meditation and mindfulness in physical therapy...

1/29/2016

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©2015 MFMER | slide-1

Meditation and Mindfulness in Physical Therapy Practice

Improved Outcomes, Happy Clinicians, Healthy Workplace

Pauline H. Lucas, PT, DPT, WCS

Mayo Clinic, Arizona

CSM 2016


Learning Objectives

• Describe neuroplasticity and the neurophysiological changes that result from (chronic) stress and from meditation

• Define mindfulness and meditation

• Evaluate current evidence for the use of meditation and mindfulness to reduce stress, pain, prevent/treat clinician burn-out

• Practice and teach basic meditation and mindfulness techniques


Session Outline

• Neuroscience: stress, pain, neuroplasticity

• Clinician burnout

• Mindfulness and Meditation

• Lab 1: mindfulness

• Research review

• Lab 2: awareness/attention, relaxation response

• Case studies, resources

• Q and A


Stress in America, 2014 (APA)

©2015 MFMER | slide-5 ©2015 MFMER | slide-6

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Stress

Perceived physical or psychological threat to safety, status, well-being

• Demands>resources

• Lack of control

• Lack of meaning

• Perception and stress


Stress

• Not wanting what you have

• Not having what you want

• “Stress is resisting what is”

~Eckhart Tolle


“Good” Stress


“Bad” Stress


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Internal Stress: Thoughts



Stress Response


Autonomic Nervous System (ANS)

Sympathetic (SNS)

Fight-flight-freeze

• Catabolic

• Mobilize glucose for energy

• Arousal, alertness, motivation

• Tissue breakdown

Parasympathetic (PNS)

Rest and digest

• Anabolic

• Restoration of energy reserves

• Relaxation

• Tissue healing, repair


Hannibal, Bishop, 2014

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Cortisol

• Catabolic hormone

• Produced by adrenal cortex

• Higher levels in the morning

• Maintains blood glucose levels

• Suppresses non-essential organs (to increase E to brain and neuromuscular system)

• Anti-inflammatory

• Chronic elevated cortisol: immune suppression, HBP, hyperglycemia, reduced libido, obesity, etc


Limbic System


Neuroplasticity

• “Neuroplasticity can be defined as the ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections.” (Cramer, S.C, 2011)


Brain changes with chronic stress

• Hippocampus (memory):

• new neurons, connection between cells, memory loss, sociability

• Amygdala (fear center):

• size, reactivity to perceived threat, “amygdala hijack” =emotional reactivity

• Medial prefrontal cortex (learning and memory): size


Effects of chronic stress

• Anxiety, depression

• Digestive problems

• Heart disease

• Insomnia

• Weight gain

• Memory and concentration impairment

• Muscle pain/tension

• Type II diabetes

• Sexual dysfunction, etc.

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• population-based prospective cohort study

• N=267, free of CWP but at future risk based on their psychosocial profile

• Assessment of HPA axis function (cortisol levels).

• Follow up 15 months

• CONCLUSION: Among a group of psychologically at-risk subjects, dysfunction of the HPA axis helps to distinguish those who will and will not develop new-onset CWP.


• CLBP (16) vs healthy controls (18)

• Cortisol levels (7 days)

• Hippocampus volume

• Brain response to thermal stimuli (fMRI)

• Pain is a stressor (allostatic load), cortisol

• cortisol from chronic pain can cause

• Reduction/change in cortical thickness

• Dysregulation HPA axis

• size hippocampus


Results

• Cortisol levels in patients with CLBP > controls

• Patients with CLBP with smaller hippocampal volumes have higher levels of cortisol

• Cortisol levels and chronic pain intensity are associated with a stronger pain response in the anterior hippocampal formation


Conclusion

• Supports “stress model of chronic pain”: maladaptive stress responses in the transition from acute to chronic pain.

• Interventions aiming at stopping/reversing chronic pain-related allostatic load could prove to be as important as treating the source of nociception itself

• Cultivating mental states aimed at down-regulating the impact of stress and further implementing clinical interventions promoting anxiety and stress reduction may be essential to prevent and relieve chronic pain.


Meditation for Chronic Pain

• Baseline anxiety scores: predictors of pain, depression, and a reduced quality of life.

• Pain is a stressor, and a maladaptive response to acute pain may intensify the pain experience and condition a sensitized physiologic stress response to pain-provoking stimuli.

• Exaggerated, prolonged, or recurrent activation of a sensitized stress response to pain or non–pain-related stressors may initiate or exacerbate pain and disability


Let’s get personal!

Stresses in physical therapy:

General “life stressors” + work specific stress

• Demands>resources

• Lack of control

• Lack of meaning

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Compassion Satisfaction: the pleasure a

clinician derives from being able to do

his/her work well, finding their

contribution meaningful.

Compassion Fatigue components:

Burnout

Secondary traumatic stress


• Burnout (BO): “a syndrome of emotional exhaustion, depersonalization, and reduced accomplishments that can occur among individuals who do ‘people work’ of some kind”

• Causes for BO:

• personality characteristics

• work-related attitudes

• work/organizational characteristics

• BO: chronically over activated SNS!


Reduce risk for BO in PT

• Boundaries

• Realistic expectations

• Support from management

• Finding best job fit

• Hobbies

• Social activities/support

• SELF-CARE! Exercise, sleep, relaxation, meditation, etc.

• Increase PSN and decrease SNS activity


Session Outline



•


• Research review



• Q and A


Why is a PT teaching meditation and mindfulness?


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Mindfulness

Mindfulness means maintaining a moment-by-moment awareness of our thoughts, feelings, bodily sensations, and surrounding environment, w/o judgment, with acceptance.

-Greater Good Science Center, Berkeley


Mindfulness in practice

• Breathing

• Moving

• Hand washing

• Walking

• Eye-contact

• Hand shake

• Eating

• Etc.

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Meditation

Directing one's attention toward a symbol, sound, thought, or breath to alter the state of consciousness to attain a state of relaxation and stress relief; used for spiritual growth, healing, deepening concentration, and unlocking creativity.

-Mosby's Dictionary of Complementary and Alternative Medicine-


Types of Meditation

• Mindfulness meditation

• Mantra meditation

• Guided visualization

• Transcendental meditation (TM)

• Vipassana (insight) meditation

• Walking meditation

• Loving Kindness meditation

• Centering prayer

• Etc.


Scientifically validated benefits

• Decreased stress

• Reduced symptoms associated with:

• Depression

• Anxiety

• Pain

• Insomnia

• Enhanced ability to pay attention

• Increased quality of life


Meditation ingredients

• Willingness to take time to practice

• Gentle non-judgmental attention

• A point of focus

• Kinesthetic

• Visual

• Auditory


Let’s Practice!


Session Outline





• Research



• Q and A

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Research Challenges

• Interpretation of results

• Selection bias

• Lack of blinding

• Placebo effect

• Practitioner bias

• Publication bias

• Co-interventions

• Lack of follow up


Evidence for meditation benefit-NIH

• Reduce HBP

• Reduce IBS symptoms

• Reduce flare-ups with ulcerative colitis

• Reduce anxiety, depression, insomnia

• Supports smoking cessation

• Improved immune function in people with HIV and cancer

• Improved QoL in people with breast cancer


• Reduced inflammation

• Reduced ADHD symptoms

• Reduced menopause symptoms

(NIH.gov)


• 8 weeks MBSR vs wait list

• N=16 new meditators

• MRI before and after program


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“The results suggest that participation in MBSR is associated with changes in gray matter

concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing, and

perspective taking.”


• 47 trials with 3515 participants

• 9 RCTs evaluating the effect on pain: moderate evidence that MBSR reduces pain severity to a small degree when compared with a nonspecific active control

• Variable across painful conditions, visceral more effect than MSK


Conclusion:

“Mindfulness meditation programs could help reduce anxiety, depression, and pain in some clinical populations. Thus, clinicians should be

prepared to talk with their patients about the role that a meditation program could have in

addressing psychological stress.”


• N=109

• Non-specific chronic pain

• MBSR (“mindfulness meditation”) vs waitlist

• SF-36

• Baseline, course completion, 6 months

• Decreased anxiety and depression, better psychological well-being, feeling in control of the pain, higher pain acceptance. Small effect sizes were found for pain measures.

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• 93 HCP

• MBSR based course

• 4 mindfulness practices/mindfulness at work

• 2.5 hours/week plus 7-hour retreat

• 45 min/day, 6 days/week: home practice (CD)

• Maslach Burnout Inventory, SF12-v2


Outcome

• Improved Maslach Burnout Inventory scores

• Emotional exhaustion

• Depersonalization

• Personal Accomplishment

• Improved mental wellbeing

“A continuing education course based on MBSR was associated with significant improvements in burnout scores and mental wellbeing for a broad

range of HCP”


• Facilitators:

• Interventions fit into HCP schedule

• Financial assistance

• Barriers:

• High work demand

• Time limitations

• Personal time management

• Lack of appropriate space

• Lack of evidence


Let’s Practice!


Session Outline





• Research review


• Case studies and resources

• Q and A


Putting it into practice

• Clinician-“Physical Therapist heal thyself!”

• Patient

• Education: http://ed.ted.com/lessons/how-stress-affects-your-brain-

madhumita-murgia

• Teach techniques

• Integrate in existing treatment

• PT practice/clinic/workplace

http://ed.ted.com/lessons/how-stress-affects-your-brain-madhumita-murgia














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“Often physical therapists undertake to teach people to do healing things for their bodies while neglecting two of the most powerful allies people

have for healing; the breath and the mind.”

Jon Kabat-Zinn:”Full Catastrophe Living”


Case Study 1

• 47 y/o female

• Stage 2 breast cancer (recurrence)

• s/p mastectomy, 6 weeks chemo, undergoing radiation

• Expander in place

• Referral: “Exercise program for general conditioning”


• Symptoms: fatigue and bilateral leg pain

• Goals (pt): improve energy level, go back to executive job, lose weight

• Findings:

• “Recovering workaholic”, dislikes exercise, fear of moving the shoulder and arm

• Poor posture, limited left shoulder ROM, shoulder muscle weakness, soft tissue restrictions left upper quarter, shallow breathing


Treatment

• Education/Meditation

• Breath awareness and 3 part breath

• Body awareness (“sensations without story”)

• Coaching (walking program)

• Yoga-based range of motion exercises, full body

• Manually assisted left shoulder/chest stretches and relaxation techniques.

• Yoga-based strengthening full body, focus on correct alignment


Resources

Books:

• Soul Centered-Sarah McLean

• Buddha’s Brain-Rick Hanson PhD

• Full Catastrophe Living-Jon Kabat-Zinn

• The Mayo Clinic Guide to Stress-Free Living-Amit Sood MD

• How God Changes Your Brain-Andrew Newberg MD


Resources

• Dr. Sarah Lazar TED talk: https://www.youtube.com/watch?v=m8rRzTtP7Tc

• NIH Meditation information:https://nccih.nih.gov/health/meditation/overview.htm#hed2

• Free guided meditations UCLA http://marc.ucla.edu/body.cfm?id=22

• Insight Timer App

• Mayo Clinic Meditation App

https://www.youtube.com/watch?v=m8rRzTtP7Tc



NIH meditation

NIH meditation

NIH meditation

http://marc.ucla.edu/body.cfm?id=22



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I wish you well!


References

https://nccih.nih.gov (1/9/2016)

Hannibal, K. E., & Bishop, M. D. (2014). Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical therapy, 94(12), 1816-1825.

Zeidan, F., Martucci, K. T., Kraft, R. A., Gordon, N. S., McHaffie, J. G., & Coghill, R. C. (2011). Brain mechanisms supporting the modulation of pain by mindfulness meditation. The Journal of Neuroscience, 31(14), 5540-5548.

Mensah, S. B., & Anderson, J. G. (2015). Barriers and facilitators of the use of mind-body therapies by healthcare providers and clinicians to care for themselves. Complementary therapies in clinical practice, 21(2), 124-130.

Goodman, M. J., & Schorling, J. B. (2012). A mindfulness course decreases burnout and improves well-being among healthcare providers. The International Journal of Psychiatry in Medicine, 43(2), 119-128.

Rosenzweig, S., Greeson, J. M., Reibel, D. K., Green, J. S., Jasser, S. A., & Beasley, D. (2010). Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice. Journal of psychosomatic research, 68(1), 29-36.

Goyal, M., Singh, S., Sibinga, E. M., Gould, N. F., Rowland-Seymour, A., Sharma, R., ... & Ranasinghe, P. D. (2014). Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine, 174(3), 357-368.

la Cour, P., & Petersen, M. (2015). Effects of mindfulness meditation on chronic pain: a randomized controlled trial. Pain Medicine, 16(4), 641-652.

Cramer, S. C., Sur, M., Dobkin, B. H., O'Brien, C., Sanger, T. D., Trojanowski, J. Q., ... & Chen, W. G. (2011). Harnessing neuroplasticity for clinical applications. Brain, 134(6), 1591-1609.


• Britta K. Hölzel, James Carmody, Mark Vangel, Christina Congleton, Sita M. Yerramsetti, Tim Gard, Sara W. Lazar. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging, 2011; 191 (1): 36 DOI: 10.1016/j.pscychresns.2010.08.006

• Assessing mindfulness and acceptance processes in clients-Ruth Baer, 2010

https://nccih.nih.gov

https://nccih.nih.gov

http://dx.doi.org/10.1016/j.pscychresns.2010.08.006

http://dx.doi.org/10.1016/j.pscychresns.2010.08.006

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