Chronic Back Pain 1 Bad Back? The Orthopedic Story Whats the - - PDF document

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Beyond Symptom Management: Mindfulness for Chronic Pain

Ronald D. Siegel, Psy.D. Center for Mindfulness and Compassion Cambridge Health Alliance Harvard Medical School

Disclosure

Neither I nor my spouse has any financial relationship with commercial interest to disclose.

Chronic Back Pain

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Bad Back? The Orthopedic Story What’s the Evidence?

• 2/3 of people who have never suffered

from serious back pain have the same sorts of “abnormal” back structures that are

• ften blamed for the pain
• Millions of people who suffer from chronic

back pain show no “abnormalities” in their backs

• Many people continue to have pain after

“successful” surgical repair

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“Smoking Gun” Studies

• What countries have chronic back pain

epidemics?

• Who gets chronic back pain?
• What is the quickest way out of acute back

pain?

Autonomic Nervous System

HPA Axis

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A Well-Adjusted Brain

Cartesian Model of Pain

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Cold Pressor Test Gate Control Models of Pain

• Pain is not proportional to extent of tissue

damage

• Pain is exacerbated by fear
• Chronic back pain is thus due to both

effects of muscle tension and increased sensitivity to pain

Not Imaginary Pain

• While psychological stressors of all types can

contribute to chronic back pain, the pain is not imagined or “All in the head”

• Caused by real muscle tension
• Patients need to hear this repeatedly

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Mindfulness for Rehabilitation

• 1. Medical Evaluation
• 2. Cognitive Restructuring
• 3. Resuming Normal Activity
• 4. Working with Negative Emotions

Mindfulness

What is Mindfulness?

• Sati in Pali

Connotes awareness, attention, & remembering

• Also includes

Non-judgment Acceptance Kindness & friendliness

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Therapeutic Mindfulness

• 1. Awareness
• 2. Of present experience
• 3. With acceptance

Mindfulness Practice is Not:

• Having a “blank” mind
• Becoming emotionless
• Seeking bliss
• Escaping pain

The Story of the Two Arrows

When touched with a feeling of pain, the uninstructed run-of-the-mill person sorrows, grieves, & laments, beats his breast, becomes

• distraught. So he feels two pains, physical &
• mental. Just as if they were to shoot a man with an

arrow and, right afterward, were to shoot him with another one, so that he would feel the pains of two arrows (Salllatha Sutta [The Arrow] ).

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(Pain) x (Resistance) = Suffering

• Pain can be observed to be separate from

“suffering”

• Apparently solid pain states are observed

to be like frames in a movie, ever- changing

Pain is Inevitable, Suffering is Optional

• Suffering Includes:

Grimacing, wincing, bracing. Aversive thoughts. Wishes for relief. Self-punitive thoughts. Anger, fear, depression regarding condition.

Mindfulness for Experimentally Induced Pain

• Compared to novices, Experienced

Meditators:

find pain less unpleasant can observe pain less reactively find that open monitoring reduces pain unpleasantness have less anticipatory pain anxiety

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Insula

• Associated with

interoception

Visceral and “gut” feelings Processes transient body sensations

• Activated during

meditation practice

Prefrontal Cortex (PFC)

• Evaluates emotional responses and regulates

emotion “Yes, looks like a lion, but lions aren’t found here, so it’s probably a beige rock”

Neurobiology of Mindfulness and Pain

• Meditators practicing mindfulness when

exposed to pain:

had decreased activity in the lateral prefrontal cortex (lPFC) – evaluates sensation had increased activation in the posterior insula – registers sensation

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Beyond Relaxation Training

• Not controlling

physiological arousal

• Mindfulness

Fosters cognitive change Increases symptom tolerance Increases capacity to choose whether to act on urges Uncovers emotions

Mindfulness & Cognitive Restructuring

Seeing Thoughts as Thoughts

• Mindfulness increases cognitive

flexibility

• Seeing role of beliefs in the problem
• Not pain sensations themselves, but our

reactions that determine suffering

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Enhancing Metacognitive Awareness

• Notice prevalence of anxious thought

and feeling

• Notice future-oriented catastrophizing
• Notice “budgeting” activity

Mindfulness & Resuming Normal Life

Creative Hopelessness

• Attempts to get rid of

pain intensify and perpetuate disorder

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Relinquishing Control

• Letting go of quest

to fix alleviate pain

• Useful to control

behavior

• Impossible to control

sensations

Resuming Lost Activities

• Exposure and

response prevention central to treating kinesiophobia

• Resume activities
• ften enough to be

convinced that they are not damaging

The Importance of Exercise

• Strength, flexibility,

and endurance training

To treat kinesiophobia To rehabilitate muscles

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In the Gym

• Implosion treatment

Ignores Back School instructions

• Potential for rapid recovery
• Potential for refusal, drop out

In the Consultation Room

• Begin with activities that are:

Easy Pleasurable or rewarding Can be done 3 or more times/week

• Continue until no longer feared

Convinced it doesn’t make pain worse

Friends and Family

• To support patient in expanding activity

Stop protecting patient from pain Encourage normal activity

• Treat fear in significant others

Psychoeducation

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Increasing Symptom Tolerance

• Pain as object of

awareness

• Bring attention to

wider area if necessary

Working with Intentions

• Pain is distinct from urge to eliminate it
• Attention can be brought to urge to

alleviate pain

• Urge arises, reaches crescendo, and

passes

Mindfulness & Working with Negative Emotions

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Opening to Painful Emotions

• Experiential avoidance increases

anxiety & muscle tension

• Mindfulness practice

Enhances interoception Develops affect awareness and tolerance

MBSR vs CBT vs TAU Chronic Low Back Pain

• Meaningful improvement in disability

MBSR 60.5% CBT 57.7% TAU 44.1% P=.04

• Meaningful improvement in pain distress

MBSR 43.6% CBT 44.9% TAU 26.6% P=.01

Cherkin, et al. JAMA 4/16

Other Pain Disorders

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Same 4 Steps

• 1. Medical Evaluation
• 2. Cognitive Restructuring
• 3. Resuming Normal Activity
• 4. Working with Negative Emotions

Other Muscle Tension Disorders

• Dynamics very similar to chronic back

pain

Headaches; TMJ; neck, knee, foot, wrist, shoulder pain

• Need to rule out treatable causes

Then follow same steps

Hyperacusis

• Fear of discomfort

amplifies sound

• Avoidance hyper-

sensitizes hearing

• Mindful acceptance

resolves disorder

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Fibromyalgia

“. . .we are creating an illness rather than curing one.“

• - Dr. Frederick Wolfe

Is it Serious?

• Danger of insufficient response to distress

Neglecting medical evaluation and treatment

• Danger of excessive response to distress

Maladaptive pursuit of pain relief

For recorded meditations, visit: www.mindfulness-solution.com email: rsiegel@hms.harvard.edu For back pain worksheets, visit: www.backsense.org