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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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A Well-Adjusted Brain

Cartesian Model of Pain

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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:rsiegel@hms.harvard.edu

For back pain worksheets, visit:www.backsense.org