Mindfulness-Based Approaches to Managing Chronic Pain

March 2014

Kimberly Murdoch BSW, RSW, dipl HSC, NTS, DAc

Disclosure

As a partner in For Health Wellness Consultants Kimberly Murdoch profits from sales of:

For Health meditation CDs and downloads For Health corporate seminars on

resiliency and productivity

Objectives

Learn about the neurobiology and research related to mindfulness approaches

Understand and experience mindfulness techniques

Discuss ways to introduce mindfulness in the exam room with complex chronic pain patients

Become aware of books and online resources for your own learning and to support your patients in using mindfulness for managing distress

Strong evidence that mind‐bodyinterventions such as mindfulness elicit beneficial psychological and pathophysiological effects on various human diseases

What is Mindfulness?

• The most basic definition is the regulation of attention through mind-body awareness skills

•Operational definition, “Mindfulness is a particular way of paying attention, on purpose, in the present moment, and non-judgmentally” Jon Kabat-Zinn, PhD

• Mindfulness is developed through a relaxed, passive attention to a repetitive or absorbing stimulus that turns off the “inner dialogue” thereby decreasing arousal of the sympathetic nervous system Herbert Benson, MD, Harvard Medical School

What is Mindfulness?

•Mindfulness includes:

• the aim

• the methods

• the outcomes

J Kabat-Zinn

Pain and the Mind-Body Connection

“Pain is not just a “body” problem, it is a whole-systems problem.” Jon Kabat-Zinn

Mindfulness-Based Chronic Pain Management programs are biopsychosocial interventions that address several of the factors that impact pain and the ability to heal

Multiple Factors Intersecting

Multiple factors impact perception of pain and ability to heal:

thoughts, emotions, attentional biases, sleep, nutrition, physical activity, socio-economics and social support, life history, medical interventions and medications, concurrent pathologies, stress levels…

Mindfulness Skills

Breath Awareness

Guided Body Scan

3-Minute Breathing Space

Mindful Daily Living

Breath Awareness

• Find a quiet place and consistent time for practicing

• Attentional bias: Cultivate an attitude of “trying easy”

• Training attention on

breathing sensations

Mindfulness Research Summary

Research suggests that mindfulness-based therapies may be effective adjunctive interventions for:

chronic pain, depression, anxiety, trauma, Borderline Personality Disorder, OCD, ADHD, addiction, stress

Currently few valid, reliable measures of mindfulness

Research and Mindfulness-Based Interventions in Patients with Chronic Pain

Reiner et al.: most of the reviewed chronic pain studies (9/16) demonstrated a statistically significant decrease in pain intensity among persons receiving mindfulness-based interventions (MBIs)

Reductions in pain intensity were generally well maintained in 3-month follow ups

Along with other beneficial effects of mindfulness approaches, MBIs may help to reduce pain intensity

Reiner K, Tibi L, Lipsitz JD. Do Mindfulness-Based Interventions Reduce Pain Intensity? A Critical Review of the Literature. Pain Med. 2013;14:230–242

Limitations of Research

Minimum threshold of 10 participants per group for study inclusion was probably too low

Large majority of studies (13/16) included data only for treatment completers which could bias results to favor MBIs

Some studies involved novice meditators and other studies focused on experienced meditators

Some of the controlled trials lacked randomization Some studies investigated the effects of mindfulness on other processes (e.g. emotion reactivity

or regulation) instead of the basic processes of mindfulness itself

Reiner K, Tibi L, Lipsitz JD.(2013). Do Mindfulness-Based Interventions Reduce Pain Intensity? A Critical Review of the Literature. Pain Med.14:230–242

Mindfulness Impact on Threat Appraisal and Emotions

The Center for Investigating Healthy Minds (CIHM), University of Wisconsin, Richard Davidson, neuroscientist and team conducting studies of “The Brain on Meditation” since 1992, identified outcomes:

“Meditators' brains were active, particularly in the left prefrontal cortex, the part of the brain responsible for positive emotions” (Davidson, 2004)

What We Know About the Effects of Mindfulness on Neurobiology

fMRI Conclusions:

Mindfulness meditation induces specific changes in fMRI signal in several structures, including the amygdala, hippocampus, pons, anterior cingulate, and intraparietal sulcus

Lazar, G. Bush, G. Fricchione, R.L. Gollub, G. Khalsa, H. Benson, H. (2000). Functional Brain Mapping of the Relaxation Response using 3T fMRI S.W. Neuroreport, 11, 7

What About Briefer Mindfulness Interventions?

Moyer and colleagues at the University of Wisconsin-Stout

Random assignment to either a 5-week mindfulness meditation group or wait list group

Meditation group meditated at home 2x/week, 25 minutes each time, on average

Meditation subjects showed same significant increase in left hemisphere cortical activation as those who did full intervention of earlier studies

Wait list group did not demonstrate these changes

Moyer, C. A. et al. (2011). Frontal Electroencephalographic Asymmetry Associated With Positive Emotion Is Produced by Very Brief Meditation Training. Psychological Science

Research Summary

75% of all illness is related to stress and lifestyle habits. Former U.S. Surgeon General

Studies have found that regular practice of meditation or relaxation provides benefits to:

cardiac patients, surgery recovery, immune function, pain relief, diabetics, anxiety…

Physiological Benefits of Mindfulness Skills

Decrease blood pressure, heart rate, muscle tensionReduction in serum

cholesterol Improved immune function Reduction in cortisol levelsReduce pain and anxiety Improve sleepChanges in neurotransmitters

- ↑ serotonin, ↓ depressionDecrease inflammation

Psychological Benefits of Mindfulness Skills

More optimism and decreased depressionGreater self-awarenessImproved coping abilitiesReduced aggressionGreater efficiency and productivityImproved learning capabilities, concentration

and memoryPromote feelings of inner calm and tolerance

Mindfulness Skills

Breath Awareness

Guided Body Scan

3-Minute Breathing Space

Mindful Daily Living

Applications and Benefits

To alter physical symptoms such as hypertension, IBS, nausea, insomnia etc.

To decrease pain and the use of pain medications

To decrease anxiety and fearTo alleviate depression and angerTo prepare for and experience medical

procedures, treatments and tests

Applications and Benefits continued…

To promote healing and recoveryTo enhance inner strengths, resiliency,

optimism, and self-esteemTo increase feelings of well-being, comfort and

controlTo increase self-awarenessTo change negative thought patternsAt end of life

Exclusion/Inclusion Recommendations

Exclusion: Patients with cognitive impairmentsPatients experiencing mental clouding

associated with their pain conditions or medications

Inclusion:“Patient preference and enthusiasm are a good

guide” Dr. William Marchand, George E. Wahlen Veterans Affairs Medical Center and the University of Utah (July 11, 2012 ScienceDaily.com)

How to Make Mindfulness Meditation Miserable

I shouldn’t have thoughts during meditation.My body is supposed to be relaxed.My body should be still.Emotions keep coming up. I shouldn’t have

feelings such as anxiety or anger. I shouldn’t cry during meditation.

My environment should be perfectly quiet.I can’t do this. I’m not a patient person.

Difficulties and Challenges

No timeIntrusive thoughts or body sensations (pain)Emotions or memories come to the surfaceRestlessness, can’t sit stillFalling asleep, wandering mindEnvironmental noisesAnxiety about “letting go”I’m not doing it ‘right, trying too hard = frustrationAppearance of images

Summary

Many studies have found that mindfulness-based approaches provide benefits to:

pain management, surgery recovery, anxiety, depression, immune function, cardiac patients, diabetics, resiliency

Mindfulness approaches can be introduced to patients with chronic pain in the exam room

Key Components to Mindfulness Practice

● Find a quiet place for practicing

● Cultivate an attitude of “trying easy”

● Train the mind to focus attention

● Practice daily

© 2013