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Meditation and Mindfulness in Physical Therapy Practice

Improved Outcomes, Happy Clinicians, Healthy Workplace

Pauline H. Lucas, PT, DPT, WCS

Mayo Clinic, Arizona

CSM 2016

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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

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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

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Stress in America, 2014 (APA)

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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

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Stress

• Not wanting what you have

• Not having what you want

• “Stress is resisting what is”

~Eckhart Tolle

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“Good” Stress

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“Bad” Stress

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Internal Stress: Thoughts

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Stress Response

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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

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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

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Limbic System

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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)

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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

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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.

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• 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

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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

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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.

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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

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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

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• 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!

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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

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Session Outline

• Neuroscience: stress, pain, neuroplasticity

• Clinician burnout

•

• Lab 1: mindfulness

• Research review

• Lab 2: awareness/attention, relaxation response

• Case studies, resources

• Q and A

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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

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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-

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Types of Meditation

• Mindfulness meditation

• Mantra meditation

• Guided visualization

• Transcendental meditation (TM)

• Vipassana (insight) meditation

• Walking meditation

• Loving Kindness meditation

• Centering prayer

• Etc.

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Scientifically validated benefits

• Decreased stress

• Reduced symptoms associated with:

• Depression

• Anxiety

• Pain

• Insomnia

• Enhanced ability to pay attention

• Increased quality of life

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Meditation ingredients

• Willingness to take time to practice

• Gentle non-judgmental attention

• A point of focus

• Kinesthetic

• Visual

• Auditory

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Let’s Practice!

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Session Outline

• Neuroscience: stress, pain, neuroplasticity

• Clinician burnout

• Mindfulness and Meditation

• Lab 1: mindfulness

• Research

• Lab 2: awareness/attention, relaxation response

• Case studies, resources

• 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

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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

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• Reduced inflammation

• Reduced ADHD symptoms

• Reduced menopause symptoms

(NIH.gov)

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• 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.”

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• 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

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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.”

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• 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

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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”

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• Facilitators:

• Interventions fit into HCP schedule

• Financial assistance

• Barriers:

• High work demand

• Time limitations

• Personal time management

• Lack of appropriate space

• Lack of evidence

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Let’s Practice!

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Session Outline

• Neuroscience: stress, pain, neuroplasticity

• Clinician burnout

• Mindfulness and Meditation

• Lab 1: mindfulness

• Research review

• Lab 2: awareness/attention, relaxation response

• Case studies and resources

• Q and A

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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

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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”

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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”

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• 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

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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

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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

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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

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I wish you well!

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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.

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• 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