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Beyond Symptom Management:
Mindfulness for Chronic Pain
Ronald D. Siegel, Psy.D.
Center for Mindfulness and CompassionCambridge 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 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
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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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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 botheffects 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 PaliConnotes awareness, attention, & remembering
• Also includesNon-judgmentAcceptanceKindness & 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 theTwo 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 unpleasantcan observe pain less reactivelyfind that open monitoring reduces pain unpleasantnesshave less anticipatory pain anxiety
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Insula
• Associated with interoception
Visceral and “gut” feelingsProcesses 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
• MindfulnessFosters cognitive changeIncreases symptom tolerance Increases capacity to choose whether to act on urgesUncovers 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 often enough to be convinced that they are not damaging
The Importance of Exercise
• Strength, flexibility, and endurance training
To treat kinesiophobiaTo 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:EasyPleasurable or rewardingCan be done 3 or more times/week
• Continue until no longer fearedConvinced it doesn’t make pain worse
Friends and Family
• To support patient in expanding activityStop protecting patient from pain
Encourage normal activity
• Treat fear in significant othersPsychoeducation
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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 interoceptionDevelops affect awareness and tolerance
MBSR vs CBT vs TAU Chronic Low Back Pain
• Meaningful improvement in disabilityMBSR 60.5%CBT 57.7%TAU 44.1% P=.04
• Meaningful improvement in pain distressMBSR 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 causesThen 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:[email protected]
For back pain worksheets, visit:www.backsense.org
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