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Distinct Brain Systems Mediate Nociceptive Input and Self-Regulation of Pain

Does cognitive self-regulation influence the pain experience by modulating representations of nociceptive stimuli in the brain or does it regulate reported pain via neural pathways distinct from the one that mediates nociceptive processing? Woo and colleagues devised an experiment to answer this question.1 They invited thirty-three healthy participants to undergo fMRI while receiving thermal stimulation trial runs that involved 6 levels of temperatures. Trial runs included “passive experience” where participants passively received and rated heat stimuli, and “regulation” runs, where participants were asked to cognitively increase or decrease pain intensity.

Instructions for increasing pain intensity included statements such as “Try to focus on how unpleasant the pain is. Pay attention to the burning, stinging and shooting sensation.” Instructions for decreasing pain intensity included statements such as “Focus on the part of the sensation that is pleasantly warm. Imagine your skin is very cool and how good the stimulation feels as it warms you up.” The effects of both manipulations on two brain systems previously identified in the literature were examined. One brain system was the “neurological pain signature” (NPS), a distributed pattern of fMRI activity shown to specifically track pain intensity induced by noxious inputs. The second system was the pathway connecting the ventromedial prefrontal cortex (vmPFC) with the nucleus accumbens (NAc), shown to play a role in both reappraisal and modulation of pain. In humans, the vmPFC tracks spontaneous pain when it has become chronic and potentially dissociated from nociception.2,3 In patients with sub-acute back pain, the vmPFC-NAc connectivity has been shown to predict subsequent transition to chronic back pain.4 In addition, the vmPCF is hypothesized to play a role in the construction of self-representations, assigning personal value to self-related contents and, ultimately, influencing choices and decisions.5

Woo and colleagues found that both heat intensity and self-regulation strongly influenced reported pain, however they did so by two differing pathways. The NPS mediated only the effects of nociceptive input. The self-regulation effects on pain were mediated by the NAc-vmPFC pathway, which was unresponsive to the intensity of nociceptive input. The NAc-vmPFC pathway responded to both “increase” and “decrease” self-regulation conditions. Based on these results, study authors suggest that pain is influenced by both noxious input and cognitive self-regulation, however they are modulated by two distinct brain mechanisms. While the NPS encodes brain activity closely tied to primary nociceptive processing, the NAc-vmPFC pathway encodes information about evaluative aspects of pain in context. This research is limited in that the distinction between pain intensity and pain unpleasantness was not included and the subjects were otherwise healthy. Further research is warranted on the effects of this cognitive self-regulation model on brain pathways in patients with chronic pain conditions.

Even with the noted limitations, this research invites the clinician to consider the role of both nociceptive mechanisms and cognitive self-regulatory influences on a patient’s pain experience and suggests treatment choices should take both factors into consideration. Mindful awareness training is a treatment that contributes to cognitive self-regulatory brain mechanisms.6 When mindful, pain is observed as and labeled a sensation. The term “sensation” carries a neutral valence compared to “pain” which may reflect greater alarm or threat to an individual. The mind is recognized to have a camera lens-like quality that can shift from zoom to wide angle. While pain can draw attention in a more narrow focus on the painful body area, when mindful, an individual can deliberately adopt a wide angle view, focusing on pain free areas and other neutral or positive states. In addition, when mindful, the unpleasant sensation rests in awareness not characterized by fear and distress, but by stability, compassion and curiosity. Patients may not have control over the onset of pain, but with mindfulness training, they can take control over their response to the pain. This deliberate adoption of mindful principles and practices can contribute to cognitive self-regulatory brain mechanisms that can ultimately impact pain perception.

I am excited to share additional research and practical clinical strategies that help patients self-regulate their reactions to pain and other symptoms in my 2019 courses, Mindfulness for Rehabilitation Professionals at University Hospitals in Cleveland OH, April 6 and 7 and Mindfulness-Based Pain Treatment in Houston TX, October 26 and 27 and Portland OR May 18 and 19. Hope to see you there!


1. Woo CW, Roy M, Buhle JT, Wager TD. Distinct brain systems mediate the effects of nociceptive input and self-regulation on pain. PLoS;2015;13(1):e1002036.
2. Baliki MN, Chialvo DR, Geha PY, Levy RM, et al. Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain.J Neurosci. 2006;26(47):12165-73.
3. Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(pt9):2751-68.
4. Baliki MN, Peter B B, Torbey S, Herman KM, et al. Corticostriatal functional connectivity predicts transition to chronic back pain. Nat Neurosci.2012;15(8):1117-9.
5. D’Argembeau. On the role of the ventromedial prefrontal cortex in self-processing: The Valuation Hypothesis. Front Human Neurosci. 2013;7:372.
6. Zeidan F, Vago DR. Mindfulness meditation-based pain relief: a mechanistic account. Ann N Y Acad Sci. 2016 Jun;1373(1):114-27.

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Mindful Attention to the Breath Reduces Amygdala Activity

As so many of our patients are shallow breathers, I found this research on the effects of mindful attention to the breath (MATB) on prefrontal cortical and amygdala activity especially informative and relevant to patient care. Twenty-six healthy volunteers with no prior meditation experience were introduced to MATB by an experienced meditation teacher and instructed to practice a 20-minute audio guided MATB meditation daily for 2 weeks.1 At the end of the 2-week training period, subjects underwent fMRI scanning while viewing distressing emotional images with MATB and with passive viewing (PV). Participants were shown aversive pictures or no pictures and were instructed to “Please focus your attention on your breath as you were instructed in the training” or “Please watch the picture without changing anything about your feelings.” Subjects indicated their current affect on a 7 point scale ranging from -3 (very negative) to +3 (very positive).Mindfullness

Breathing frequency significantly decreased during MATB compared to PV. Researchers controlled for this by including breathing frequency as a covariate in further behavioral and brain data analysis.

Analysis of affective ratings showed that participants felt significantly less negative affect when viewing distressing visual stimuli during MATB than PV. During negative visual stimuli, MATB significantly decreased bilateral amygdala activation compared to PV. Also, right amygdala activation decrease specifically correlated with successful emotional regulation. That is, those participants with greater reductions in right amygdala activation reported greater reductions in aversive emotions during the MATB. In addition, emotion-related functional connectivity increased between the prefrontal cortex and amygdala during the viewing of negative images and MATB.

It’s exciting to have some initial science behind the benefits of MATB. I teach all of my patients MATB and have found it rewarding to get feedback from participants in my courses about their integration of MATB into their own patient care. Patients with complex pain conditions can be challenging to treat, however sometimes a simple practice of taking 2 to 3 minutes prior to and/or at the end of a treatment to have a patient calmly focus on their breath with the mindful attitudes of acceptance, kindness and curiosity can help a person shift from tension and distress to calm and confidence. I look forward to presenting this and additional research on the impact of mindful meditation on brain structure and function in my upcoming course, Mindfulness-Based Pain Treatment, in Seattle, November 4 and 5. Hope to see you there!


1. Doll A, Holzel BK, Bratec SM, et al. Mindful attention to breath regulates emotions via increased amygdala-prefrontal cortex connectivity. Neuroimage. 2016;134:305-313.

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The Chronic Stress of Chronic Pain: Clinical Implications

For many of our patients, chronic pain is a chronic stress. Unfortunately, the resulting ongoing physiological stress reaction can have neurotoxic influences in key brain regions, including the prefrontal cortex, amygdala and hippocampus, and drive maladaptive neuroplastic changes that may further fuel a chronic pain condition.1 For example, chronic stress generates extensive dendritic spine loss in the prefrontal cortex, hyperactivity in the amygdala, and neurogenesis suppression in the hippocampus.2,3,4 In parallel, patients with chronic pain have been shown to exhibit reduced gray matter in the prefrontal cortex, increased neuronal excitability in the amygdala and reduced hippocampal neurogenesis.5,6,7

These three brain areas have been identified to play an important role in fear learning and memory.8 Modulated by stress hormones and stress-induced neuroplastic changes, stress may:
(a) enhance the memory of the initial pain experience at pain onset
(b) promote the later persistence of the pain memory
(c) impair the memory extinction process and the ability to establish a new memory trace.9

Sections of the brainIn other words, an ongoing stress reaction, triggered by distressing cognitions and emotions in response to pain or other life circumstances, could reinforce and strengthen the memory of pain. The experience of pain could be generated not by nociceptive activity, but by a well-established memory of pain and inability of the brain to create new associations. Leading researchers in the cortical dynamics of pain at Northwestern University suggest this learning process and persistence of pain memory could be a major influencing mechanism driving chronic pain.9,10

In addition, neurogenesis suppression in the hippocampus is associated with depression, while increased amygdala excitability is associated with anxiety, two mood disorders that frequently accompany and complicate chronic pain conditions.11,12

Why is this important? Appreciating the complex factors that contribute to chronic pain conditions can point to treatment strategies that address these factors.13 For example, strategies that help reduce a patient’s stress reaction, mitigate the experience of fear and anxiety, and/or promote relaxation, positive mood and self-efficacy could conceivably reduce the stress reaction and reverse maladaptive neuroplasticity. While chronic pain is a multifaceted and highly complex condition with no simple answers or one-size-fits-all successful treatment strategy, initial research suggests promise for this approach to modulate cortical structure. In a study of cognitive-behavioral therapy (CBT) in the treatment of chronic pain, an 11-week CBT treatment course increased gray matter in the prefrontal cortex and hippocampus.14

In addition, a systematic review of brain changes in adults who participated in Mindfulness-Based Stress Reduction identified increased activity, connectivity and volume in the prefrontal cortex and hippocampus in stressed, anxious and healthy adults.15 Also, the amygdala demonstrated decreased activity and improved functional connectivity with the prefrontal cortex. Although yet to be studied in patients with chronic pain, these neuroplastic changes could potentially promote improved cortical dynamics in our patients.

I am excited to share this model of chronic stress and chronic pain and evidence-based applications of mindfulness to pain treatment in my upcoming course Mindfulness-Based Pain Treatment in Arlington, VA August 4 and 5, 2018 and in Seattle, WA November 3 and 4, 2018. Course participants will learn about mindfulness and pain research, practice mindful breathing, body scan and movement and expand their pain treatment tool box with practical strategies to improve pain treatment outcomes. Research examining the application of mindfulness in the treatment of patients at risk of opioid misuse will be included. I hope you will join me!


Vachon-Presseau E. Effects of stress on the corticolimbic system: implications for chronic pain. Prog Neuropsychopharmacol Biol Psychiatry. 2017; Oct 25. pii: S0278-5846(17)30598-5.
Arnsten AF. Stress signaling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci 2009:10(6):410-422.
Zhang X, Tong G, Guanghao Y, et al. Stress-induced functional alterations in amygdala: implications for neuropsychiatric diseases. Front Neurosci. 2018 May 29;12:367.
Kim EJ, Pellman B, Kim JJ. Stress effects on the hippocampus: a critical review. Learn Mem. 2015;22(9):411-6.
Fritz HC, McAuley JH, Whittfeld K, et al. Chronic back pain is associated with decreased prefrontal and anterior insular gray matter: results from a population-based cohort study. J Pain. 2016;17(1):111-8.
Veinante P, Yalcin I, Barrot M. The amygdala between sensation and affect: a role in pain. J Mol Psychiatry. 2013;1(1):9.
Vachon-Presseau E. Roy M, Martel MO, et al. The stress model of chronic pain: evidence from basal cortisol and hippocampal structure and function. Brain. 2013;136(Pt 3):815-27.
Greco JA, Liberzon I. Neuroimaging of fear-associated learning. Neuropsychopharmacology. 2016;41(1):320-334.
Mansour AR, Farmer MA, Baliki. Chronic pain: role of learning and brain plasticity. Restor Neurol Neurosci. 2014;32(1):129.
Baliki MN, Apkarian AV. Nociception, pain, negative moods and behavior. Neuron. 2015;87(3):474-491.
Schmaal L, Veltman DJ, van Erp TG, et al. Subcortical brain alterations in major depressive disorder: findings from ENIGMA major depressive disorder working group. Mol Psychiatry. 2016;21(6):806-12.
Shin LM, Liberzon I. The neurocircuitry of fear, stress and anxiety disorders. Neuropsychopharmacology. 2010;35(1):169-91.
Greenwald J, Shafritz KM. An integrative neuroscience framework for the treatment of chronic pain: from cellular alterations to behavior. Front Int Neurosci. 2018 May 23;12:18.
Seminowicz DA, Shpaner M, Keaser ML, et al. Cognitive-behavioral therapy increases prefrontal cortex gray matter in patients with chronic pain. J Pain. 2013;14(2):1573-84.
Gotink RA, Meijboom R, Vernooij, et al. 8-week Mindfulness Based Stress Reduction induces brain changes similar to traditional long-term meditation practice – A systematic review. Brain Cogn. 2016;108:32-41.

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Positive Activities

Coaching Patients to Engage in Positive Activities to Improve Outcomes

Substantial attention has been given to the impact of negative emotional states on persistent pain conditions. The adverse effects of anger, fear, anxiety and depression on pain are well-documented. Complementing this emphasis on negative emotions, Hanssen and colleagues suggest that interventions aimed at cultivating positive emotional states may have a role to play in pain reduction and/or improved well-being in patients, despite pain. They suggest positive affect may promote adaptive function and buffer the adversities of a chronic pain condition.

Hanssen and colleagues propose positive psychology interventions could contribute to improved pain, mood and behavioral measures through various mechanisms. These include the modulation of spinal and supraspinal nociceptive pathways, buffering the stress reaction and reducing stress-induced hyperalgesia, broadening attention, decreasing negative pain-related cognitions, diminishing rigid behavioral responses and promoting behavioral flexibility.

In a feasibility trial, 96 patients were randomized to a computer-based positive activity intervention or control condition. The intervention required participants perform at least one positive activity for at least 15 minutes at least 1 day/week for 8 weeks. The positive activity included such tasks as performing good deeds for others, counting blessings, taking delight in life’s momentary wonders and pleasures, writing about best possible future selves, exercising or devoting time to pursuing a meaningful goal. The control group was instructed to be attentive to their surroundings and write about events or activities for at least 15 minutes at least 1 day/week for 8 weeks. Those in the positive activity intervention demonstrated significant improvements in pain intensity, pain interference, pain control, life satisfaction, and depression, and at program completion and 2-month follow-up. Based on these promising results, authors suggest that a full trial of the intervention is warranted.

Rehabilitation professionals often encourage patients with persistent pain conditions to participate in activities they enjoy. This research highlights the importance of this instruction and patient guidelines can include the activities identified in the Muller article. In addition, mindful awareness training may further enhance a patient’s experience as he or she learns to pay close attention to the physical sensations, emotions and thoughts that accompany positive experiences. I look forward to discussing this article as well as sharing the principles and practices of mindfulness in my upcoming course, Mindfulness-Based Pain Treatment at Samuel Merritt University, Oakland, CA. Course participants will learn about mindfulness and pain research, practice mindful breathing, body scan and movement and expand their pain treatment tool box with practical strategies to improve pain treatment outcomes. I hope you will join me!


Hanssen MM, Peters ML, Boselie JJ, Meulders A. Can positive affect attenuate (persistent) pain? Curr Rheumatol Rep. 2017;19(12):80.
Muller R, Gertz KJ, Molton IR, et al. Effects of a tailored positive psychology intervention on well-being and pain in individuals with chronic pain and physical disability: a feasibility trial. Clin J Pain.2016;32(1):32-44.

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An Introduction to Mindful Awareness Training for the Treatment of Pain at CSM

As brain research in pain processing suggests, pain engages overlapping cortical networks responsible for nociception, cognition, emotion, stress and memory, a treatment model targeting nociceptive mechanisms alone can be inadequate to address the complexities of a patient’s pain experience.1 To help physical therapists understand and more effectively address multiple factors influencing a patient’s pain, the APTA, Orthopaedic Section and Pain Management Special Interest Group have brought together 10 physical therapists and a physician from around the country to present an informative and dynamic 2-day pre-conference course, Keep Calm and Treat Pain, Feb 21 and 22 at CSM 2018 in New Orleans. Presentation topics include the Science of Pain, Pain Education, Pain Psychology, Motivational Interviewing and Sleep and Pain. In addition, I will present An Introduction to Mindful Awareness Training and Its Role in Pain Treatment, and my colleague at Herman and Wallace, Megan Pribyl, PT, MSPT, will present Pain and Nutrition: Building Resilience Through Nourishment.

Sensory TractAs we are in the midst of the opioid crisis, this programming could not come at a better time. In this regard, I am especially excited to share information on how mindfulness training has been shown to help patients who are reducing opioid medications to increase positive affect, decrease pain interference and reduce opioid craving.2, 3 I will also describe how mindful awareness training helps address a patient’s fears and fear avoidant behavior and will guide mindfulness exercises.4, 5

I am honored to be a part of this pioneering program that combines didactic presentations with experiential exercises and lab practice to offer participants the latest science of pain and practical skills to more successfully treat pain. In addition, I am presenting an Educational Session sponsored by the Federal Section on the topic Mindful Awareness Training for Veterans with Comorbid Pain and PTSD based on my research experience at the Puget Sound VA in Seattle. I hope to see you at CSM!

While these presentations offer a taste of mindfulness training to improve patient outcomes, they provide just a glimpse into its potential. My joy and passion is my course, Mindfulness-Based Pain Treatment, where I can offer an in-depth exploration of the role mindful awareness training in pain treatment through a thorough review of mindfulness and pain research, the detailed exploration of the application of mindful awareness training to the biopsychosocial pain model and multiple experiential exercises and lab practices that provide participants with practical strategies to bring into the clinic Monday morning. I hope you can attend a Mindfulness-Based Pain Treatment course offered by Herman and Wallace in 2018 at Samuel Merritt University in Oakland, CA, June 9 and 10, Virginia Hospital Center in Arlington VA Aug 4 and 5, or Pacific Medical Center in Seattle, WA Nov 3 and 4. I look forward to helping you expand your toolbox of treatment techniques for patients with pain conditions.


1. Simons LE, Elman, I, Borsook D. Psychological processing in chronic pain: a neural systems approach. Neurosci Biobehav Rev. 2014;39:61-78.
2. Garland EL, Thomas E, Howard MO. Mindfulness-Oriented Recovery Enhancement ameliorates the impact of pain on self-reported psychological and physical function among opioid-using chronic pain patients. J Pain Symptom Manage. 2014;48(6):1091-9.
 3. Garland EL, Froelinger B, Howard MO. Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: exploratory ERP findings from a pilot RTC. J Behav Med. 2015;38(2):327-36.
4. Schutze R, Rees C, Preece M, Schutze M. Low mindfulness predicts pain catastrophizing in fear avoidance model of chronic pain. Pain. 2010; 148(1):120-7.
5. Jay J, Brandt M, Jakobsen MD, et al. Ten weeks of physical-cognitive-mindfulness training reduces fear-avoidance beliefs about work-related activity. Medicine (Baltimore). 2016;95(34):e3945.

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Mindful Eating and Constipation, Stress and Anxiety

Mindful eating requires slowing down and paying attention to the present moment experience of eating. Rather than mindlessly put food into your mouth and not really taste what you’re eating, you deliberately notice the appearance, smell, texture and taste of the food and pay attention to your thoughts, feelings, and physical sensations. Eating mindfully can interrupt habitual eating behaviors and promote greater self-regulation of food choices.1 Warren and colleagues conclude mindful eating has the potential to help address maladaptive eating behaviors and the difficulties many face with controlling food intake.2

Although mindful breathing, body scan and movement are the core skills I teach patients with persistent pain, I introduce mindful eating as another strategy to cultivate present moment awareness. Patients can have surprising shifts in their relationship to food and frequently comment, “If I ate more mindfully, I would enjoy my food more and eat less!”

Lucie Khadduri, PT, DPT, PRPC clinician and Adjunct Professor at the University of Puget Sound School of Physical Therapy, took my course last spring and describes her patient’s experience with mindful eating:

I have been meaning to email for some time to thank you for the April 2017 course on Mindfulness for Rehab Professionals. Your class really impacted my daily PT practice in a positive way. I wanted to share with you one story in particular to illustrate the power that these new tools you have given me have helped others.

I have this male patient who is about 35 years old who struggled with chronic constipation, bloating and anxiety related to his intense fecal urges that were then followed by an inability to defecate. When he started PT, he had just left his job and took a job working from home just so that he could have consistent, stress free bathroom access.

I spoke to him about diaphragmatic breathing and mindfulness and its impact on the autonomic nervous system. What helped him the most, though, was the mindful eating exercise. He has since started applying these concepts to when he eats. He told me on his discharge visit that in the past, he would eat 4 slices of pizza very quickly, without thinking about it and then have horrible pain afterward. Now, he says it is easy to eat 1 slice and have a salad not because he knows salad is better for him, but because his mouth and mind crave different textures and colors in his food. Mindful eating gave him the ability to slow down, focus on the physical sensations of eating and he found that this has changed his relationship with food. As a result, his constipation is much better managed and his anxiety and stress are much better.

Thanks again for an excellent class. I often encourage patients to go to your website for your free 10 minute meditations.

Thank you, Lucie, for sharing this story. It reflects one of the many ways patients benefit from training in mindful awareness. I look forward to introducing colleagues to mindful eating and additional experiential mindful exercises and current research in my upcoming class, Mindfulness-Based Pain Treatment, at Loyola University Stritch School of Medicine, Maywood, Il, September 30 and October 1.


1. Miller CK. Mindful eating with diabetes. Diabetes Spectr. 2017 May;30(2):89-94.
2. Warren JM, Smith N, Ashwell M. A structured literature review on the role of mindfulness, mindful eating and intuitive eating in changing eating behaviors: effectiveness and associated potential mechanisms. Nutr Res Rev. 2017 Jul 18:1 – 12.

Image courtesy of California Institute of Technology

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Why Teach for Herman & Wallace?

Faculty member Carolyn McManus, PT, MS, MA is the instructor of Mindfulness Based Pain Treatment, a course which enables practitioners to learn about the impacts of cognitive and emotional state on pain. Herman & Wallace was very lucky to have her join the faculty in 2014, and she has written in to share more about her reasons for doing so. Join her in the Bay Area this May 14-15!

I am inspired to teach for Herman and Wallace because I need more colleagues to help meet the continual demand for my skills and treatment approach. I teach patients mindfulness, body awareness and strategies to self-regulate the nervous system. Patients need to learn how to pay attention to the body in a therapeutic manner, release muscle tension, reduce the stress reaction and adopt an attitude that promotes healing and well-being. With the ability to rest the mind in the present moment, listen to the body with mindful awareness and take control of reactions to stress and pain, patients can reduce pain, make greater progress with exercise programs and improve activity levels. There is a huge demand for this treatment approach. I always have a full schedule and an insanely long wait list. More therapists who can offer mindfulness-based pain treatment are needed.

I also want to get the word out that there is a lot we can do to prevent chronic pain

I also want to get the word out that there is a lot we can do to prevent chronic pain. Research suggests that a reduction in pain inhibitory mechanisms contribute to persistent pain. These mechanisms can be influenced by stress and cognitive and emotional modulation. Working with patients in pain for over 30 years, I have developed a clear and simple way to explain the role of cognitive and emotional factors in pain perception. I find that once patients truly understand how their reactions can amplify or inhibit nociceptive pathways, they are empowered to take an active role in a holistic treatment approach. We can improve the chances of recovery for patients at risk of chronic pain by identifying them early early on and providing them with education and mindfulness-based strategies to self-regulate the nervous system. Patients can be offered specific skills to reduce the stress reaction, fear, catastrophic thinking and the negative attitudes that amplify and prolong pain.

I want to teach other therapists to successfully help patients in pain in the way I have for many years. One recent course participant made my day when she said to me, “I now have so much more to offer my patients.”

If you are interested in offering a new course with Herman & Wallace, don't hesitate to reach out! Fill out the form at https://www.hermanwallace.com/teach-with-us and let us know about your course idea and why you would be a good fit for the team.

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Mindfulness and the Descending Modulation of Pain

The following comes to us from Carolyn McManus, PT, MS, MA, our resident expert in the power of mindfulness and it's applications to rehabilitation. Carolyn was recently featured in a video from the Journal of the American Medical Association for her contributions to a newly published research article. Join Carolyn at her course, Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain on May 14th and 15th in California's Bay Area!

Neuroimaging studies show that cortical and sub-cortical brain regions associated with cognitive and emotional processing connect directly with descending pain modulating circuits arising in the brainstem. As diminished nociceptive inhibition by descending pain modulation is a likely contributing factor to the persistence of pain, these cortical and sub-cortical connections to relevant brainstem regions provide a means by which maladaptive cognitive and emotional processing can contribute to the persistence of pain1. It is possible that strategies to help patients self-regulate cognitions and emotions could promote pain reduction through restoring the balance between excitatory and inhibitory mechanisms of the descending pain modulatory system.

To be mindful is to rest the mind in the present moment with stability and acceptance and without additional cognitive or emotional elaboration. Mindful body awareness is a central component. Training in mindful awareness has been shown to improve attention regulation, emotional processing and body awareness and contribute to reduced pain intensity, catastrophizing, depression and anxiety2,3,4,5. Training in mindfulness has also been shown to modulate brain activity in areas associated with body awareness and pain processing6,7. It is possible that the adaptive modulation of cortical and sub-cortical areas engaged with mindful cognitive, emotional and physical self-regulation could contribute to reducing pain through improving the balance between excitatory and inhibitory mechanisms of the descending pain modulatory system.

One of my patients reflected the clinical benefits of mindfulness training when he said, “I needed to learn how to not freak out when my exercises or daily activities increased my pain. Focusing my mind on the present moment was enormously helpful. I would tell myself, “Breathe. Just be here. Calm down.” By breathing and relaxing I could take control of how I was reacting and I immediately saw a difference. My pain did not increase out of control.”

I am thrilled to be sharing my 30+ year experience in mindfulness and patient care in my upcoming course through Herman and Wallace.

1. Ossipov M, Morimura K, Porreca F. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care 2014;8(2):143-151.
2. Holzel BK, Lazar SW, Guard T, et al. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Science. 2011;6: 537–559.
3. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013 Feb;14(2):230-42.
4. Lakhan SE, Schofield KL. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One. 2013 Aug 26;8(8):e71834.
5. Schutze , Slater H, O’Sullivan P, et al. Mindfulness-based functional therapy: A preliminary open trial of an integrated model of care for people with persistent low back pain. Front Psychol. 2014 Aug 4;5:839.
6. Zeidan F, Martucci KT, Kraft RA, et al. Brain mechanisms supporting modulation of pain by mindfulness meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
7. Nakata H, Sakamoto K, Kakigi R. Meditation reduces pain-related activity in the anterior cingulated cortex, insula, secondary somatosensory cortex and thalamus. Front psychol. 2014;5:1489.

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Mindfulness and Chronic Pelvic Pain

Mindful awareness has been defined as “the awareness that emerges through paying attention on purpose, in the present moment and non-judgmentally, to the unfolding experience, moment by moment.” Kabat Mindful awareness can be cultivated through training in sitting meditation, mindful body scan, walking meditation and mindful movement. Over the past 3 decades, a growing body of research has identified multiple health benefits from training in mindful awareness. Keng, Lakhan, La Cour One pilot study evaluated the feasibility and efficacy of an 8-week mindfulness program for patients with chronic pelvic pain. Fox Pre- and post-assessments included daily pain scores, the Short Form-36 Health Status Inventory, Kentucky Inventory of Mindfulness Score and the Inventory of Depressive Symptomatology. Upon program completion, participants reported significant improvement in daily maximum pain scores, physical function, mental health, social function and mindfulness scores. These pilot results are positive and promising.

In my experience, mindfulness gives patients the skillful awareness necessary to self-regulate their reactions to pain and stress. Many of these reactions are maladaptive and amplify distress and pain. With training in mindfulness, patients are able to observe physical, cognitive and emotional reactions to pain and stress and adopt healthy choices that de-escalate suffering. I am excited to share my 30 years of experience and training in mindful awareness and its application to patient care and provider self-care through my 2-day course with Herman & Wallace. Join me at "Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain" on January 16-17, 2016 in Silverdale, WA.


1. Kabat Zinn, J.Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2013, 2nd ed. New York: Bantam.
2. Keng, S.L., Smoski M.J., Robins, C.J. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev, 2011;31(6), pp. 1041-56.
3. Lakhan, S.E., Schofield, K.L. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One, 2013;8(8), e71834.
4. La Cour, P., Petersen, M., 2014. Effects of mindfulness meditation on chronic pain: A randomized controlled trial. Pain Med, Nov 7. doi: 10.1111/pme.12605.
5. Fox, SD, Flynn E, Allen RH. Mindfulness meditation for women with chronic pelvic pain: a pilot study. J Reprod Med, 2011;56(3-4):158-62.

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What is "Mindfulness" and How Does Mindfulness Work?

Carolyn McManus, PT, MS, MA is the author and instructor of "Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain". Carolyn is a specialist in managing chronic pain, and has incorporated mindfulness meditation into her practice for more than 2 decades. Today she is sharing her experience by analyzing some of the most foundational research in the field of mindfulness and meditation.

Mindfulness awareness has been described as the sustained attention to present moment awareness while adopting attitudes of acceptance, friendliness and curiosity. (1,2) In patients with persistent pain, mindfulness has shown to reduce pain intensity, anxiety and depression and in improve quality of life. (3,4) Researchers suggest that mindful awareness may work through 4 mechanisms: attention regulation, increased body awareness, enhanced emotional regulation and changes in perspective on self. (5)

1. Attention Regulation: In chronic pan populations, improved attention regulation has been suggested to result in less negative appraisal of pain, greater pain acceptance and reduced pain anticipation. (6)

2. Body Awareness: Improved body awareness has been shown to help patients with chronic pain recognize the difference between muscle tension and relaxation, identify early warning signs that precede a pain flare and reduce maladaptive reactions to pain. (7)

3. Emotional regulation: Training in mindful awareness has been shown to enhance emotional regulation, improve mood and reduce anxiety and depression in patients with chronic pain. (6, 7, 8)

4. Changes in Perspective on Self: In a qualitative study, participants with chronic pain reported becoming less identified with their pain condition or diagnostic label. (7) They felt less “fragmented, experienced a greater integration of mind any body and described the experience of wellness even though they had a persistent pain condition.

I constantly see these changes in my patients who learn to be mindful. Empowered with a skillful way to pay attention, they have greater control over the direction of their mind and thoughts and an increase in body awareness that promotes the ability to relax and the self-regulation of their stress reaction. They avoid escalating distressing emotions and experience a renewed feeling of wholeness and well-being. I am delighted to share my training and experience in mindfulness and years of teaching mindfulness to patients in persistent pain through Herman and Wallace continuing education programs.


1. Kabat Zinn, J., 2013. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2nd ed. New York: Bantam.
2. Bishop, S.R., Lau, M., Shapiro, S., et al., 2004. Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), pp. 230–41.
3. Lakhan, S.E., Schofield, K.L., 2013. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One, 8(8), e71834.
4. Reiner, K., Tibi, L., Lipsitz, J.D., 2013. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med, 14(2), pp. 230-42.
5. Holzel, B.K., Lazar, S.W., Guard, T., et al., 2011. How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective. Perspect Psychol Science, 6, pp. 537–59.
6. Brown, C.A., Jones, A.K., 2013. Psychobiological correlates of improved mental health in patients with musculoskeletal pain after a mindfulness based pain management program. Clin J Pain, 29(3), pp. 233-44.
7. Doran, N.J., 2014. Experiencing wellness within illness: Exploring a mindfulness-based approach to chronic back pain. Qual Health Res, 24(6), pp. 749-60.
8. Song, Y., Lu H., Chen H., et al. Mindfulness intervention in the management of chronic pain and psychological comorbidity: A meta-analysis. Int J Nurs Sci, 1(2), pp.215-23.

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Upcoming Continuing Education Courses

May 31, 2019 - Jun 2, 2019
Location: Advocate Illinois Masonic Medical Center

May 31, 2019 - Jun 1, 2019
Location: St. Joseph's Hospital - Phoenix

May 31, 2019 - Jun 2, 2019
Location: St. Joseph's Hospital - Phoenix

May 31, 2019 - Jun 2, 2019
Location: Carolinas Healthcare System - Union

May 31, 2019 - Jun 2, 2019
Location: Texas Children’s Hospital

Jun 1, 2019 - Jun 2, 2019
Location: Johns Hopkins Bayview Medical Center

Jun 1, 2019 - Jun 2, 2019
Location: Highline Physical Therapy

Jun 2, 2019 - Jun 4, 2019
Location: Touro College: Bayshore

Jun 7, 2019 - Jun 9, 2019
Location: Texas Children’s Hospital

Jun 7, 2019 - Jun 9, 2019
Location: Physical Therapy Services of Lansing

Jun 7, 2019 - Jun 9, 2019
Location: Beaumont Health - Royal Oak

Jun 8, 2019 - Jun 9, 2019
Location: CentraState Medical Center

Jun 8, 2019 - Jun 9, 2019
Location: Loyola University Stritch School of Medicine

Jun 8, 2019 - Jun 9, 2019
Location: Saint Luke\'s Health System

Jun 21, 2019 - Jun 23, 2019
Location: Aurora Medical Center

Jun 21, 2019 - Jun 23, 2019
Location: The George Washington University

Jun 21, 2019 - Jun 23, 2019
Location: Urological Associates of Western CO

Jun 21, 2019 - Jun 23, 2019
Location: Inova Alexandria Hospital

Jun 22, 2019 - Jun 23, 2019
Location: WakeMed Health & Hospitals

Jun 28, 2019 - Jun 30, 2019
Location: Mount Carmel Health

Jun 28, 2019 - Jun 30, 2019
Location: Mizzou Physical Therapy-Rangeline

Jun 29, 2019 - Jun 30, 2019
Location: Advantage Physical Therapy

Jun 29, 2019 - Jun 30, 2019
Location: Vertex Physical Therapy Specialists

Jul 12, 2019 - Jul 14, 2019
Location: The Virginian

Jul 13, 2019 - Jul 14, 2019
Location: Johns Hopkins Medicine

Jul 19, 2019 - Jul 21, 2019
Location: Loyola University Stritch School of Medicine

Jul 20, 2019 - Jul 21, 2019
Location: East Sacramento Physical Therapy

Jul 21, 2019 - Jul 23, 2019
Location: Rutgers University - Doctoral Programs in Physical Therapy

Jul 26, 2019 - Jul 28, 2019
Location: Bon Secours St. Francis Health System

Jul 27, 2019 - Jul 28, 2019
Location: Providence Healthcare