​INVITED BLOGPOST

When patients with chronic back pain present with poor body awareness, high stress levels, catastrophic thinking and fear-avoidance behaviors, physical therapists need biopsychosocial treatment interventions in addition to standard practices based on structural impairment to achieve pain relief and functional improvement. Mindful awareness training is an innovative treatment that addresses multiple components of a patient’s pain experience that can amplify pain. For patients with chronic back pain, mindful awareness training has been shown to reduce pain bothersomeness, improve function, and decrease health care utilization and costs (Cherkin et al., 2016; Anheyer et al., 2017; Herman et al., 2017).

Mindful awareness has been defined as “the awareness that emerges through paying attention on purpose, in the present moment and nonjudgmentally to the unfolding experience, moment by moment.” (Kabat-Zinn, 2013). It involves the calm observation of sensations, cognitions and emotions. Whether the object of attention is pleasant, unpleasant or neutral, the immediate experience is observed with openness, friendliness and curiosity. No effort is made to suppress, eliminate or change the experience. This non-reactive awareness is the first step to consciously self-regulate maladaptive reactions. Patients learn to observe the sensation of pain and physical, cognitive and emotional reactions to pain. Similarly, they can observe a stressful situation and their reaction to the stressful situation. Patients learn to make new, deliberate, pain and stress de-escalating choices rather than remain trapped in unconscious, automatic, pain and stress amplifying reactions.

Mindful awareness is developed through formal training practices and the informal integration of mindfulness into daily life activities. Formal training includes mindful breathing, body scan and movement. Informal training requires practicing mindful awareness when engaged in routine daily activities. For example, when mindfully washing hands, a patient may notice the sensory experience of breathing, the body standing, warm water against skin and his or her mood and thoughts.

A qualitative study by Doran (2014) examined how a mindfulness-based therapy impacted perceptions and management of chronic back pain in 16 individuals with a pain duration of 4 to 28 years (Doran, 2014). At 6-months and 1-year post-program interviews, participants reported changes in their experience of pain.  Main themes reported included participants:

• became familiar with the pattern of pain and habitual reactions to pain;
• recognized the difference between being tense and being relaxed in relation to pain;
• identified early warning signs that precede a pain flare-up;
• stopped the cycle of projecting past experience of pain onto a fear of future pain; 
• changed maladaptive attitudes and approaches to pain;
• reduced identification with the diagnostic label or story about pain;
• became more flexible in their attitude toward pain;
• reduced self-blame and inner conflict;
• felt less “fragmented” and experienced a greater integration of mind and body. 

Invited blogpost from

Carolyn McManus, MSPT, MA

President, Pain Management Special Interest Group, APTA Orthopaedic Section 

http://www.carolynmcmanus.com

2017  Pain in Motion

References and further reading:  

Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial. JAMA. 2016;315(12):1240-9.

https://www.ncbi.nlm.nih.gov/pubmed/27002445

Anheyer D, Haller H, Barth J, et al. Mindfulness-based stress reduction for treating low back pain: A systematic review and meta-analysis. Ann Intern Med. 2017;166(11):799-807.

https://www.ncbi.nlm.nih.gov/pubmed/28437793

Herman PM. Anderson ML, Sherman KJ, et al. Cost-effectiveness of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care among adults with chronic low back pain. Spine. 2017. Spine. 2017 Oct 15;42(20):1511-1520.

https://www.ncbi.nlm.nih.gov/pubmed/28742756

Kabat Zinn, J. 2013. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2nd ed. (revised and updated ed.), New York, NY: Bantam Books.

Doran NJ. Experiencing wellness within illness: Exploring a mindfulness-based approach to chronic back pain. Qual Health Res 2014;24(6):749-760.

https://www.ncbi.nlm.nih.gov/pubmed/24728110

Physical therapists have the opportunity to train in mindful awareness and integrate mindful attitudes, principles and practices into the treatment of patients in pain. Resources include:

Ted Talk on an Introduction to Mindfulness

https://www.youtube.com/watch?v=JVwLjC5etEQ

Books on Mindfulness and Pain:

Burch V, Penman D. You Are Not Your Pain: Using Mindfulness to Relieve Pain, Reduce Stress, and Restore Well-being. New York: Flatiron Books, 2015.

Kabat Zinn, J. 2013. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2nd ed. (revised and updated ed.), New York, NY: Bantam Books.

Guided Meditation Apps:

https://insighttimer.com/meditation-app

https://www.headspace.com

https://smilingmind.com.au/smiling-mind-app/

My Blog on additional Mindfulness and Pain Research:

http://carolynmcmanus.com/the-mind-body-medicine-blog/