part of my physical therapy, I have to wear a splint on my arm for 6 to 8 hours a day to help me stretch my muscles back to where they were before the accident. Often, my arm starts to ache when I wear this, but I can work some trigger points through the back side of it, which is open. I can also take the splint off temporarily, work some trigger points on the inside and put it back on. When I have worn it for several hours, my arm is usually pretty tender all over, and it hurts to move it. I use the ball to work all of the areas that are tender and stiff.  

The difference between the two arms.  I have gained quite a bit of range of motion, but I have some way to go still. My arm usually extends farther after I have had my arm in the hot whirlpool bath for 15 minutes at the physical therapist's office.   
My arm in the splint.  
Sometimes, I can just set the ball on the table, or another hard surface like a book, and roll the exposed part of my arm on the ball.  

Another tool that I have used recently is called the Palm Massager (made by a company called Pressure Positive, available online).  

Palm massager.
This handy tool is held in the palm of the hand. The fingers fit comfortably into grooves molded into the tops of the three "arms" of the tool. Each "arm" has a rounded end. Two of these ends are relatively small, while the remaining end is larger.  

The finger fits in the groove on top of the arm.

This design makes it easy to use quite a bit of pressure without totally trashing your fingers. I have used it for trigger points in the back of the neck, and, lately, I have used it to work my inner elbow. It is good for going deep.  

Using on the back of the neck.  It is even better if you can lean back into it, so that the muscles that you are working are relaxed.  

Late one night, I was using the palm massager on my inner elbow, and I was able to find some places that hurt that I had not been able to reach before. I worked them, and I could see that it was increasing my mobility. I was pretty excited. The next morning, I was dancing and singing: I've been dreaming of an arm that moves... to the tune of, "I've been dreaming of a true love's kiss," from the movie, Enchanted. It has become sort of a theme song for me.  

Another tool is the Knobble (also by Pressure Positive, available online).

The Knobble
This tool looks a lot like a round door knob. It has a rubber-like surface on its side, which helps in gripping the tool. I often like to hold the tool sideways and use the rubberized side for the trigger point therapy.

The Knobble, side view.
The Knobble is great for places that you want to get into deep with minimal effort. I have used it on my arms, my quads (but I decided later that I like the lacrosse ball against the wall better for the quads) and also on my pecs (using the side).

In position to use the Knobble on my arm.  My fingers are held up to show how the Knobble is placed.  They are wrapped around the Knobble when working the trigger points.  
Holding the Knobble sideways to work the pecs.  
I have even used it on the muscles of my head, staying on the gentler, rubber side.

Using the side of the Knobble on my temporalis muscle. 
Experimenting with different tools, you will probably find some that you prefer over others for particular tasks. The more comfortable you are using a tool, the more likely you will be to use it. You will also probably be more effective, giving the right amount of pressure, not too much, not too little.

Monday, January 9, 2012

How "cruel" are your shoes?

I read a story written by comedian Steve Martin some years ago entitled, "Cruel Shoes." In this story, a woman goes to a shoe store to purchase shoes, and is not satisfied with any that are brought out to her by the salesperson until she finds a pair that are so uncomfortable that they contort her feet and make them bleed. When she tries these on, she is finally pleased, and decides to get them.

When I was younger, there were times when I walked all over BYU campus in heels, sometimes spiked, not all of the time, but at least once a week for a school year when we had church services in a building on the opposite side of campus from where we lived. I knew it wasn't good for my feet; however, I have short legs, and I thought wearing high heels made my legs look longer. Besides, I did not want to make myself look weird. So, I kept wearing them and put my feet up to rest when I got home.

In my late thirties to early forties, I noticed that whenever I wore high heels (as opposed to lower heels), my knees started to hurt a lot within 15 minutes. It was so bad that I could not stand, but had to sit down. They kept hurting for a while after I took the heels off. I stuck to low-heeled pumps for several years, until a few years ago, I could not even wear those. The bottom of my foot had started to hurt in addition to the knee pain. It felt like I was walking on the bones, with no cushioning at all. I had to stop wearing dress shoes completely. Also, there was only one style of athletic shoe that did not make my knees hurt, and the last time I went to get another pair, they were discontinued.

Thankfully, it was about that time that I found out about trigger point therapy. I worked the trigger points in my legs to help get rid of the pain. The pain in the knees came from my thighs, and the pain in the foot came from my calves. But the pain was quick to return when I walked for any length of time.

I learned that I have something called Morton's foot (not to be confused with Morton's neuroma), that is, I have a longer second metatarsal (bone behind the second toe) than the first metatarsal. This predisposes me to problems with my feet and indirectly causes pain in the rest of my body. This difference in metatarsal length made it so I was walking on two points of my foot, instead of three--kind of like walking around on an ice skate, but without the high top boot. The muscles farther up my body were working very hard just to keep me standing.

Fortunately, The Trigger Point Therapy Workbook had a fairly simple and inexpensive way to compensate for my foot structure (See p. 243). I cut out an oval or circle of moleskin about an inch-and-a-half in diameter for each foot. I stuck it (it is a peel-and-stick product) on the bottom side of a foam insert that had been cut to fit my shoe, in the area under the first metatarsal.
Foam insert, cut to size. 

Example of piece of moleskin attached to bottom of foam insert. 

I was amazed at the difference this made. I could actually stand tiptoe, something I had not been able to do for a long time. It eliminated my knee and foot pain (as long as I stick with low shoes). Putting the pad under the first metatarsal gives it a little more "length" so that it can hit the ground before the second metatarsal.  The first and fifth metatarsals, and the heel, act as a tripod to bear the weight of the body.

So, if you have ongoing foot pain, knee pain, or back pain, it might be a good idea to take a look at the bones that protrude when you bend your toes. (There is more information on p. 243-245).

To fit yourself with one of these "custom orthotics," flex your big toe upward and feel for the bony part in the center of the fleshy pad below the big toe.
Feel the bone in the fleshy pad below the big toe.  

Trim the circle or oval of moleskin to fit comfortably under that bone, without going under the bone that is further into the foot (the second metatarsal). Check where to place the pad* first (before you peel off the backing), then peel the backing off and stick it to the bottom of the foam insert. Then place the insert in your shoe. Mine usually last a month or two before the insert starts to wear out.

Also, consider the type of shoe that you wear. Clair Davies writes, "Wearing high heels keeps the soleus [this is a large flat muscle that wraps around the back of your calf] muscles shortened, which is a sure way to create and perpetuate trigger points. The ankle instability typically caused by high heels also strains the soleus muscles with each step." (p. 239).  Trigger points in the soleus can cause "deep pain in the sacroiliac area and maintain spasms in the muscles of the low back" (p. 238). It also sends pain to the back of the calf, heel of the foot, and inside ankle.

So, how cruel are your shoes?
*I have noticed that some people have a very large difference in length of the first and second metatarsal.  They may need to have a thicker pad to compensate.  Experiment a little bit to see what helps you.