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.
As 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 my dad was visiting Michigan, we had the day to ourselves as my kids were in school. I was so excited to have quality time with my dad. Unfortunately it was pouring down rain. We decided on a leisurely brunch and then a movie. Dad chose the movie, “Wind River.” While not a movie I would normally pick, I was happy to go along. A little more than half way through…there was a horribly violent scene against a young women. I panicked, plugged my ears and closed my eyes. Unfortunately some images were burned into the back of my mind. When the movie was over, I remained seated and tears just came. My dad held me while I cried. I was able to calm down and leave the theater, but the images continued to bother me. During the next few days, I made it a priority to care for myself and allow my nervous system to process and heal.
What happened to me? I have never had any traumatic personal experience. Why did I react so strongly? I talked with my therapist about it and she suggested I might have experienced secondary traumatic stress. We know, as pelvic health therapists, we need extra time to hear the “stories” of new patients. We do our best to create a safe space for them so they can trust us and we can help them discover pathways to healing. Yet no one has taught us what we are supposed to do with the traumatic stories our patients share. How are we to cope with holding space for their pain? How do we put on a happy face as we exit the room to get the next patient?
Teaching Capstone over the last few years, Nari Clemons and I have talked with many of you who were feeling emotionally overloaded especially when treating chronic pelvic pain and trauma survivors. Some of you were experiencing job burnout, others were deciding maybe it was time for a career shift, away from the pelvis. We realized something needed to be done as our field was losing talented pelvic health therapists. We have also struggled ourselves with various aspects of our profession.
Recently I had a patient referred to me for fecal incontinence. She looked so familiar to me and we realized she had seen me before, years ago, for bladder issues. She was a sweet 60 something single woman who had raised 6 kids on her own after her husband left her. We laughed as she remembered something funny I had said back then. Then we got down to business. In recent years my patient “Inez” had been diagnosed with both diabetes and Crohn’s disease. She was managing the Crohn’s very well but her sugars were much harder for her to get under control. When I asked her about her current complaints and symptoms she reported that most days her bowels were perfect. She reported one or two soft easy to pass stools per day. But when she had to leave the house for a doctor appointment, she would have explosive diarrhea. This didn’t happen if she went to the grocery store or to visit a friend. Upon further questioning she realized she was really anxious about her diabetes and her interactions with her medical provider regarding her diabetes had not been positive. She felt frustrated, scared, and powerless.
As a pelvic health PT I could have treated Inez in a variety of ways. With my initial exam I did not see any glaring musculoskeletal issues. I suggested to Inez the possibility that her nervous system was sending the wrong kind of signals to her bowels when she got anxious and that we could address this in PT. Inez agreed that she would like to try this approach. We decided that we would reevaluate after four visits to see if we needed to change the plan. Over four visits I used craniosacral therapy protocols to address nervous system upregulation and tension. I taught Inez relaxation techniques and encouraged 10 or 15 minutes of daily relaxation practice. Inez opened up about her relationship with her kids and how they tended to be takers but not givers. She would get frustrated and feel a bit used at times. We had conversations about boundaries and saying “no” and I shared some of my own experiences and struggles as well. Lastly we talked about how what we think can affect how we feel and what we do. Inez’s faith was important to her. She found a few bible verses that were meaningful to her about fear and anxiety and would repeat those during her daily relaxation time. On her fourth visit, Inez was all smiles. She brought me a jar of her homemade salsa as a graduation present. As we sat down to talk she reported to me that she saw her doctor yesterday. She had no bowel issues. And more than that, as her doctor began to talk over her she said to him, “No. Stop. You are always talking and never listening. I need you to listen to me today.” She went on to explain to him how it worried her that she was not able to control her diabetes well and she didn’t think he was doing enough to help her. Her physician did stop and listen and asked Inez, “what would you like me to do for you?” She asked for a referral to a specialist and he obliged. Inez was thrilled that she was able to manage her anxiety in a way that helped her bowels and to find the courage to confront her doctor to get the care she felt she needed.
As we grow in the knowledge of how the human body works it seems like all roads lead back to the nervous system. All of our treatments and interactions with patients affect the nervous system in one way or another. In our fast paced, stressed out world, finding ways to be intentional in addressing the nervous system can be a game changer for patients (as well as for ourselves). If this is an area you would like to grow in, please consider a new course being offered this January in Tampa, Florida. Participants taking Holistic Interventions and Meditation will experience and explore evidence-based information on strategies to address the nervous system. Topics covered include practical meditation, use of essential oils, supplements, yoga, calming and centering manual techniques and instruction in how to best dialogue with patients struggling with pain, anxiety and the effects of trauma. Nari Clemons and I hope to see you there.
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:
The first time I experienced the effects of Post-Traumatic Stress Disorder (PTSD) was when my patient dissociated during a treatment session and relived the rape that had occurred when she was ten years old. It was devastating. I didn’t know what to do. She was unresponsive to my intervention. Her eyes didn’t see me, alternating between wide-eyed, horrified panic and clenched-closed, lip biting excruciating pain. It was my late night and I was alone in the clinic. I sat helplessly next to my sweet patient hoping and praying that her torture would end quickly. When she finally stopped writhing, she slept. Deep and hard. Finally she woke up disoriented and scared. She grabbed her things and left. For me, this experience was my initiation into the world of trauma.
Approximately 5-6 % of men and 10-12% of women will suffer from PTSD at some point in their lives. Researchers believe that 10% of people exposed to trauma will go on to develop PTSD. The expression of PTSD symptoms can present differently in men and women. Men may have more externalizing disorders progressing along a scale that includes vigilance, resistance, defiance, aggression and homicidal thoughts. Women tend to present with internalizing disorders such as depression, anxiety, exaggerated startle responses, dissociation, and suicidal thoughts. The research is clear that both men and women with PTSD display changes in brain function. The mid brain (amygdala, basal ganglia and hippocampus) tends to be overactive in sounding alarm signals while the prefrontal cortex fails to turn off the mid brain when a threat is no longer present. Since the prefrontal cortex is not always functioning correctly, traditional talk therapy may not be as effective for treating PTSD. Instead, say many researchers, breath and movement exercises may help regulate brain functioning. Yoga, Tai Chi, and meditation have been shown to have a positive impact on down regulating the mid brain and improving cerebral output. As pelvic floor therapists we deal with trauma on a daily basis, whether we know it or not. Although we are not trained in psychology, understanding PTSD and equipping ourselves with tools to support our patients is imperative for both our patients and ourselves.
You might be wondering what happened after that frightful night in the clinic? My patient was determined to get better. She had a non-relaxing pelvic floor. She was a teacher and was plagued by urinary distress. She either had terrible urgency or would go for hours and not be able to empty her bladder. So we met with her therapist to learn strategies to help us to be able to work together without triggering dissociation. It was a slow road, but the three of us working together helped my patient not only reach her goals but to be able to be skillful enough to maintain her gains using a dilator for self-treatment.
Summer can make women cringe at the thought of baring most of their bodies yet finding just the right coverage for their breasts. Some scrounge for padded tops to pump up their actual A cup. Some seek the greatest amount of coverage to support every ounce of skin. And still others search for flattering tops to accentuate cleavage and minimize tan lines. Just like one swimsuit does not fit every woman, only one aspect of post-breast cancer rehab is not generally sufficient. A combination of exercise, mindfulness, and myofascial release may need to be implemented for optimal recovery.
Ibrahim et al., (2017) produced a pilot randomized controlled trial considering the effects of specific exercise on upper limb function and ability to return to work after radiotherapy for breast oncology. The study involved 59 young women divided into an exercise group or a control group that received standard care. The Disability of Arm, Shoulder, and Hand (DASH), the Metabolic Equivalent of Task-hours per week (MET-hours/week), and a post hoc questionnaire on return to work were all used and recorded over 6 time periods after the 12-week post-radiation targeted exercise program. Women who had a total mastectomy still had upper limb dysfunction, but no there was no statistically significant difference in DASH scores between groups. Both groups at 18 months had returned to their pre-illness activity levels, and 86% returned to work (at just 8.5 fewer hours/week). The authors concluded exercise alone does not change the long-term outcome of upper limb function post-radiation.
Mindfulness-based cognitive therapy (MBCT) for persistent pain in women after treatment for primary breast cancer was explored by Johannsen et al., in two 2017 articles, one concerned with clinical and psychological mediators and the other focused on cost-effectiveness. Each study included 129 women with persistent pain from breast cancer, placed in a MBCT group or a wait-list control group. The first study showed attachment avoidance was a statistically significant moderator, with subjects who had a higher attachment avoidance having lower pain intensity after MBCT. In the subjects undergoing radiotherapy, MBCT had a smaller effect on pain than those not having radiotherapy. The authors’ next study focused on the minimal clinically important difference (MCID) on pain intensity. Baseline and 6 months post-treatment data on healthcare utilization and pain medication were analyzed from national registries. The average total cost of the MBCT group was 730 euros less than the control group, and more women in the MBCT group had a MCID in pain than those in the control group.
Preterm birth can have deleterious health effects not only for the child, but also for the mother. A child may be born so early that various health systems are not matured, leading to susceptibility and delay in development and growth. Maternal health may also be severely impacted, with conditions such as anxiety and psychological stress. Managing the prevention of a pre-term delivery can be stressful and challenging for a pregnant woman, and authors Ha & McDonald (2016) report that this issue is not well studied. A cross-sectional survey was completed to find out not only what a woman’s preferences and concerns are, but also to find out which recommendations were likely to be followed by the patient. This is important, the authors state, because women who are actively involved in medical decisions are more likely to feel satisfied with their childbirth experience.
The survey was completed by 311 women at a median of 32 weeks gestation. Mean age was 30.9, and the majority of them identified as European/White-Caucasian. Most of them were married or in a common-law relationship and had received some level of post-secondary education. The majority of women who were told they were at increased risk of preterm labor (PTL) preferred close-monitoring rather then PTL prevention. Of interest is that the majority of women reported they would use other sources of information besides their primary provider, with the most reported source being the internet or family and friends. This point begs the question of how high is the quality level or accuracy of the available information on the internet or in the general public? Common available options for prevention included progesterone, cerclage, and pessary use. If a woman is not interested in using recommended prevention strategies, the goal of the rehabilitation clinician should be to, on a constant basis, monitor for symptoms and signs of early labor, and encourage the patient to keep any recommended provider appointments, and stay in close contact with her provider so that close-monitoring may be carried out.
An additional goal for rehabilitation is to provide the mother with strategies that may assist her in managing her anxiety, stress, movement dysfunctions, sleep, and other activities. Prior research has validated the benefits of relaxation training in pre-term labor: a cost-effective, low risk and easily implemented strategy. Training women in such a tool during pregnancy fits well into the rehab provider’s scope, and can be instructed in the clinic (or home!) for home program implementation. Larger newborns, longer gestations, and higher rates of prolonged gestations have been recorded when using relaxation training training for pre-term labor.Janke et al., 1999) Chuang et al. (2012) have documented fewer admissions to neonatal intensive care unit, decreased rates of extreme pre-term birth, and shorter stays in hospital with use of relaxation training. Meditation, mindfulness, deep breathing, visualization, and movement within recommend medical limits may all be valuable tools that make up a part of a patient’s rehabilitation experience. In an article describing how prenatal meditation influences infant behaviors, yoga, singing, and massage therapy are all cited methods for improving maternal and/or fetal health.Chan, 2014
“To me it felt like I was just sitting on bed rest, waiting to have a seizure, you know, waiting to start circling the drain.” “Every time I went to the doctor I had this…anxiety attack.” These are the words of pregnant women diagnosed with preeclampsia and on bed rest. Other phrases reported by the authors who interviewed women on bedrest included “…an impending doom…”, “…meltdown…”, “nervous wreck.” A few of the major themes that emerged in the interviews was that of negative thoughts and feelings, family stressors, and not being heard. And while using the term “crazy” is not truly appropriate, women who are forced to abruptly stop interacting and participating in their typical life activities must be regarded as being very high risk for more than just physical issues. Kehler et al., 2016
In an ideal situation, bed rest during pregnancy is prescribed to help keep the mother and fetus healthy. Unfortunately, bed rest in itself is associated with potentially negative consequences in physical and mental health, and providers are not always up-to-date on changing recommendations for bedrest. Perhaps the cautious attitude of providers towards minimizing risk guides some choices. In addition, many women describe frustration about lack of clear guidelines, difficulty managing their stressful feelings, and varying degrees of support from medical providers.
During pregnancy-related bed rest, research has described how the entire family is affected. Physically, the mother may have changes in her circadian rhythms, increased anxiety, depression, and hostility. The rest of the family can also experience and demonstrate stress. Other children may act out, partners may be more stressed and worried, and financial strain may be a concern. Bigelow & Stone, 2011 Although we as rehab professionals may not have solutions for every issue, we may be able to facilitate accessing resources and at a minimum hear what a woman is dealing with during this stressful time. Many women, even when on bedrest, are allowed to attend medical appointments such as physical therapy, and should be provided with appropriate physical and mental activities to help minimize muscle atrophy and stress. Home health or hospital-based providers are also in a perfect position to educate providers on the value of referrals while the patient is at home or in the hospital.
After my Dad’s 3rd trip to the emergency room not being able to breathe because of his sleep apnea and congestive heart failure, his cardiologist recommended he ”just relax” when his suffocating feelings occurred. Of course, not being able to catch his breath would always heighten anxiety, which made it even more difficult to inhale and exhale. Ultimately, what my Dad needed to learn was mindfulness to deal with his relatively benign inability to breathe, since the focus of mindfulness is acceptance of rather than control over your circumstances.
The concept of mindfulness has been studied in adults, but it is gaining popularity among the pediatric population. Ruskin et al., (2017) used a prospective pre-post interventional study to assess how children with chronic pain respond to mindfulness-based interventions (MBI’s). For 8 weeks, 21 adolescents engaged in group sessions of MBI. Before, after, and 3 months post-treatment, the authors collected self-report measurements for a variety of factors such as disability, anxiety, pain quality, acceptance, catastrophizing, and social support. Subjects were highly satisfied with the treatment, and all would recommend the group intervention to friends. From baseline to 3-month follow-up, pain acceptance, body awareness, and ability to cope with stress all improved in the subjects. Further randomized controlled studies are needed, but the initial conclusion was MBI’s were received well by adolescents.
A feasibility study performed by Anclair, Hjärthag, and Hiltunen in 2017 considered the effect of mindfulness and cognitive behavioral therapy for the parents of children with chronic conditions, looking at Health-Related Quality of Life (HRQOL), measured with Short Form-36 (SF-36), and life satisfaction. Ten parents received group-based cognitive behavioral therapy (CBT), and 9 participated in a group-based mindfulness program (MF). Treatment was implemented for 2-hour weekly sessions over the course of 8 weeks. The CBT treatment was based on the Acceptance and Commitment Therapy, focusing on changing thoughts and emotions about stressful issues as well as behaviors. They avoided the acceptance aspect, as it would overlap the MF intervention. The MF therapy used the Here and Now Version 2.0 (including daily themes on knowing your body, observing breathing, acceptance, meditation, coping, understanding thoughts versus facts, and self-care reinforcement). The parents in each group significantly improved their Mental Component Summary (MCS), Vitality, Social functioning, and Mental health scores. The MF group even showed notable improvement in Role emotional and some of the physical subscales (Bodily pain, General health, and Role physical). The CBT group showed improved satisfaction with Spare time and Relation to partner, and CBT and MF groups improved life satisfaction Relation to child. The authors conclude CBT and MF may positively affect HRQOL and life satisfaction of parents with chronically ill children.
After greeting a patient referred for temporomandibular joint dysfunction, the conversation began with an outpouring of emotion over a failed bladder sling surgery that left the woman with significant chronic pain, causing her to clench her jaw all the time. No matter what I was to find objectively with the examination, there was no doubt the treatment had to extend beyond joint mobilization, soft tissue work, and exercise. This woman clearly saw her cup as half empty, so filling her mind with a new approach to thinking about and dealing with her pain was essential for relieving her secondary jaw pain.
Su et al. published a study called, “Pain Perception Can Be Modulated by Mindfulness Training: A Resting-State fMRI Study” (2016). The pain-afflicted group had 18 participants while the control group had 16. Brain behavior response of all subjects was measured per resting-state functional magnetic resonance imaging and 3 forms (Dallas Pain Questionnaire, Short Form McGill Pain Questionnaire-SFMPQ, and Kentucky Inventory of Mindfulness) before and after 6 weeks of mindfulness-based stress reduction treatment. Training consisted of mindfulness meditations such as a body scan, hatha yoga, walking and sitting meditation, and instruction on how to use the methods for pain management. After six 2.5-hour sessions/week and one 8-hour non-verbal session in the 4th week, the fMRI showed an increased connection from the anterior insular cortex (AIC) to the dorsal anterior midcingulate cortex (daMCC), and the SFMPQ scores were significantly improved in the pain-afflicted group. The authors suggested mindfulness training can change the brain connectivity responsible for our perception of pain.
Chadi et al.2016 performed a pilot study of female adolescents with chronic pain regarding the efficacy of mindfulness-based treatment. The experimental group (n=10) and the wait-list control group (n=9) consisted of girls between the ages of 13 and 18. For 8 weeks they met for a 90 minute session led by a psychiatry resident. Some of the mindfulness practices in this study included body scan, sitting and walking meditations, love and kindness meditations, mindful eating, compassion and deep listening, and breathing exercises. The wait-list control group also completed the 8-week program. Although all participants reported a positive change in the way they coped with pain, no statistically significant changes in quality of life, depression, anxiety, pain perception, and psychological distress were found. Significant salivary cortisol level improvements were observed (p<0.001) post mindful-based treatment session, indicating feasibility in pursuing further research with a larger randomized controlled trial.