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

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 1

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 often 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 2

“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 3

A Well-Adjusted Brain Cartesian Model of Pain 4

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 5

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 6

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] ). 7

(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 8

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 9

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 10

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 11

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 often enough to be convinced that they are not damaging The Importance of Exercise • Strength, flexibility, and endurance training � To treat kinesiophobia � To rehabilitate muscles 12

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 13

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 14

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 15

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 16

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 back pain worksheets, visit: www.backsense.org For recorded meditations, visit: www.mindfulness-solution.com email: rsiegel@hms.harvard.edu 17