Welcome back to the Healing Pain Podcast with Deepak Ravindran, MD
We’re speaking with Dr. Deepak Ravindran regarding the association between post-traumatic stress disorder and chronic pain. Dr. Ravindran has more than twenty years of experience in helping people overcome pain. He’s one of the few consultants in the UK with a triple certification in musculoskeletal medicine, pain medicine, and lifestyle medicine. Dr. Ravindran is a full-time NHS consultant in pain medicine, as well as anesthesia at the Royal Berkshire NHS Foundation Trust and Redding and the lead for the pain service. In this episode, we discuss how to provide trauma informed pain care, as well as Dr. Ravindran’s book called The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain. If you enjoyed this episode, make sure to take a screenshot on your phone and share it over to Instagram and tag me. My Instagram handle is @DrJoeTatta and I’ll be sure to tag you back. Let’s begin and let’s learn about a pain-free mindset and the connection between trauma and chronic pain.
Watch the episode here:
Understanding Posttraumatic Stress Disorder (PTSD) And Chronic Pain With Deepak Ravindran, MD
Dr. Ravindran, welcome to the podcast. It’s great to have you here.
Likewise, Joe. Thank you for having me. It’s been great to be here with you.
I’ve been looking forward to chatting with you. I read your latest book, which is out, which we’ll talk about throughout this episode and I want to point people to it. It’s called The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain. It’s a wonderful book because it’s integrative, holistic, multidisciplinary and interdisciplinary. It’s a great resource for both professionals and people living with pain. You’ve been practicing now for more than twenty years. Most of that is within pain management. I also know that even though you wrote a book on pain, your sights are starting to point toward the intersection on trauma and pain. Also, what that means for us as professionals and the spiral that people may get caught in who have trauma, co-existing trauma, or who are maybe traumatized by inadequate or poor pain care. It’s a good place to start and talk about that.
The way I try to provide pain care in my practice is what I call Trauma-Informed Pain Practice. A lot of it is almost regular work that’s been done in many parts of the US and in the UK in the criminal justice system, education and social care. It has become common to know that everyone, all of us have some form of trauma that we’ve experienced in the past. The earlier you experienced the trauma, the more of an impact it has on your developing nervous and immune system. Over the years, the immune and nervous systems get more intertwined with each other and how they manifested. If we are to accept the neuro understanding that pain is fundamentally a form of protection, then you could always say that the nervous and immune systems are working in tandem to provide protection. If at any time they have been exposed to a threat, danger or trauma of any kind, whether that be that developmental trauma, an adult trauma, or a pandemic as we are in now. All of that will impact our nervous and immune system and that could manifest in some people as pain. Pain from a particular organ or structure.
Trauma-informed means that at least we are always aware that everyone could have trauma. We realize that, we have to recognize that, and we want to respond to it. Most importantly, in the UK we call it secondary care, but in the US, it would be hospital system care, it would be that inherent need for us to resist re-traumatization in our communication, in our talk, in our manners, in our way of therapeutic relationship. How can we ensure that we don’t re-traumatize them? That’s what I bring to my pain practice as well.
When you mentioned the word trauma, the first thing that comes to mind for a lot of people is ACEs or Adverse Childhood Experiences. You mentioned those. In 2020 and 2021, people have started to focus on, “There are more than those basic Adverse Childhood Experiences.” All of us, at some point in some way, may confront a trauma. The Coronavirus pandemic is one of them and all the sequela out of that. Are you perhaps positioning it to a place? Because we know that all of us still have a long way to go with regard to safe and effective pain care. As practitioners, should we start to look at the system that we have right now for pain as, in some way, traumatizing people and adding potentially to the pain that has developed?
Absolutely, Joe. Both the US from what I’ve heard on your podcast before from your guests and from what I know from my colleagues, friends, and relatives in the US and in the UK here, and for that matter in other developing and developed countries. The way we do pain care does need a large-scale change. The paradigm of how we look after our patients has to change. My USP is looking at it from a trauma-informed to be integrative, to be across the community, and locally in my area of Berkshire in the UK, that’s what I’ve done. We’ve helped set up a community pain service wherein you’ve got psychologists and physiotherapists espousing these values. You’ve got the secondary care service trying to keep that in mind. We need to have a different journey, but we still have incentives and funding of healthcare systems that are often skewed towards procedures. There is often that factory line approach of doing one thing and sending it to another specialist. You’ve got the separate joints and separate organs siloed approach and that doesn’t help. I would agree that pain care does need a radical change or of a kind.
Along your journey in this 22 year or so history with medicine and specializing in pain management, was there a particular watershed moment where you realized, “I’m not only involved in medicine. I’m not only involved in the care and management of pain, but I’m also involved in the care of trauma?”
Usually, with all these things, it comes a little late in life. My first eleven years after I finished my undergraduate in 98 hours, I was qualified in India. In my post-graduate, I specialized in anesthesia and critical care, and pain medicine in India in one of the tertiary institutes in Pondicherry. I came over to the UK in Oxford and in London to further do some training and qualify in pain medicine fellowship. I started out as a consultant, and like any other pain physician consultant, I felt that as long as I had a good arm and a nice long needle, I potentially could block anything. With my superior knowledge of opioids, I thought I could practically use medications and interventions to solve all pain problems.
Pain was exciting because it looked that’s where the research in the neuroscience was still to be done. I had a great belief that medicines and interventions could solve the problem, but rapidly within the first 2 or 3 years within my own practice, I was realizing that I was achieving any credible success with my medications and interventions in only about 30% of patients. It was starting to become a problem for me because the patients would get some relief, they go back into the community and they come back again. This rolling chair didn’t work for me because the wait list were getting high.
There was not much funding and one of the things I started realizing around 2013 to 2015 was that patients will be coming back. The volume of notes would be getting higher and higher. I was starting to see a trend in a few patients wherein they would have visited orthopedics, probably a few specialties within orthopedics. They would have then been to the neurologist, gastroenterologists, internal physician, and rheumatologists. They would be getting a diagnosis of fibromyalgia on the way, but they also have osteoarthritis and other autoimmune problems.
One such patient, I shall call her Debbie, was the turning point for me in 2015. It was probably about the sixth time I’d been seeing her in my pain clinic over that 2.5 or 3-year period she was with us. I had done epidural and facet joint injections. Because she’d had back surgery with some sciatica, I’d sent her off for a spinal cord stimulator. Sod’s Law, it was infected so the implant had to come out and there she was back again with general widespread pain. When I saw the three volumes of notes, I asked, “What do you want, Debbie?”
She wasn’t able to engage in a pain management program because she was a single mom. She said she couldn’t make time. Her son was autistic and he was needing care. When I unraveled it, I suddenly realized that many of my patients are having these long sets of notes. There are so many Debbies and these Debbies were not just in my chronic pain clinic as an anesthetic. I was doing still one day of anesthesia practice in a theater setting. I was seeing Debbies in the preoperative clinic. I was doing inpatient ward rounds throughout my hospital system and I was seeing Debbies in the in-hospital ward rounds admitted with a rheumatological problem.
The pattern was there. They were seeing multiple specialists getting multiple diagnoses. What was evident was that they were all having a history of some form of trauma, often developmental, but then a series of adverse life events as well. I did an audit in my practice in the pain clinic. I randomly said, “For a ten-week period, I’m going to ask everyone who comes into my clinic, about 150 patients over an eight-week period, ‘Would you be willing to fill out the ACE score and a resilience score to see where they are?’” I was gobsmacked to a certain extent when I found that 45% of the patients who came to my secondary care pain clinic had Adverse Childhood Experience scores of 4, 5, 6 or 7 with emotional abuse and neglect being the predominant ones.
I realized for a pain clinic that is sitting in secondary care or for that matter, any pain clinic, if 45% of the patients coming to a service have had some form of developmental trauma or ongoing trauma issues leading to such high volumes, the service has got to reconfigure itself such that the specialist knows how to manage that group. That’s when I realized that the last few years of my practice here have been spent in attempting to go upstream. I’m trying to position and say that as pain physicians or for that matter, trauma-informed clinicians, we should not be so downstream as seeing patients 3, 4 or 5 years in their pain journey. We should be seeing them early on upstream, close to after their primary care physician so we can prevent further trauma from happening, and then try to see if we can change some of what has already happened.
I love that you took patient notes and did your own little experiment and investigation. Often we think, “I have to run an entire randomized controlled trial and it has to be published in a paper.” As professionals, we know so much and we have so much information. The constraints of our training have made us think, “I can’t change anything within my own practice,” but I liked that you took that into your own hands. You did a little investigation and started looking at the data on your own.
I love that you mentioned you use the ACE score as well as the resiliency score, because so often people use the ACE which may or may not show the entire picture. Sometimes people are resilient. What you found with five ACEs that’s almost double what the limit is as far as what people say. 1 or 2 ACEs are okay. Anything beyond three, we know that the nervous system becomes primed and the immune system becomes primed as well. That’s when central sensitization and nociplastic pain and all the things that we’re talking about developed.
As you are telling me this story, I’m a physical therapist, and I believe all of us in pain care have a tremendous responsibility for us to serve people well. As you’re talking about trauma and all these Debbies that are in your clinic, and you’re starting to take action and change your practice and change the way you’re looking at these downstream effects. I’m wondering how much of the vicarious trauma that you’ve become aware of yourself that all of us as professionals are a part of. Vicarious trauma is a well-known theory that’s been looked upon in the field of pain medicine and medicine in general and how it affects us as professionals. The healing container that we’re creating, if we’re doing it the right way in and in an open way, we’re bringing people into this space to help them heal. Sometimes there can be some vicarious trauma that we take on as well.
I’ve had to think a lot of my practice to see how I can escape that. Before I go ahead, can I clarify? Would you be open to also saying vicarious trauma would be how much of an impact it has on the practitioner in terms of listening to that history in that sense? Is that what you mean by that?
Yes. It’s the impact that it has on us to work with people who are suffering every day and how it affects both our physical as well as mental health.
To a certain extent, I’ve tried to dilute the defect by innovating the trauma-informed care. It allows me to slightly move away from there because although I have a questionnaire that asks for this history, and it allows me to become aware of someone who comes in with an ACE score of 4 or 5 but with chronic pain in my practice, I don’t delve into the trauma itself. I use that as a standpoint to say, “How can I tailor my discussions with this person in front of me? How can I be compassionate and talk about opioids if that’s what they come there for or talk about interventions, if that’s what they are looking for?”
I place it in context because if I know that it’s an ACE score of six, who has not worked for some time, but got chronic pain with a bundle of notes and 5 or 6 consultations, but MRI scans don’t show much. My conversation is different from someone who might have the same ACE score of six but comes with a clear focal structural issue or a clear idea of, “This is what I want, doctor. Could you give this to me? Can you do this for me?” That allows me to tailor my discussions and my practice. I won’t delve too much into the history until I do need to talk about it.
I try to shield myself from that vicarious trauma issue there. Where it does happen, I’m blessed in the sense that where I work, I’ve got access to good psychologists and physiotherapists. I practice within that environment. I have access to nurses, physiotherapists, and psychologists. We’re all trained in motivational interviewing. To a certain extent, we work with the patient in front of us and we try to use it as almost a debriefing thing. If I do have those feelings, I talk it out. I’m also blessed with the fact that my wife is a psychiatrist at home. Sometimes I can get home therapy as well if needed. If nothing else works, I’ve got mindful running.
In your book, you talk about the pain-free MINDSET. It’s a little acronym, which is great. Tell us about that holistic approach to pain management.
With this story of Debbie that I mentioned, in terms of medications and interventions, that wasn’t working for a lot of my patients who are coming up there. I realized, fundamentally one of the things that the general public have to understand and we in the pain community are aware of this distinction between nociception and pain. I realized even my surgical colleagues, a lot of my GP, primary care colleagues still don’t or weren’t getting the nuance of what we were trying to say. I thought I’ll use that as a USP of saying, “What is the neuroscience you need to know and how can you build upon that?”
Thanks to your wonderful course on nutrition and chronic pain, I realized how much of the role nutrition could play in alleviating pain in that sense and where we can bring that in. Matthew Walker’s book came out around 2016 or 2017 about why we sleep and he had a big role in looking at the research around sleep and pain being a more reciprocal bi-directional thing rather than one after the other. For physical activity and movement, we had a few books from Kelly McGonigal and a few other folks coming around how exercise and physical activities are much more than that.
We’ve always had behavioral therapies which have been used in many different fashions, but then the research was coming out about the benefit of yoga, Tai Chi, meditation and mindfulness. All of those therapies, which were considered complementary or allied, we’re now having the bunch of evidence in the last years to say that they probably had as much a role to play or probably a better role to play than medications or intervention. I suddenly realized that there was this opportunity to put it together into an easy-to-remember acronym.
That’s what the M and the I are for. Medications and Interventions. N is Neuroscience of stress, which is where traumatic stress came along, and D was the Diet and nutrition. E is for exercise. I would have preferred physical activity, but the acronym wasn’t working out with that. T is for Therapies of mind and body. That’s how the MINDSET approach came along. It is as much a paradigm change as well because I’m asking my fellow colleagues, my healthcare professionals once you realize that the nervous and the immune system are interlinked and that traumatic stress or stress has a pathophysiological output, you cannot go back to practicing biomedical dualistic medicine, the Cartesian Model like we are doing. In that sense, it’s a mindset shift that’s required both from the public and the healthcare professionals. That’s what worked out for the publishers as well. They like that USP.
Tell us the acronym for that MINDSET again and what the letters stand for.
The M is for Medications, anything that we have in pain. I is for Intervention. That can be injections, surgery, any form of intervention. N is for the Neuroscience of pain and stress, particularly traumatic stress. D is Diet and nutrition, the microbiome. S is for Sleep. E is for Exercise and physical activity and T is Therapies of mind and body.
With regard to the therapies of mind and body, I know you’ve studied a number of them like ACT Acceptance and Commitment Therapy, mindfulness, CBT. I know you did a lot of research on Pain Neuroscience Education, which is more or less a mind and body therapy in some way. As a physician who specializes in pain management, what are your thoughts? They all have positive research around them. They’re all beneficial to certain people in certain ways. I’m wondering as a physician, how do you categorize them in your mind and how do you start to talk to patients and refer people on toward a certain therapy?
I’ve thought long and hard about this. It’s exactly as you said. I looked into the behavioral therapy literature. I bought the Pain Neuroscience Education book by Adriaan Louw and I looked at how he approached it. The reality is that we are all living in a healthcare system where a lot of these mind-body therapies are still struggling to have the quality of evidence that’s behind them to back the state funding it at infinitum. We are going to struggle with acupuncture, Reiki or yoga being given on tap for patients for as long as required.
Wayne Jonas with the Integrative Healthcare Model in some of the VA centers has been able to introduce that on a long-term basis for the veterans probably, but in the UK, certainly and most parts of India or in Africa there, a lot of these therapies are going to be left out of the mainstream. They’re always going to be looked down as the next step or could be thought of in the background. You can add it in or not. I’ve tried to take a pragmatic approach in the sense that there are some approaches that are done for you like acupuncture or for that matter, a lot of chiropractic care, osteopathic care. You go down, you lie down, they massage it and they do it so it’s a DFY.
You have the done with you model, which is all the pain management programs, a few of the Pain Neuroscience Education, pilates, and all these other exercise therapies, which is to a certain extent you can be doing it with someone to learn how to do it. You have the DIY approach where you get on and do it yourself because of mind-body scan techniques or things that you can learn off YouTube, and you can do that. The reality is that in the UK, at least everybody’s being pushed. All patients are being empowered. Everybody’s being asked to take activation and take a little bit of control in their hands and they feel more empowered to take control.
My thought process is, how can I present all these therapies of mind and body, which are very important, but they do have a placebo response component integrated into them? There is an element of how a good CBT practitioner probably will achieve as much improvement as an ACT practitioner, as an MBCT practitioner, or a pilates trainer. The aim is how do you enhance therapeutic relationships? I’ve taken the pragmatic approach to say that as a physician, as a pain guide, what I can tell you is if you come to me asking for pain management advice, I will talk to you about medications and interventions if they’re appropriate. I’m going to give equal importance or equal weight to the other five aspects of the mindset, which traditionally physicians don’t talk about or just say, “Look it up.” I’m going to pay attention to that.
When it comes to therapies of mind and body, I’m going to say, “How far away is it from your house? These therapies are mind and body. You need to look them up the way you do exercise. You need to do them regularly. You need to make it a habit. You need to know how to make it easy, attractive, good to do habit that you can incorporate as part of your lifestyle.” Therefore, if it means that you can’t do it yourself. You can’t meditate. You want someone to massage you or do acupuncture because that works better for you than exercise, then decide who the acupuncture practitioner you love, how far away they are, and how often you can afford them. The reality is you might live in an area where your healthcare system will give it to you on tap, but more often than not, they’re going to say you have four sessions and off. How are you going to afford it for the next 5, 10, 15 or 20 years of your life? It’s a pragmatic decision that I ask them to take and I laid out as a guide to say, “These are your choices. They all are excellent. Find the right person, find the technique, and off you go.”
How are you overcoming the stigma with regard to the psychosocial therapies in practice when you’re talking to people about pain? You’ve studied Pain Neuroscience Education so you know the concept of the reconceptualization of pain and you’re familiar with Cognitive Behavioral Therapies. All of those involve talking to people about the influence of the mind and the nervous system. As a physician, you’re their first point of contact before they get to a physiotherapist, a psychologist, an OT or anyone else. How are you destigmatizing this process and certain aspects of that mindset, which they’re now hearing for the first time? What are those because so often we think that the stigma exists in telling people that Cognitive Behavioral Therapy will help them. However, I’ve come across people who felt stigmatized by talking about nutrition. It’s not only the mindset part of it or the Cognitive Behavioral Therapies. I think it’s unique to the person.
I have tackled this in two ways. One is the fact that the book offers one option of saying that and laying it out and saying, “If you want to come and see me, this is what I believe in. This is already out there. This is our practice.” The second step is as physicians, we are the first port of call, whether it’s a primary care physician or a secondary care physician. We have the responsibility and opportunity to make these behavioral therapies attractive. We, physicians, do not sell them adequately well enough because sometimes we don’t know enough about them to sell them in an attractive fashion to our patients. That’s part of the reason why I wanted to read about it because if I had to encourage my patients to say, “Please talk to my psychologist, because what they do for you is valuable, the way they will approach it is valuable,” I have to make it sound appealing and worth it to do that.
Marketers know how to promote a product that’s useful. Physicians can take a leaf out of the book to say your mood will influence and that attempt at changing the mood, whether it’s challenging the mood or accepting the mood is important. Sometimes it requires someone with better skills than a doctor to do it more effectively and in a sustained manner. In physiotherapy, you’ve got this concept of psychologically informed physiotherapy practice. There might be a reason to have psychologically informed physicians as well who can understand how to encourage patients to do it. That’s what I’ve tried to do in my practice. What’s made it easier for me is in a way long COVID or the pandemic of COVID has made us realize that there is such a huge overlap between the nervous system and immune system in terms of how symptoms come. It’s the same that happens with our understanding of pain and nociplastic pain and central sensitization.
I can show them that the nervous and immune systems are hugely overlapping. Eighty percent of your dopamine or serotonin is produced in your intestine, then it goes into the immune system and travels into your brain. When you’ve got such a huge overlap between your nervous and immune system, we need to find different ways of dampening the immune system in your nerves, in your brain, and your spinal cord. We can use drugs or injections, which act from the bottom down to dampen it. It may or may not work but it got side effects. What about therapies that could act from the top down, which could dampen the same nervous and immune system? That’s what my colleagues will do with you. This is not about saying it’s in your head but it’s saying, “How do I dampen the nervous system, calm it down and protect it?” These colleagues of mine do a much better job. They will be able to see you in between this, “Let me refer you to a video. Why don’t you watch this video? Why don’t you watch this resource?”
Much of what I’ve learned from that literature around digital advice is you’ve got to provide 7 to 10 touchpoints to a potential patient before they can start accepting what you’re saying. What I will say is one. My physiotherapist will say the same thing. I’m encouraging my GP and my primary care colleagues to say the same thing. They may look at a few videos or listen to a few podcasts. By the time they are coming to see my psychologist, they have had enough information to say, “This is what I want. I’m interested and I want to do it with you.” I’m hoping that that would help in destigmatizing in the long run. It’s still some way off but that’s my approach.
Professionals ask me all the time, how do you get people to engage with nutrition? How do you get your patients to engage with mindfulness? Because when I talk to them about it, they won’t do it.” I always say to them, “Show me your website. Show me your intake paperwork.” It’s all those touchpoints that you were talking about. Before someone comes to me, they’re on my website. They see all these different topics I’m talking about. They see the intake paperwork where I’m asking about the nutrition, their mood, thoughts, feelings, emotions, fears and things like that. We’re talking about it during the session. All these touchpoints and the touchpoints before they get to you, before they’re in your consultation room are so important. It helps you do your job better. It makes your job easier versus when someone comes to you and all they know is you treat pain, but they have no idea how you treat it. They have to figure out, “What is this? How does it work? Do I want this?” Some people don’t necessarily want nutrition and in that case, you say, “That’s fine. We’ll cross off the N on the mindset as you have in your book but I have all these other tools that can help you as well in similar ways.”
What I found useful is understanding this concept of behavior change by Prochaska and DiClemente, the Transtheoretical Model of Change. That made my clinical practice less strenuous for me because if people are in the precontemplative phase, I should not feel bad that they haven’t listened to my advice and haven’t taken the drug or aren’t doing what they’re doing. They are just not in that phase where they’re ready to change. My role is to increase awareness, make them aware of the choices and leave it to them to decide. If I can change and provide the touchpoints such that when they come, they’re headed in the contemplative phase or in the planning phase. That’s where they’re ready to take my advice, ready to act on it and give it a whirl. If they can put it into action, if I give them the pain management program, that’s the action phase, then all they need is the maintenance aspect of that.
It will relapse again and make them aware that they’ll relapse but that process is what I’ve tried to take through in my book as well to say, “Try to assess where our patient is in that journey. If you find them in precontemplative, don’t spend time putting them in a pain management program, making them wait 4 or 5 months. Give them the resources, give them the information, let them think about it, and let them come back because we are not living their life. They are living their life. They know their pressures and they’ll come back when they’re ready.
This is an important topic that I thought you touched on that I want to talk about. I brought this up with a distant colleague of mine and her response was, “All of these patients need to be in multidisciplinary pain programs.” I said, “First of all, we don’t have enough. Even if the funding was there, we don’t have enough professionals to staff it.” We have a problem with staffing with regard to qualified professionals. We have a problem with regard to funding of these programs, but that the point that you touched on is probably the most important point. We can’t take people and throw them into a multidisciplinary program, which takes a lot of work and time for an individual. Sometimes they’re an inpatient, sometimes they’re outpatient, but it’s a significant amount of time that people have to spend. If they’re not ready for that, we potentially could be wasting everyone’s time and money, and the patient may relapse because they’re not necessarily ready for it.
However, what you’re saying is you’re recognizing that precontemplation phase. You’re saying that potentially the most important point, the pivot point, the choice point that happens is one caring human that can shift it for them. Once that one caring human shifts something for them, maybe it’s the multidisciplinary program. Maybe they need two professionals. Maybe they need another professional that’s more specialized in something. It’s an important point you bring up because I’ve seen some things start to pop up about, “We need multidisciplinary pain programs.” I’m like, “We do. We definitely need more of them, but I don’t think that’s the solution.” The solution is how do we take the one person who they’re coming to, that could be a physician like yourself, a physical therapist, or a psychologist. How do we optimize that one encounter so it’s successful for the patient?
You hit the nail on the head in that. This is an American tool. I forget the lady but I don’t know why Dr. Hibbard comes to mind. She apparently started a tool called the Patient Activation Measure, PAM score. That was brought to her and it has been adopted in the UK by the NHS England and NHS Improvement as a tool for understanding long-term condition management in the UK. The PAM score is a set of thirteen questions which is similar to the Patient Self-Efficacy score, the PSEQ we have in a broad layout. It spits out a number out of a hundred for those thirteen questions that somehow are average and logged out to a number. That is divided into four levels. If level 3 and 4 means that people are scoring 60 or 70-plus, that means they are quite health literate. They are motivated to take control of their health and make decisions for themselves.
Level 3 or 4 in my area, I’ve got the approval locally to say those people would be suitable for a digital program. Thanks to the pandemic, we’ve now got a digital pain management program, wherein you don’t need that huge resource implication of having multiple practitioners, physiotherapists, psychologists, and OTs being involved. You could stratify patients to say, “High activated levels could do a digital program with a bit of light touch physio, a physical health coach or a minimal touch to treat them through,” but then you have the intermediate phase wherein your score PAMs of level 2 or level 3. wherein they are a little bit hesitant. They’re not sure. They want some coaching, support and motivation. That is where probably the multidisciplinary programs that you talk about, wherein you bring the group effect, accountability, and habit formation. You give them some directed smart goals, which they can do. You then scale it up like atomic habits, small habits and build it up there.
For the level one, the ones who are quite low in their activation, that might be someone whose social support systems and resilience is not great, who has been deeply traumatized, who’s got ongoing mental health issues or family issues or comorbidities. Those might be the people where we need to give our most resources and say, “You need a little bit of social care rather than a big fancy program. You need something else. You probably need your employment sorted. You need something job security sorted. You need some food stamps or food insecurity looked at and poverty taken care of in some way.” That stratification is important if we need to allocate resources properly as healthcare practitioners.
I appreciate what you said because it tells me that you have a system in your mind of how to triage someone in a way who has pain. I know the UK system is a little bit more structured than the US system is. We don’t have that closed system the way that you have it in the UK. We’re definitely lacking that. Although as we know in pain, we have a lot of room to develop in the pain world pretty much in every country. Part of that development process I believe is creating patient-forward material that people can access and read about. Your new book is one of those. It’s called The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain. You can find it on Amazon and in many bookstores near you but Amazon is always a great place. As we close, tell people how they can learn more about you and how they can learn all the great work that you’re up to.
My website, which is my name, DeepakRavindran.co.uk. It’s a UK website there but otherwise, I’ve become a little bit more active on the usual social media handles of Instagram and Twitter. My Twitter is @DeepakRavindra5. A five for some reason. Don’t ask me why. It just happened.
We’ll make sure you stay active on there because we’ll be sharing your episode out quite regularly. That website you can reach to www.DeepakRavindran.co.uk and you can find all of Deepak’s work there. You can find his book, The Pain-Free Mindset online and on Amazon. I want to thank him for joining us, talking about integrative chronic pain and the intersection between pain and trauma. Make sure you share this episode with your friends and family on Facebook, LinkedIn, Twitter. Tag him since he’s new to social media. Keep him busy and tell him how much you liked this episode and how much you’re enjoying his book. I’ll see you soon.
- Dr. Deepak Ravindran
- The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain
- @DrJoeTatta – Instagram
- Pain Neuroscience Education
- Amazon – The Pain-Free Mindset
- Instagram – Dr. Deepak Ravindran
- @DeepakRavindra5 – Twitter
About Deepak Ravindran
Dr Deepak Ravindran has 20 years of experience in helping people overcome their pain. He is one of the few consultants in the UK with triple certification in musculoskeletal medicine, pain medicine, and lifestyle medicine. Dr Ravindran is a full time NHS consultant in pain medicine and anaesthesia UK at the Royal Berkshire NHS Foundation Trust in Reading and the lead for the Pain Service.
In 2015, he helped set up the integrated pain and spinal services (IPASS), which provides community pain services for West Berkshire and has been awarded ‘Emerging Best Practice’ by the British Society for Rheumatology and was shortlisted for a Health Service Journal award. His team won the Grunenthal National Pain Award for General Patient Education in 2017.
He has been a visiting lecturer at the University of Reading since 2016 and has authored and contributed multiple chapters in many pain management handbooks for healthcare professionals, and patients support groups.
Dr Ravindran is a University Gold Medallist in anaesthesia and pain medicine from one of India’s prestigious tertiary super-specialist institutes (JIPMER) and has completed anaesthetic training at Oxford and his pain fellowship at UCL, London.
More recently, he has helped establish the Berkshire Longcovid Integrated
Service (BLIS) for managing Post Covid syndrome (Longcovid) for his local health care system. He lives in Berkshire UK with his wife and 2 kids.
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Welcome back to the Healing Pain Podcast with Davide Lanfranco, PT, MCSP
We’re discussing how to target pain catastrophizing by using a core process of acceptance and commitment therapy called cognitive diffusion. My expert guest is physiotherapist Davide Lanfranco. Davide is an Italian physiotherapist who works in London. He is a member of the Chartered Society of Physiotherapy and is one of the Founders of FisioScience International, an online platform which aims to spread evidence-based knowledge about pain. In this episode, you’ll learn how pain catastrophizing impacts both physical and mental wellbeing, all about the cognitive change process of cognitive fusion, how it’s different from other cognitive interventions and how we can teach patients unhook from unpleasant or unwanted thoughts about pain.
Cognitive fusion is a time-tested, science-backed approach that has helped thousands of people experiencing chronic pain, as well as those suffering from stress, depression, anxiety, trauma, and addiction. Cognitive fusion is a key part of my latest book, Radical Relief, which is rooted in the principles of acceptance and commitment therapy. Radical Relief, which is written for both practitioners and for people living with pain uses metaphors, colorful imagery and includes more than 40 mindfulness activities to help you identify the blocks that may be keeping you stuck and offers tools for taking meaningful action toward a more fulfilling life. It’s available on Amazon and in most countries. Let’s begin and let’s learn about cognitive fusion techniques and how it can help pain catastrophizing with physiotherapists Davide Lanfranco.
Watch the episode here:
How to Apply Cognitive Defusion Techniques To Target Pain Catastrophizing In Physiotherapy Practice With Davide Lanfranco, PT, MCSP
Davide, welcome. It’s great to have you here.
Thanks for having me.
I know you’ve done some great work in the world of physical therapy or physiotherapy as it’s known on your side of the world, and especially with regard to psychologically informed physical therapy or psychologically informed physiotherapy. We’re going to talk about pain catastrophizing, why it’s important, why people should learn more about it, and how we can target it with different types of techniques. One particular, which is called cognitive fusion. A good place to start is to explain to people what pain catastrophizing is so they can understand it in simple terms.
Pain catastrophizing is not a nice term. I apologize with the least scenario theories any of you experiencing persistent pain because pain catastrophizing, at least at me gives me the idea of someone that is almost overdramatic. We know that people experiencing persistent pain are not overdramatic, that’s not the problem. I would use pain catastrophizing here because I don’t have a better term to describe it. We can say that pain catastrophizing can be described as an exaggerated, negative orientation towards an actual or an anticipated pain experience. Pain catastrophizing is not there only when pain is present. People can have the features of pain catastrophizing, even when we are pain-free in anticipation for a possible future experience.
Let’s talk about the story of the history of its term, probably the first good paper that describes pain catastrophizing and brings to the attention of the scientific word validated scale to describe it is the paper of 1995 of the health psychologist, Sullivan. In this paper, Sullivan, apart from presenting the pain catastrophizing scale, but is still widely used and is a quick and effective tool as an idea of a much pain catastrophizing is going on. He describes what pain catastrophizing is, and he describes it as characterized by three different features. In the paper, he says the three characteristics of pain catastrophizing are rumination, magnification and helplessness.
Let’s have a look at what they are, what they mean and what they look like. Rumination is not a term that has been created by Sullivan because he seems the first one to use it that was a few years before. Rumination is a term that has been much associated with problems like depression or anxiety. Only lately has been introduced in the realm of pain. Rumination can be described as that worry and inability to inhibit the pain-related thoughts. It can be described as a pattern of pervasively thinking about once emotional symptoms, or for example about the pain in this case, but as well as the causes and the consequences of his symptoms. Rumination is not only about the experience why the pain itself, it’s about thinking about what may have caused it and what may happen in the future, what could be the potential consequences of that.
Rumination also is a person that can tell you, “I cannot stop thinking about my pain.” That brings me to the memory patient that was discharged. When she came for the initial appointment, this lady who has been experiencing lower back pain for many years told me when I asked her, “How can I help you?” She said, “When I wake up in the morning, I think about my back. When I get out of bed and go have breakfast, I keep thinking about my situation. As I eat breakfast, I cannot stop thinking about what is going on, and as the days goes on, when I’m in the meeting, when I’m at work, when I’m shopping, I keep thinking about my pain. The only moment when I don’t think about my pain is where I’m in engaged in an interesting conversation. At that moment I can add a little bit of freedom from those thoughts.”
That is a description of how rumination can show up. There is an overwhelming amount of evidence in the literature describing a strong association between rumination, anxiety and depression. People who tend to ruminate a lot tends to potentially sink into depression. It’s an important factor that has to be addressed. The other one is magnification. It relates to an exaggeration of the experience. This can be a bit tricky because we always commit the scene of judging someone else’s experience. We tell them, “You shouldn’t be in so much pain. You shouldn’t be feeling these according to what I know.” We run the risk if you’re careful of invalidating the person’s experience. Magnification relates to a big exaggeration of the experience. For example, thoughts are like, “This pain will never get better. There’s nothing that can be done to help me.” These sources of magnification.
The third feature that described the pain catastrophizing is helplessness. Helplessness is quite self-explanatory. It relates to the perceived inability of dealing with the situation. Thoughts like, “I cannot get on top of this. I will never get better. No one can help me.” Pain catastrophizing is something that does not occur only on people with persistent pain or people with being in pain for many years. Pain catastrophizing can happen to any person, even if their pain is more acute or subacute. It’s that type of people that we have to be even more careful and more ready to target. I encourage people to read the paper of 1995 on pain catastrophizing. Even if it’s several years old, it’s still fresh, actual and interesting to read.
It’s a great introduction to our episode because pain catastrophizing is been around for a long time, and at many decades grew out of the traditional cognitive-behavioral literature around ruminating thoughts with regard to anxiety and depression. Someone studied it and translated some of that research and evidence over into chronic pain with regard to pain catastrophizing. The way you started off Davide is the most important thing you’ll say the entire episode in the sense that word’s been around for a long time. It’s used in popular culture and pop psychology, but it’s confusing to someone with chronic pain, in a way it sounds like we’re telling them that their thoughts are maladaptive, aren’t good, bad, or however you want to frame it. Catastrophizing exists in everyone in many different shades and it also exists in people without pain.
I’m catastrophizing. I keep thinking, “Will I say clever things? Will the people like it if everything goes south?” Part of being human is our mind trying to do its job to keep us safe. Sometimes it gets over-protective.
It’s a normal mode of the mind with regard to worrying about things in the future or planning with regard to things in the future. How important is it for clinicians to normalize this pattern of thinking for people living with chronic pain?
It’s important. It’s crucial both in people who experience more of an acute condition, and it’s crucial as well for people to experience more of a persistent condition. There is an overwhelming amount of literature telling us pain catastrophizing is a predictor of chronic symptoms. We know that people that are in a more acute subacute phase with a high level of pain catastrophizing so their score’s high at the pain catastrophizing scale, for example, has a higher likelihood, possibility or chances to develop chronicity. We know that in low back pain, 20% of the people that develop low back pain will end up having a persistent problem. Still, even if the real mechanism is not clearly fully understood, we know that pain catastrophizing is a strong predictor of these chronic symptoms.
In people instead that are already chronic or experienced already longstanding conditions, those catastrophizing thoughts are a key factor that contributes to maintain the chronic pain and the disability. The fact that the person engaged in such catastrophizing anxious thoughts is more likely to have a higher level of disability and that maintains the condition. Pain catastrophizing predicts, not only with things but predicts actual pain intensity and psychological distress as well. People with a higher level of pain catastrophizing are more likely to develop anxiety, depression and a higher level of pain. I read the paper that was published on pain and came out fresh from the printer. It’s published in November 2020 on pain catastrophizing. It predicts less physical activity in all adults with knee osteoarthritis.
What they did in this paper, they recruited 143 older adults with knee osteoarthritis and they ask them to complete electronic daily diaries for the period of 22 days, at the same time to wear an accelerometer in order to capture their physical activity and sedentary behavior. They ask them at the beginning of each day to report their level of pain catastrophizing regarding the day to come. They demonstrated that when the patients were catastrophizing more than usual about their pain in the head, they spend more time in sedentary behavior and engage in fewer means of physical activity. That food space in the morning were a predictor of how much physical activity they were doing during the day, but the other side is that the more time they spend in sedentary behavior, the less physical activity they did, the more it contributed to a greater pain catastrophizing in the next morning. It’s a vicious cycle. More pain catastrophizing, less activity, more pain catastrophizing as a result of even less activity.
They found another connection between pain catastrophizing and avoidance of physical activity in this case, in people with osteoarthritis, but it stands to reason that it relates to a great deal about their condition. The conclusion was, if you address pain catastrophizing, you also reduce sedentary behavior. Addressing pain catastrophizing is crucial and understanding that the person is having catastrophic thoughts in the early days when they come into the clinic is important. It’s something that has to be addressed more.
Two interesting important points that you mentioned there, the first is your last point there that pain catastrophizing leads to less physical activity. As a rehabilitation professional, a physical therapist, a physiotherapist, that’s important. Not only can we target pain catastrophizing from the cognitive perspective, but helping someone engage in physical activity in essence using the body to affect the mind is a way to impact pain catastrophizing. The other important point is that often we think about pain catastrophizing with regard to chronic pain. You mentioned that the most important place we could help people target catastrophizing is in the acute phase of pain so it doesn’t turn into the chronification so acute pain doesn’t turn into chronic pain that lasts longer than that 3 to 6 month period of time. What I find interesting about that is, as physiotherapists, we’ve been so focused on pain education which is important and has its place. Pain education hasn’t showed us that it’s necessarily effective in the acute phases of people with pain.
There are some studies showing that neuroscience education compared to perceived education have similar results. I still think that providing the patients with the basic information regarding their experience to help them make a sense of their experience, it’s important and can be crucial in their recovery. At the same time, we need to target their cognition and the way they relate to the problem, and addressing in the early stages their faults and the type of faults they have and how they relate to those faults. It can be crucial for the recovery ahead.
As a physiotherapist, I know you’ve used a number of interventions, pain neuroscience education, or pain education, cognitive behavioral therapy, acceptance and commitment therapy. In your mind when you approach these different methods and you think about patients, what’s the difference you see between ACT, CBT and pain education?
There are significant differences in the way they approach the problem in which we approach cognition. The big difference is that pain neuroscience education is more into a reconceptualization of the experience. It’s helping the person understanding that the pain they’re experiencing is not because they have herniated disc, but it’s because of other factors and the pain experience is much more complex. The more traditional cognitive restructuring that belongs to the traditional cognitive behavioral therapy, instead is more into challenge the thoughts, to change the thoughts, to replace the thoughts, to change the way the person thinks about their experience bringing evidence.
Someone says, “I’m worthless, I’m beyond help.” You may say, “No. This evidence is not right.” Helping the patients to see the situation from another perspective, to replace the thought or to suppress the thoughts as well. What acceptance and commitment therapy do instead, we don’t care much about the content of the thought, the veridicity of the thought, or the type of belief the person has. We care about how the person is relating to that thought, how much that thought is impacting on their cognition, and how we can act in a flexible way in order not to be impacted by that thought in a nutshell.
You mentioned beliefs there, which pain-related beliefs come up in the literature, pain-related beliefs come up in many different types of pain education interventions, and it can be difficult for someone who first comes to a mindfulness and acceptance approach. There are many different types of them out there, but act as ACT is one of them. It’s difficult for practitioners to think, “I have to change someone’s belief about pain,” versus having someone relate differently to their belief. It’s difficult because sometimes when you’re trained a certain way, it’s hard for them to be flexible, shift gears, and realize, “Maybe I don’t have to change someone’s belief, or maybe that belief will never change, but I have to help them relate to that belief or allow that belief to be present as they do other types of activities in their life.”
It’s crucial and important. As physiotherapists, sometimes we do big damages in the relationship with the patients when we try to convince them at every cost that they are wrong and we are right. Some words from a colleague of mine named Paolo Marighetto, when he teach his courses, there is always a sliding which is trying to convince the patient that they are wrong and we are right, or their experience is not the way they think it is, it’s like trying to convince the Pope to become Muslim. You can give it a go, but good luck with that. If someone comes to me and there’s a twenty years long belief that there something growing in the back, I can try to refrain to reconceptualize that belief once or twice, but that’s it. Otherwise, I would lose ruin the relationship with the patient. It’s ACT that teaches us how to make sure that the belief can stay there, we show you how to make it impact lesson your life. We have to stop the tendency views, this attitude of trying to change people believe, in general, is not right.
You said something important. I interviewed a pain researcher and psychologist from where you are in England. She’s run a number of meta-analyses and systematic reviews on traditional cognitive behavioral therapy for chronic pain. In her last review, she mentioned that we don’t have a whole lot of information on whether or not traditional cognitive behavioral therapy can be causing some harm for people. Any intervention at all can do good, it can be neutral and have no effect, or it can cause harm. One of my main concerns that I’ve always talked to therapists about with regards to beliefs and pain is that if you’re so attached to that belief and you’re driving home that belief to a patient. That belief isn’t changing and they’re not changing, and you’re not aware that they’re unable to change, or they’re not at the phase yet where people will change.
Sometimes it takes people years to change our beliefs about things. You mentioned damage. You may be doing harm for someone where if you take a more mindful and acceptance approach, you can navigate around that belief in a way that’s, one, healthier for the patient. Two, healthier for you too, as a clinician. If you’re going to work every day trying to change beliefs about pain, some people have had pain for decades and those beliefs we know from good research don’t change so frequently. That leads to a tremendous amount of frustration and burnout in practitioners, especially pain practitioners where frustration or burnout is high already.
It’s a form of self-protection and self-care as well. Human beings are not convinced by facts and objective truth. It would be easy otherwise to do our job, but if we could show you not, these are the evidence, “Thank you. I will follow them.” We sometimes don’t see the objective truth in front of us. It’s simply seeing someone the way you think is longer, it won’t do much.
What may seem logical to us as licensed healthcare practitioners based on facts is not so logical to people living with pain that facts don’t necessarily change behavior. That brings us to cognitive fusion, which is a method in acceptance and commitment therapy. Tell us a process, and ACT as well as the method what cognitive defusion is.
Cognitive defusion is 1 of the 6 aspect core elements that contribute to creating psychological flexibility. Acceptance commitment therapy is one of the aims of psychological flexibility in people. Psychological flexibility is defined by cognitive diffusion, acceptance, present moment awareness, values, committed action and self as a context. Cognitive defusion is one of the six phases of that. Before saying what cognitive defusion is, we should say what cognitive fusion is. It’s exactly the opposite. Cognitive fusion is, when a client is relatively fused with their problematic thoughts when they are immersed in the content of what they’re saying without even being able to recognize that circumstances could be other than overviewing them. A fully fused client or someone who’s fused with their thoughts it’s not even able to recognize that they are having thoughts. They replace. They think that the thoughts they are having are true.
To a point in which they don’t even realize there are thoughts passing through their mind and they’re buying so much into that they feel real. The problem with this anxious thought is not in the content itself. That’s why we don’t have to change the context to have a better outcome. The problem with anxious thoughts is that they feel real to the person. They feel threatening, dangerous and real. Cognitive fusion is buying into those thoughts, dwelling upon those thoughts so they become the filters through which we see the world, the glasses through which we see the world.
A person with a high level of cognitive fusion often use terms like, have to, can’t, must, must not, and shouldn’t. Rigid absolute terms. Cognitive defusion is the exact opposite. Cognitive defusion is about helping the person to take a step back from those thoughts. We don’t try to change the content of the thought. We don’t try to convince them of other things. Teach from out to take a step back so the thoughts are not in front of their eyes anymore, stopping them from doing things from having the freedom to choose what they want to do. We teach them how to take a step back so the thoughts are further away from them and they can engage with life.
We are not asking and not kicking the thoughts away. We are giving you a bit of space, so in that space, you can take actions that bring into the direction you want to go. Cognitive defusion is an interesting part of ACT that is completely different from the previous traditional cognitive behavioral therapy, different from pain neuroscience education and has a lot of similarities to mindfulness. If you have practiced mindfulness or you’re familiar with this tradition as well, you may know about watching your thoughts from the distance, seeing your thoughts passing by, not get entangled with them or hooked up with them. For acceptance commitment therapy, the problem is not on the content of the thought, what your mind is telling you and what goes on inside your head. It’s how you relate to them. Cognitive diffusion is about changing this relationship.
Davide put his hands over his face with regard to cognitive fusion, meaning the thoughts are so close to you that you can’t see through them. As if you’re looking at life through a cloudy lens. From that view, the only thing you can see are those thoughts in front of your eyes. As you started to move your hands down away from your face, you gain some distance from those thoughts or those thoughts have less of an impact on your behavior instead of changing the thoughts with a traditional cognitive behavioral therapy. That is what Davide and I were discussing, the difference between acceptance and mindfulness approach to thoughts versus traditional cognitive behavior therapy. If you’ve studied traditional mindfulness or the traditional mindfulness research, there’s a word called decentering, which is similar to cognitive fusion. They’re pretty much exactly the same thing, different researchers have different words and different definitions for how we can use the mind to help people with the thoughts that they’re confronted with. Have you found that cognitive fusion is beneficial for helping people with pain catastrophizing in your practice, Davide?
It has been helpful. I wanted to spend a couple of more words on why cognitive defusion can offer benefits that other types of cognitive restructuring or other methods of dealing with thought offer. I found an interesting paper in the European Journal of Pain that states pain-related thought suppression is one of the most common responses in athletes that are experiencing pain. That leads to more severe and recurring depressive symptoms and is linked to suicide attempts. Thought suppression is about anything but allowing the thought to be there. Distracting yourself, watching movies, putting the music on, trying to think positively that belongs to these toxic messages that are delivered by the society. Think positive, positive thoughts, positive vibes, put away everything that is scary negative, and is not nice and just replace and change it with positive stuff. These toxic messages lead us to the understanding that negative thoughts, scary thoughts or anxious thoughts are wrong, and that must be pushed away. When you push them away, you get their own equal effect. They come back even stronger. Research has shown us that suppressed thoughts are characterized by an increase in the return of the suppress content, and you may be familiar with them in polar bear experiment. I don’t remember in which we show people a polar bear, they told them to try to not think about the polar bear, and it was impossible.
When we tell our patients, and it’s something I hear often from my colleagues they are saying to the patients, “Try to be positive, things will be all right. Don’t think too much about it. Don’t stress too much. Thank you.” If she or he could have done it, they would have done it already. You don’t need to tell the person, “Think positive. Don’t stress about it. Don’t worry.” Acceptance and commitment therapy and cognitive defusion teaches us how to do this from another perspective and how to take a step back. Cognitive defusion is something powerful, but people with the eye level of cognitive fusion don’t even recognize they’re having thoughts in the first instance. That is the truth. “I have a bad back, that is the truth. It’s not even a thought that is passing through my mind.” They think that it is the truth.
Before going and using fancy and nice techniques that acceptance commitment therapy offers, the first step with these patients is helping them being more aware of their cognition. I would make another example with a patient I had. She came and she said that she was experiencing tremendous low back pain with bilateral, like pins and needles. That was present mostly when she was standing. She was an avid surfer. Surfing was becoming a big problem for her, and the other big problem was in cooking. She couldn’t stand more than 20, 30 minutes, if she stood more than that, she had to lie down one hour to recover. She’s a single mother with two children and every time she went home and cook, after 20, 25 minutes of cooking, she was knackered, and she had to lie down.
She couldn’t even have dinner with the kids because she had to recover from preparing the dinner, and that went on and on for months. She told me as she approaches to cook, the background pain was around 2 out of 10 on a VAS scale. After 20, 25 minutes, it shoots up immediately to 9 out of 10. She was not aware of what was happening in between. She was not aware of the thoughts that are showing up in her mind. We did basic exercise, and we did some exercises to become more aware of what her mind was telling her. When I asked her to notice what was going on in her head, the thoughts were like, “Here we go again. Even this night I won’t be able to have dinner with my children. Which kind of mother I am?”
It was a lot of shame and embarrassment in the role of mother because she couldn’t even provide for the children and all those thoughts are turbinating in her head without her even being aware of them that led to a huge pain experience. By simply allowing her to become aware of them, it helps to decrease the level of pain. First of all, if you want to fight someone, you need to see their face, you need to know who is better at fighting, even if fighting is not the right metaphor in this case, but being aware of your own cognition, what you’re psyching is throwing at you, and your own faults.
If I can spend a few more minutes, how can you do that? We have a simple meditation exercise. You can ask your client to close their eyes and do 30 seconds, 1, 2 minutes meditation. Ask them to put focus on their breathing and tell them, “Sooner or later your mind will wander somewhere else, positive, negative, or neutral.” The goal of the exercise is not to empty your mind. The goal of this exercise is to recognize when your mind is hooked up by other things, and at that point, bring it back to your breathing. Constantly, as soon as you realize your mind is somewhere else, bring it back to your breathing. You develop this muscle-based skill of recognizing when your mind is going somewhere else so you’re not hooked up in rumination, hopelessness, and magnification for two hours, maybe for twenty minutes with less effects.
If the person doesn’t want to do a close eyes meditation, you can ask them, “You can make it more practical and functional when you’re showering, brushing your teeth, washing your pots, dressing yourself, walking, immerse yourself fully in what you’re doing.” Put all your senses varying what you’re doing, your eyes, sight, smell, and tastes. As soon as you realize your mind has gone somewhere else, bring it back to the activity. With this process of back and forth, you would get much more skillful at that and you will be able to recognize earlier on when your mind is somewhere else ruminating about pain.
It’s quite simple, the beginning of it. It is to help people notice what the flow and content of their thoughts are. Going back about pain catastrophizing by magnification, rumination, and helplessness, that helps us with a framework as far as practitioners to understand what’s happening inside the mind, but we can’t approach people with that because it’s too technical. Immersing yourself in a one-minute mindfulness exercise or taking that skill and using it with a simple activity like washing the dishes or walking the dog. Learning how to consistently take that skill of unhooking from the mind and coming back to the present moment versus running away with the mind. Pushing thoughts away and distracting from thoughts and that thought suppression in and of itself can lead to more distress.
That’s important because people do try to distract from thoughts. In certain traditions and other types of approaches, there is an approach to suppress thoughts but it’s like that beach ball under water. If you take a beach ball and you push it under water, as soon as you take your hands off, it pops right back up to the surface. The harder and more forceful you push the ball down, the more you try to suppress that ball, the higher it pops out of the water and our thoughts can be the same way, especially with regard to chronic pain. If we take this one cognitive process of cognitive defusion, and instead of applying it to people with pain, we apply it to professionals. If we apply it to ourselves as pain practitioners, how can cognitive defusion be a beneficial psychological skill for professionals who work with people living with pain?
People who work with a professional that works with people experiencing persistent pain can burn out more easily than people that work with other type of conditions. We know that some of these patients can be challenging and draining your energies as well. The symptoms are sometimes complex and unpredictable, we may find ourselves hooked up in types of thoughts like, “This is because of me. I didn’t things right. I should have done more. I’m not doing this right. What am I missing?” All these faults multiplied per all the amount of people you see, over the weeks, months and years do lead to a lot of stress.
A lot of people tried to calculate how many faults a person has per day. A paper a few years ago said between 60,000 to 90,000 faults is not right. A paper in 2020, who came out on Nature Communications stated that a healthy adult has around 6,000 daily thoughts. Most of them are negative. Imagine thinking, buying, dwelling, ruminating thousands of thoughts every day, week, month, and multiply, it’s a huge number of thoughts. When we work with people who have complex symptoms and required a lot of that help, the risk that we get hooked up with the story that we are not good enough, for example, can be detrimental. Applying these methods on ourselves can be beneficial and I invite everyone to do it.
With regard to ACT and cognitive defusion, do you approach cognitive defusion as a technique, or you’re looking at this more as a process that you’re guiding someone through as they’re going through therapy with you and learning about their pain?
As a process. Now, there is the cognitive fusion questionnaire in which you can have a better understanding of how much the person is fused with their thoughts. It may be useful, it maybe not, but I think it is useful to approach it as a process. When you’re asking your patient to do a movement and they are fearful of, start simply by asking them, “I wonder what is showing up in your mind? What is your mind telling you?” As you say, “What is your mind telling you,” you already are doing a little bit of defusion because you are implying that there is another entity communicating with them. What is your mind telling and showing you? What thoughts are coming up? You start appreciating getting a taste of how much they can defuse and what thoughts come up, and you can do something that is required. It’s not that everyone needs to have cognitive defusion done, but that is a useful tool for the vast majority of people.
As a physiotherapist, how did you come to adopt ACT into your care? When did that begin and what did that look like for you as a professional?
It began years ago when I burned out. I was experiencing a high level of anxiety and intrusive thoughts. I went to see a therapist and I told them the same thing my patients said, “I want to get rid of this. I want you to do something so I can feel better. I can start my life where I left it. I give my pain to you and you sort it out, then you give it back to me fixed.” Poor thing, the therapist was a great one, but it was not a good communicator. It was an ACT therapist, and he said, “We have to work on acceptance.” When he said that, I’m like, “Let me pay you and see you never again.” Instead, I remained there. He didn’t explain well because I said, “I don’t want to accept anything. I want you to fix it.” Session after session, it went better and better, and I remain fascinated by his approach. I said, “There is a lot of that we can use here in our patients.”
The distinction between pains, anxiety, depression, low back pain, neck pain exists only in our head. The processes that lay beneath these labels are similar to person-to-person because we are human beings, and we work the same way. In people experiencing pain, there is anxiety, not even people recovering from replacement. A lot of his processes are present in every person, even if the condition is different. ACT teaches us how to deal with the process. It is more of a process-based therapy rather than having a protocol, but it’s not a protocol that you apply to people. I found it is good that study about it, and since hypnosis is part of my clinical practice.
Davide, I’ve interviewed many psychologists, many pain physical therapists, many pain researchers. You’re the first person who has said the distinction between physical pain, anxiety and depression only exists in our mind. That is unique, and what we need to spread more of that message around. People who study this every day have yet to say that. It tells me that you’ve taken this work. You embody it for yourself and use it with your patients, but if we take that distinction that there is no difference between physical pain, anxiety and depression. How does that change what we do as physiotherapists? How does it change how we look at and how we treat pain?
In a lot of ways, there’s still a distinction between those three. We have ways to measure physical pain. We have the Oswestry to measure different aspects of depression and anxiety, but you’re saying, “This sounds great on paper, it looks great in a research study.” When you’re working with someone, you can’t parse out all these little pieces, like, “Let’s pick up physical pain and let’s put it here. Let’s pick up anxiety and put it here. Let’s pick up depression and put it there.” In essence, you have to treat these three together at once.
When it comes to medical practice, if you are a surgeon, if you are someone prescribing specific heavy drugs, you need to know what the diagnosis is. You give certain drugs for people with no susceptive pain and other types of drugs with people with other types of pain. When it comes to helping people, going back to their normal life, these labels lose their importance. We all speak about bio-psycho-social model of care and we have to move towards a bio-psycho-social model of care, but we are all stuck instead stealing the biomedical model of care because we still have this division between the mind and the body, the body and the psyche, the body and the soul. We still talk about psychosomatic pain, but I still don’t understand what it is.
There are psychological components. We have brain, with a psyche, so there are always psychological components in everything. What we need to do as a physiotherapist and practitioner is to try to diffuse from those false ideas and beliefs we have, and see what we have in front of us and see what they want to go back to. What life they want to live? What is important for those people, and what are the barriers between them and the life they want to achieve? We work on decreasing the barriers and we forget about the rest. If it’s nociplastic pain, fibromyalgia pain, primary chronic pain or secondary chronic pain, if it’s not a susceptive type of pain, we need to work on it. As Steven A. said and he published a couple of interesting paper on process-based therapy, not on a diagnose based therapy.
In your work now, are you still using pain education, or using it less? How do you approach someone when you have a bit of pain education in one back pocket, acceptance and commitment therapy in another back pocket? In your mind, do you have a framework or is it depends on the patient and what occurs in front of you?
It depends on the patient and what’s in front of me. For example, the lady I was mentioning before that came and said, “I cannot stop thinking about pain.” We started immediately with cognitive defusion. When someone who comes and see me and says, “I have this bulge, L5-S1, and that’s why I’ve been in pain for the last year.” I still tend to provide, in a mild and gentle way, some pain neuroscience education. There is room for both. Back in the days, I was lecturing people this is the way it works. The moment I think still providing some explanation of why varying pain is useful, and it works because evidence shows it works and people benefit from it. If I see that don’t bind to it, I don’t insist. I look more on how I can help that person to make sense of their experience and to achieve what they want to achieve in another way. I stopped fighting with them if I see that it’s not their point and it’s not fair as well. We have to convince you at every cost.
You mentioned with pain education, we’re delivering information to people, we’re sharing data with people. It’s more of a didactic approach. It’s a knowledge-based approach. Learning to pain where ACT is more experiential. These two things are different. What was that process for you to go from a more didactic to a more experiential approach to therapy?
I didn’t feel it like a problem. Alongside that, I studied as well in motivational interviewing. Motivational interviewing helps a lot in doing these because it helps deliver and communicate much better. It can be helpful even if you are not practitioner. It can be helpful if you are a pain neuroscience education practitioner to deliver the message across in a much better way. There is an interesting paper published by U&As on mixing pain neuroscience education and motivational interviewing. ACT is a more experiential approach. It involves a lot of feeling, being aware of things, getting in contact with experience, and that sometimes can carry some practitioners, some colleagues, because it feels like something much different from what a physiotherapist traditionally should do, or what we think a physiotherapist should do.
In this case, defusion techniques can help us to look from these things that are popping up in our mind, “We shouldn’t do this, this is not for us. Let’s leave it to the psychologist.” The patient will not understand but we are always concerned that the person comes to us because they want something. They want to be manipulated, massaged, stretched, needled. The person comes to see us because they want to be better, they’re stuck and they don’t know how to get out of the quicksand on their own, otherwise, they wouldn’t see you. They’re open to anything that can help them. It’s down to you, the practitioner, to deliver this message in a good way, skillful way, professional way, and help them understand that maybe other things can be more useful for them.
We’ve been talking about the mind, and how the mind can influence pain negatively, as well as positively. You’re way ahead of many people with regard to using the mind in clinical practice. People still aren’t using the mind. It’s still considered a radical approach for a physiotherapist to use the mind, or for a primary care physician to talk about the mind and talk about mental skills training with regard to pain. Why is this still considered a radical approach with regard to the treatment of pain?
I grew up with my grandparents. When I was a kid, I spent a lot of time with my grandparents and I’ve always been fascinated by my grandmother. She had seven kids, and she had three miscarriages, two of them died when they were young and one of them was a teenager when she was fifteen. She had a lot of horrible things that happen in our life. Despite that, I’ve always seen her cheerful, happy, always with a smile on. That does not reflect what is going on, but she lived and she’s still living her life at the age of 90, and she’s almost blind and deaf in a full way. She did everything she wanted to do.
I saw her thriving and living a full life. I asked myself, “Why is there are people that are so flexible to the circumstances, but are other people in a certain way, appear to be the victim of the circumstances? What if we can teach these flexibility skills to people?” At the end of the day, it’s not about what happens to you, it’s about how you react to it. That is something that is well said in the Buddhist teaching. It’s not about the circumstances, but your relationship to the circumstances. What if we can teach from something to teach our patients in pain to relate in a different way from what is going on? Yes, we may not be able to change pain. Unfortunately, in 2020, there is not a cure for chronic pain.
Chronic pain, in some case, it doesn’t get better. In some case, it lasts, it gets even uglier, but we can help those people to develop these flexibility skills through acceptance commitment therapy, for example, so they can have a better quality of life and they can live the life they want to live, a full, vibrant, meaningful life despite the circumstances. That’s why it is important and relevant to teach psychological framework like acceptance commitment therapy that teaches psychological flexibility to use within your clinical practice with people in pain and not all are the same.
I have been with Davide Lanfranco. He is a physiotherapist in London, originally from Italy. I want to thank him for joining us. Davide, let people know how they can learn more about you and follow your work.
Thank you. They can follow me on social media, on Facebook, Twitter, LinkedIn, Instagram at the platform of FisioScience International, that is a platform that me, together with other colleagues run about delivering and it’s about spreading evidence-based rehabilitation only. You can find us on all our channels.
Thanks, Davide for giving us an excellent talk on pain catastrophizing a cognitive defusion. Make sure you share this with your friends and family on Facebook, Twitter, LinkedIn, or wherever anyone is talking about acceptance in commitment therapy and pain education. We’ll see you next time.
- Chartered Society of Physiotherapy
- FisioScience International
- Radical Relief
- Davide Lanfranco
- Pain Catastrophizing
- European Journal of Pain – Article
- Nature Communications – Article
- Facebook – FisioScience International
- Twitter – FisioScience International
- LinkedIn – FisioScience International
- Instagram – FisioScience International
About Davide Lanfranco PT, MCSP
Davide is an Italian physiotherapist who has been working in London over the past 5 years. he is a member of the Chartered Society of Physiotherapy and of the Physiotherapy Pain Association. He is one of the founder of FisioScience International, an online platform which aim is to spread evidence based rehabilitation.
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Welcome back to the Healing Pain Podcast with Professor Matteo Castaldo, PhD
Our expert guest is Professor Matteo Castaldo. He graduated as a physiotherapist in 2007. After a few years of practice and many courses in Manual Therapy, he decided to pursue a research PhD where they focus on chronic neck pain, chronic headache, its mechanisms and central sensitization. He’s working as a post-Doctoral researcher exploring headaches and other chronic pain syndromes. He works part-time as a treating clinician specializing in headache and neck pain, as well as teaches post-graduate courses to a physical therapist and medical doctors. In this episode, you’ll know all about the role of biomechanics and neck-related structures and headache type pain, how to properly assess headache and neck pain. Why physical therapy is helpful for treating these conditions and the shared mechanisms between neck pain, headache, and central sensitization.
Before we begin it, don’t forget there’s still time to take advantage of our summer 2020 free book giveaway. All you have to do is visit our show on Apple Podcasts and leave us a review and then fill out the form by going to the URL, www.IntegrativePainScienceInstitute.com/giveaway. I’ll send you a free copy of my book, Heal Your Pain Now. Remember, there are only 50 copies available. Take advantage of this limited offer while it lasts. Let’s begin and let’s meet Professor Matteo Castaldo and learn about neck pain and chronic headaches.
Watch the episode here:
Neck Pain, Headache and Manual Therapy: Mechanisms And Efficacy With Professor Matteo Castaldo, PhD
Matteo, welcome to the show. It’s great to have you here.
Thank you, Joe. It’s a big pleasure to be here with you too. I was looking forward to this interview.
You reached out to me and you said, “I completed my PhD work and I have some interesting things to discuss with regards to headache pain, neck pain and central sensitization.” Those are all topics that we’ve covered on the show, but we haven’t gone deep into neck pain and headaches, some of the things you’re going to talk about. Tell us how you got started looking into some of these topics.
I graduated as a physical therapist in 2007 at my hometown, University of Parma in Italy. It took many different clinician works and I move part-time as I’m still a clinician to the research work in 2012. In 2013, I started and developed my PhD project at Aalborg University in Denmark. I have to say that in the last few years, I’ve been a part-time clinician treating mainly musculoskeletal dysfunction, particularly headache and still a researcher. When I completed my PhD and it was 2017, in that period I was moving from neck pain to headache work. I was always studying tension-type headache and in particular migraine and the central sensitization mechanism going on in the brain of those patients.
You’ve mentioned neck pain, central sensitization, headache pain, migraines and tension-type headaches. They were all related, but what did you start with first?
I started with neck pain. My PhD was mainly a comparison between central sensitization that was more prevalent and more predominant in whiplash patients as compared to mechanical neck pain patients. As we knew from the literature that if in whiplash patients, we had clear signs of central sensitization, even in the first stages after the car accident. In mechanical pain, the literature was a bit unclear about that. We wanted to assess for musculoskeletal dysfunction for the health situation of those two different neck pain populations and some sensitization mechanism to assess them, compare them and to see if there were two different populations or if the same mechanism was of the same prevalent between them.
From your research, do we know why, or do we have any idea why central sensitization tends to happen more in whiplash patients than those with mechanical neck pain?
It seems to be much more prevalent as you correctly say it in whiplash patients. Something strange is that in whiplash patients when it develops, it develops quite soon. We have some studies showing that people who still have neck pain or neck complaints from disability after one year, they already had some clear signs of sensitization after the first month from the accident. It is strange because with many other chronic pain and musculoskeletal and not only musculoskeletal conditions, we know that central sensitization is linked to the duration of the pain.
As much as you suffer from a specific condition, the more you become likely to develop sensitization, but in whiplash, it seems that it’s something that is linked to something also genetic. There are a lot of studies about the genetic work as there are some patients that are predisposed to that. It can develop central sensitization and even with as much trauma and fast. We know from some Australian research group that also the stress mechanisms are involved. There are some people that probably are more vulnerable to these mechanisms. Their stress reaction is in some way we can say bad and not as good as other people. Those patients can start developing psychological complaints, catastrophizing more pain, some hyperalgesia, and all this stuff that are linked to central sensitization development.
For clinicians reading, and they’re seeing people with whiplash-type diagnoses and injuries, how would that change their treatment approach when working with someone who has chronic pain?
It’s different because if you are managing some patients with musculoskeletal dysfunction and if they don’t have signs of central sensitization, you can use your biopsychosocial approach, but you can mainly focus on the dysfunction on exercise, education, Manual Therapy, manipulation, or whatever. If you had a patient that you can clearly recognize from your baseline assessment that has strong signs of central sensitization, we have to change the way we approach the patient. As we know that Manual Therapy will not be probably sufficient as we have some literature showing that when the patient is high sensitized, they have a lower response to the Manual Therapy approach and to medication as well.
That’s something that is linked to the patient. For example, about the symptomatic medication like triptans, the patient can take to try to interrupt the headache when it’s starting that if the patient is sensitized, that triptans have less effective. This is something that has come up from two different studies. It’s interesting that when your brain is already too sensitized, even the efficacy and the effect of the symptomatic drugs are not the same as it was before. The same is happening with Manual Therapy and our approach.
Clinicians can start to piece these out into two different boxes almost, and I want to talk about signs of central sensitization. If someone seems like they’re sensitized and they have a whiplash-type injury, then less Manual Therapy and more toward the psychosocial aspects of pain coping for that patient.
That is something that you can decide in the first assessment. As you were saying, you can put the patient into different boxes. The one in which you decided that the patient naturally has no clear signs of sensitization. You work more on Manual Therapy, some exercise and then some education. When you have a patient that has strong signs of sensitization, the management needs to be more multidisciplinary, as you need more often a psychologist. When they are sensitized, quite often they have some catastrophizing coping strategies. They are depressed. They show signs of anxiety. They are not as motivated as the other one who is trying to improve their condition. They are not motivated at all. Sometimes we also think about motivation and finding the right people following the patient 360-degrees, otherwise you will be one in the list of those chronic pain patients. We’ve had a lot of failure with different osteopaths, chiropractors, physical therapies, drugs, and whatever.
When we look at central sensitization in that population of those with whiplash, are the signs and symptoms of central sensitization the same as chronic low back pain, or do they present differently?
Do you mean when the patient shows signs of central sensitization if they got the same features?
They’re mainly the same. In your assessment, you can recognize if you’re a chronic musculoskeletal pain is sensitized or not from the interview. You have a question when you are adjusting, reviewing and talking with a patient. We’ve got some questionnaires. The most important is the CSI, the Central Sensitization Inventory, which is a good instrument. It has a cutoff of 40 points. If your patient is fulfilling more than 40 points, it’s considered highly sensitized. It is a useful item also to show the patient that there is a test saying that they need something more complex. The problem is not localized anymore, but it’s something that is spread more and needs to be treated differently.
We use, but that’s more for the research setting, the QCT, the Quantitative Central Testing. We have many of them to assess allodynia and hyperalgesia as one of the main clinical features, as we were saying in both whiplash and chronic low back pain if they are sensitized. They’ve got a widespread pain even in the healthy body part. Maybe the patient is coming to the clinic complaining of some neck pain or low back pain but if you test and assess other body parts, it should be healthy. They should not have hyperalgesia or allodynia. You will find some of that also in the healthy body parts.
How did you move on from whiplash into different types of headaches, the assessment and the treatment of headaches?
It happened when I was almost in my last year of my PhD. I was a bit confused. I was saying, “I’m almost getting my PhD, but what do I want to do later? Do I want to be a researcher, clinician and teacher? Do I want to do all of them and making my life crazy?” The idea was to keep on going with the research. I am still doing part-time research and part-time as a clinician as I didn’t want to stop with my patient. The most interesting question comes from patients. Everything that I studied in my research activity during the last few years has come from some specific questions that I had when I was treating and assessing my patients.
As I started to work with headache patients and I was mainly treating neck pain patients, whiplash or mechanical neck pain, and many of those complaints are of headache. I started to get interested in headaches and I started to study literature. I was looking at what was still lacking in the literature. I was involved in a big international project in which I was the leader of the responsible for the Italian part. We had also Denmark and Spain involved. It was a long longitudinal project that has lasted for two years. It was mainly on tension-type headache patients. After that, I moved into a migraine as it is much more interesting. Even if at that time I told that “As physical therapists, we will not be successful with migraine patients.” After a few years, I have to say that I was completely wrong because if you study the literature in the clinic if you treat a migraine patient, you will have huge and impressive results as well.
I’m glad you brought that up because I have read that myself that physical therapy works poorly for migraine-type headaches. A good place to start is, can you explain to us and articulate the difference between a tension-type headache and a migraine-type headache as far as a clinical presentation?
The clinical presentation is different. Usually, even if the patient hasn’t got a medical diagnosis, you can strongly divide into two big categories your headache patients. Mainly the two most important characteristics as migraine patients are that the pain is located unilaterally, on one side of the face. Sometimes it could shift, but not together at the same time. The pain is usually around the eye and is a pulsating pain. When we moved to tension-type headache, the pain is bilateral and the pain is dull. The patient feels like they have pressure around their head.
Some other characteristics are that usually, migraine led to much more disability. That’s something that makes a bit of unclear in the classification. If you see the epidemiology, we know from the literature that there are many more patients suffering from tension-type headaches. Those suffering from migraine, they have a stronger disability as migraine for the Global Burden of Disease Study as the term the most disabling medical condition worldwide. It’s ranking number three. It’s quite high and that’s not happening the same for tension-type headache.
What’s happening is that the patient with a diagnosis of tension-type headaches, mostly they are not searching for medical diagnosis, but they will try to manage themselves with some basic medication, lifestyle, or sometimes some exercise. The migraine patient has a strong and disabling pain, which could last also for three consecutive days as the international criteria say that a migraine attack will be up to 72 hours without rest and any second without pain. To complete another big difference is that during the migraine attack, the patient has some nausea and sometimes photophobia.
Phonophobia is a generalized hypersensitivity that makes you understand and that’s when we move about the pathogenesis. There is something in the brain that is hyperactive, hyper-sensitive and makes these patients too sensitive both to every different stimulation from outside and even from inside. We can say that migraine is much more complex than a tension-type headache, even if the tension-type headache is much more diffused around the world. The prevalence is for sure, much higher in tension-type headache, but the disability is much higher in migraines.
I want to talk about the causes of each of those, but weaving this into what you mentioned with regard to central sensitization. Does central sensitization occur both in migraine as well as tension-type or was it more primarily in the migraine type-headache?
It could be present in both as there are many studies showing that central sensitization is the main feature of primary headache and both the headache form that we are talking about are primary headaches. We have good studies since the early 2000 years. We got good scientific evidence explaining and reporting that in both tension-type headache and migraine, central sensitization could be present and sometimes could be the predominant part of the problem. Even if we know that the migraine brain has much more studies on that. It has been studied much more as it’s more interesting because who pays for scientific research? Companies and they are much more interested in finding specific drugs, which is going to target the migraine brain as compared to the tension-type headache which they take a painkiller to manage it from themselves. If we talk from the literature, we got good evidence that central sensitization could be present in both forms of both migraine and tension-type headache as well.
I’ve seen some of the functional MRI studies on migraine. They’re interesting from a clinical perspective that the wave of depolarization that happens over the entire cortex is interesting to clinicians but both of them can be disabling conditions for patients. Can you talk about the causes of each, if they’re distinct tension-type and migraine type headache with regards biomechanical, psychosocial and then some of the lifestyle factors?
As we were saying, there are more studies on migraine but we have good evidence also for tension-type headache. Something that is interesting and often we are forgetting is that there are good evidence studies since the ’80s trying to link them together and seeing that probably they are two parts of the same trouble. It’s a model that is called the Continuum Model in which their idea of these different outlets, but many different outlets have the same idea and believing that they are a continuum in which the tension-type headache is the one with less disability. In some specific population with a genetic predisposition, they can evolve towards the most disabling forms of migraine.
From our viewpoint and that’s the magic that physical therapists are important to know. When we have a patient and we don’t know which kind of headache they have, we could even say that we are not interested in the fact that it’s a migraine or tension-type. For sure in the interview, we will have some information that we will have our idea of what’s the type of headache that the patient is presenting with. The most important for us is finding some kind of musculoskeletal dysfunction, which is related and linked to the headache of the patients.
This is regardless of the medical diagnosis. The medical diagnosis for sure is much important about the medication, exclusion criteria, and some red flags, which need to be investigated when we deal with headache pain. Especially if you’ve got a headache that is changing in characteristic in a person, which is not that young as when the headache started, as headaches start at a young age. Otherwise, when we have our patients, we have to assess the musculoskeletal dysfunction, which is relevant for those patients.
We have good studies saying that those dysfunctions are prevalent in both tension-type headache and migraine. Whatever is the diagnosis, when we are the patient, the most important thing to do as physical therapists in order to be able to say, “I can take you as my patient that I’m going to try to help you with your disability, frequency and headache intensity, and with your symptoms. I need to find the link between your neck or temporomandibular joint and your headache. Otherwise, I will not be a professional who can help you.”
There’s a connection you’re saying between the structure and function of the cervical spine and someone’s headache pain, whether it’s tension-type or migraine?
Yes. The idea is it comes from neurophysiology as we have in MRI which is called the trigeminocervical nucleus, which is receiving afferent information from both the trigeminal nerve, especially from the ophthalmic branch and the first three cervical spine nerves. This creates an effect, which is called a convergence effect in which all the afferent information goes on the same station. They are projected upwards towards cortex, thalamus, hypothalamus, and many different areas that are involved in pain modulation and pain processing.
Because of that, it’s common that regardless of the medical diagnosis you can find in headache patients when you go to stimulate some specific neck area, it could be joint muscle or with some specific test and movement, you can reproduce the head pain that is felt in the patient during the attack. That’s strong because if you think how does it work with a neurologist interview with an assessment with a patient. They’re asking stuff. they’re having a neurological assessment. For sure that is highly important, but they’re not trying to reproduce the head pain that the patient is experiencing. We could be the only professional that can directly show to the patient that we can interact with their head pain.
As we can move something in the neck that they don’t know what’s going on, that can reproduce their head it’s strong for the patient as the patient say, “He understood something about my headache as he’s able by pushing or moving something to reproduce my head pain.” This is effective especially when we have a patient that has a lot of failure in his history for his headache. He has tried many different medications and healthcare professionals. Maybe it’s coming to us because we were treating the sister, colleague, or parent and he’s not motivated. After that, if you can show that you can have a dialogue with their head pain, that’s strong for the patient. It’s impressive for them.
As professionals, sometimes we forget that a thorough physical evaluation because we do it every day over and over again, but it can be validating for a patient when you’re doing something that reproduces their symptoms, that no one’s been able to see anything on an X-ray or an MRI. As you mentioned before, a basic evaluation may have missed that, but they come to your office and you place your hands on them and their pain is reproduced. If you could, you know alleviate the pain somewhat, then that’s the best-case scenario. Talking about Manual Therapy, specifically, Manual Therapy is a big term. There are lots of different techniques and approaches. What does the evidence say with regard to Manual Therapy for the treatment of headaches?
Regarding Manual Therapy, we have different important information. First of all, we know that neck pain is highly prevalent in all headache pain. It’s ranging between 75% and 90%, depending on the diagnosis. We have a comorbidity of neck pain as well, not just headaches. Most important is that quite often neck pain is considered something that could start even earlier before the head pain attack and could last until the end and even for 1 or 2 days after the attack. It’s not considering in the diagnostic criteria, even if nausea, which is less predominant is considered as part of the diagnostic criteria. It sounds quite strange that the neck pain is not considered, even if it’s prevalent. It’s important in headache patients.
Second, what is important and allow us to treat with Manual Therapy those patients is that there is a battery of tests that have been studied a lot in both migraine and tension-type headache. From my colleague, a German physical therapist, she studied all the different Manual Therapy tests that we can use for our patients from the Manual Therapy approach. She found that there are six different tests, which you can assess the patient in 25, 30 minutes and finding positive tests you can say that you can treat the patient.
When you move to the literature, we have some systematic review and meta-analysis saying that Manual Therapy could be affected as much as the drugs, especially in the short-term. Even in the long-term, after six months that you stopped with a Manual Therapy approach. You don’t have any negative effects on Manual Therapy as compared with drugs for sure. It’s something that is not considered as we have some specific American guidelines, neurologist guidelines saying that physical therapy and Manual Therapy should be used as a treatment for tension-type headaches. How often does it truly happen that the neurologist is sending to a specialized musculoskeletal physical therapist and headache patients? I don’t know the situation in your country, but at least in Italy, it is naturally happening often. Even if in the guidelines, even the European guidelines have seen the same that we should treat muscle and joints of our patients, headache patients as this could lead to an improvement of symptoms, but this is usually not considered.
Considering how many people struggle with headaches, it’s almost like chronic low back pain. Almost everyone has a headache, migraine, or a tension-type headache when you start asking them at one point in their life. The referrals to practitioners like you and I are as physical therapists are probably quite low. As you mentioned, people will go and pick up Tylenol, Advil and Aleve and potentially things that are either strong. I’ve even had people on Neurontin for migraine pain that had little effect on an outcome at all. Getting back to that Manual Therapy, if we look at let’s say massage therapy, joint mobilization and joint manipulation, like a high thrust grade five manipulation, are any of those more effective, or are they all treating a similar mechanism?
When we speak about Manual Therapy, there is always this debate going on between, “Is it better to mobilize the spine of the patient, or we need this specific spinal manipulation in order to achieve a better improvement?” There are good papers showing this matter manipulation and other ones showing that it’s better mobilization. Some others saying that the results are almost the same. If you figure out how many different Manual Therapy approach do we have worldwide that has developed in the last years between the USA, Europe and Australia. To me, that means that there is nothing better than the other one. Otherwise, we will all study the same Manual Therapy techniques. If there are many teachers, many courses, it doesn’t matter what you do.
You need to find a specific and the right approach for that specific patient, which is not always the same as we know that. For example, also what the patients want to have as a therapy. If they want to be manipulated, they will be better responders if you manipulate them. If they want to have a massage and you’re going to say no, you have to do a specific therapeutic exercise. Even if we know that probably the literature that saved that for low back pain is better to exercise instead of massage or manipulation. You will have less improvement as the patients were expecting something else. The expectation also needs to be matched.
We don’t have any technique, any approach that is correct worldwide and is the one that is the right one for every single headache patient. The most important is to rely on our musculoskeletal assessment. If you find that there are some joints, muscles, or movements that are painful or producing and alleviating the symptom, you need to work on that. That is naturally important with specific techniques you use, but coming back to manipulation and mobilization are two different ways of reaching the same goal. Sometimes it’s working better on one of the two. Sometimes it’s working better than the other one, but it’s something that you can decide pre or to assess your patient, dialogue and speak with him and assess what they want to have and what you think that is going to be better for them.
Along that same theme with regard to exercise, there are exercises that we can get people that are specific for their neck and head or there’s a more general exercise like aerobic conditioning or strengthening. Is there a certain approach with therapeutic exercise that has proven to be more effective for these types of patients?
Yes, especially migraine patients can have a good improvement. With aerobic exercise, it’s still a bit unclear how often and what is the optimal dosage for those patients of aerobic exercise, but it’s important. Something that we didn’t say before about this that is prevalent in our migraine tension-type headache is that they are quite lazy. They’re not moving at all. They experienced and the pain was going worse with some running or biking so they stopped. The neurologist said that you don’t have to train otherwise you will have some strong symptoms, but that’s true during the attack. If we think about prophylaxis made by aerobic exercise, we have some papers showing that those patients can have a good improvement at the same with therapeutic exercise.
With therapeutic exercise targeting the neck flexor or some mobility exercise. Everything could be useful for those patients. For Manual Therapy, even here, we don’t have something better than the other, but most often this patient needs to have some Manual Therapy approach, especially in the first stage of our treatment. Some therapeutic exercises, some changing the lifestyle to be more active, to eat well, and all the things that could help to improve their symptoms. There are many studies going on right now and we know that it’s important to take into account all these different aspects. From the therapeutic exercise to aerobic exercise, there is no one approach that is better than the other.
We talk about food and nutrition a lot on this show. In your research, I know there’s some information with regard to certain foods being triggers for people with migraines and other types of headaches. Has that come up in the PT literature much or is that still tucked away a little bit more in the nutrition dietetic and world?
It’s something that has been studied with some diet and eliminating some elements that we know that can exacerbate the head pain of the patients. It’s not linked to our world. As a physical therapist, what I do with my patient, when I am assessing them, I investigate with some questions. If they have identified some food and elements that when they eat them, they get worse with our headache the day after. I have some suggestions for them trying to make some small changes in their diet to see if something changes. To assess if there is a change, you need to assess the patient for at least one month. Something that is important is the diary in which you can see and the patient can write every single triggering factor like, “I ate some chocolate or white wine.” If I understood that it needs to be approached in a different and more complex way, I send them to a professional, which is specialized in nutrition.
As you and I are talking, you’re a wealth of information on headache, which is great. As I think back to when I used to train more entry-level physical therapists, a lot of new physical therapists are a little fearful to treat headache patients. They’re scared to put their hands on them. Those types of patients can be very sensitized, which means they can be reactive to any type of treatment. Are we going deep enough in entry-level training with regard to migraine and tension-type headache for the newer practitioners?
Mostly they are afraid as we are not used to treating headache patients. What I usually say in my course is, “If you are here is because you never had some specific training into a headache.” When you go, for example, and you want to update yourself with a two-day course on low back pain or neck pain, probably you are used to treating these patients. You had already many courses on the management of neck pain, low back pain, or rehabilitation of a hip or knee. When you approach as a clinician, the headache field, it’s probably something completely new. You’re scared and afraid because you’re touching something that is sensitive because you’re not used to treating the head pain as compared to low-back pain in which you trust yourself, you trust all the patients that you treated with success.”
I have to say that also in my courses, I see that even the experienced Manual Therapists are afraid when they have to explore the upper cervical spine or some tissues in the frontal part of their neck. It’s important to find some specific areas in which can reproduce head pain as we are not trained in our basic background to manage the patients. It’s something that when you decide that you want to approach this patient, it’s something that is mainly new for our colleagues.
If there’s a newer practitioner, a newer physical therapist reading this, what would be a good first step for them? Maybe they didn’t learn a whole bunch about neck pain or migraine pain in school and they’re looking either for other than this show, reading to your resource, what’s a good place for them to start?
Sometimes I have some email in which there are students and the last year of university, writing to me and asking for information about courses on migraines and the management of headaches. They say, “Will I be able to follow the course immediately after that I graduate from university?” For sure they can, but I always suggest them to take some other, I would say easier, but it’s not the right word. Some other courses have something that they will treat more often in the clinic as they are not experienced.
My suggestion is always to start working in a clinic. See the patient that you are more interested in the pathology that you see more often in the clinic, and then take some specific courses about that. After a while, as you said, if you have some Manual Therapy background or some specific neck background, it’s going to be easier to approach the headache world. Otherwise, you can do that, but it’s going to be something that you lose the cost of 20%, 30% of something that is going to be explained as you need to go back at home and search for a lot of stuff. Maybe you never heard of the technique. You never heard this theory about the pathology and whatever. A general course of Manual Therapy and something specific about the management of neck pain or neck dysfunction is something that is going to be helpful before approaching the headache world.
What’s missing from our research and what new direction would you like to see the research go with headache and the physical therapy field?
Something huge is missing for that reason that medical doctors and neurologists, we’re not dialoguing with them a lot in having patients, receiving patients from them. They say, “I have some good evidence, scientific evidence and clinical improvement, as well as showing that you can be helpful for those patients, but you need to be able to prove why. What’s happening when you treat your patients? Why are they improving?” When you target a drug, you are targeting a receptor and it’s the molecular binding. You know exactly what’s going on when you give one pill, one drug for the patient, but we are not aware of what’s going on in the brain of our patient when you are applying a Manual Therapy technique. If it’s painful, not painful or an exercise, which mechanism we are modulating and activating.
For that, the next big project that we are writing I have to say that in the period of the quarantine which had to stop with the clinic and with patients, I had time to write and I’m completing the third one. It’s a big research project and one of that is about that. We want to show with a functional MRI study what’s going on in the migraine brain before and after our Manual Therapy techniques. If we are able to modulate, especially the periaqueductal gray and nucleus lentiform are and other brain areas that we know are involved in pain modulation to be able to show to the scientific world what’s going on with our techniques. Why we should be healthcare professionals that should assess and address those patients?
We need to be able to show what’s going on and why it can be helpful. That is the big missing link. Otherwise, you can have your clinical improvement and if you are good, you will always have a lot of patients, but if you want to have something good in general for the physical therapy world that we are must be able to prove what’s going on. We are designing this study, which should start in 2021, which is going to be interesting as it has never been done before. We have the idea of what’s going on. As we know, from other studies what’s going on with Manual Therapy techniques, that we are inhibitory effect and modulating of the pain system, but nothing specific about the migraine, which we know that these are more complex brain.
That’s useful for the profession because it takes it beyond, “This person lacks some range of motion, flexibility or strength from the biomechanical,” and it places it more in the neurophysiological level. We may be helping some with strength and range of motion, but there’s also more happening with regard to neurobiology.
The most important is we need to speak the same language as a medical doctor and neurologist. We can speak from the biomechanical model, as they are not aware of that. The neurologist doesn’t know anything about the rotation of C1 of C2 and of the access of C1 or whatever trigger point it is or not. As headache is their world, we need to be able to communicate with them to speak the same language at a good strategic level and to explain what we are doing, but not from a biomechanical viewpoint, as they are not interested.
I try to have many conversations with a good neurologist that was open to physical therapy, but all the time, there was the same question. They were interested that we were having an interesting conversation, but there was a point in which they said, “Can you prove what you’re saying? I know that if I send the patient to you, the patient will improve, but I need to know what’s going on before it becomes something that is the routine.” Before, it’s normal that every single headache patient is screened by a specialized physical therapist.
Keep us up-to-date on that study. I’d love to hear about it when it comes out and you’re welcome to come back. In the meantime, how can people follow you and continue to follow your work?
As a researcher, they can find information on a big network that they know that is ResearchGate, in which you can find all the information about the researcher and also all the published paper. If they’re interested in driving some courses into the headache field, I’m teaching to a medical doctor and physical therapist in many different courses. As I said before, the idea is that if they are already an experienced physical therapist that has some Manual Therapy background, it’s something that could be interesting and something that could give a lot of new possibilities. Headache is predominant worldwide. They are waiting for us. As something that we didn’t mention before that is highly important is that even if in the last twenty years, there have been a lot of studies on drugs and medications specific for migraine, we are far away from getting 100% of patients responding to medication.
They are still searching for something else, those patients, and they need to meet us. I’m not saying that we will resolve 100% of the problem as, to be honest, we have to explain to our patients that we can help them. We can improve some of the symptoms. We can decrease the use of medication, decrease disability, which is associated with headaches. To be honest, we have to say that they will still be headache patients, but this is the same that also in an honest neurologist will explain to the patient as we can try to manage the symptoms, but they will never fix it all a headache patient. That is something that we can be helpful to those patients. If they are interested, they can write also via email and I can give some good suggestions about what to read, where to start from or good colleagues that also work in that field. They can contact me and I can give you all the useful information that I had.
You also have a website too they can find you on. Is that right?
I have a website that is one of my clinics. I’m the owner of that clinic and they can take a look at it. I’m sorry that it’s Italian, unfortunately. The information is better on ResearchGate, as ResearchGate is in English. They will find out everything about me and also the email for contacting me otherwise, they could look at PoliambulatorioFisioCenter.com, which is the website of the clinic. They can find also there is some useful information.
I want to thank Matteo for joining us on the show. Make sure to share this episode out with your friends and colleagues on Facebook, Twitter, LinkedIn, or wherever people are hanging out, talking about headache, pain, persistent or chronic pain. We’ll see you. Be well.
Joe, thank you very much.
- Matteo Castaldo
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- Matteo Castaldo Fisioterapista – Facebook
About Professor Matteo Castaldo, PhD
I graduated in physiotherapy at the University of Parma in 2007, then after many courses in manual therapy, i approached the research field. In 2017 i completed my PhD degree in Biomedical Sciences at the Aalborg University in Denmark, with a thesis on neck pain and central sensitization. To nowdays i work part-time as a postdoctoral researcher at Aalborg University (being involved in different headache projects, and part-time as a clinician, treating in my private clinic headache and neck pain patients. I also teach many postgraduate courses for PTs and MDs on the management of headache disorders.
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Welcome back to the Healing Pain Podcast with Karlyn Edwards, MS
On this episode, we’re talking about the relation of self-compassion to functioning among adults with chronic pain. Our expert guest is Karlyn Edwards. She is a clinical psychology graduate student at the University of New Mexico working with Dr. Kevin Vowles and Katie Witkiewitz. She studies important psychological factors that impact chronic pain as well as psychological interventions that can improve the lives of those living with chronic pain. She also studies how opioid and other substance misuse issues affect chronic pain, specifically how pain impacts medication treatment for those living with co-occurring opioid use and chronic pain. She also just completed one of the few studies that exist out there on how self-compassion can help people with chronic pain as far as a treatment intervention. Karlyn has also provided you with her free gift to accompany this episode. What she did was she summarizes all of the research as well as how self-compassion helps people with chronic pain into one nice concise document. To access that, all you have to do is text the word, 146DOWNLOAD, to the number 44222, or you can open up a browser on your computer and type in the URL, www.IntegrativePainScienceInstitute.com/146Download and you’ll receive that right to your inbox absolutely free. I’m excited to introduce Karlyn to all of you, as well as share her work and her research. I know you’re going to find it valuable.
Watch the episode here:
The Role Of Self-Compassion In The Treatment Of Chronic Pain with Karlyn Edwards, MS
Karly, welcome to the show. It’s great to have you here.
Thanks for having me, Joe.
You published a great study in the May 2019 European Journal of Pain. The title of that study is The Relation of Self-Compassion to Functioning Among Adults with Chronic Pain. The reason why I reach out to you is because I read a lot of research on chronic pain. There’s not a whole bunch out there on self-compassion. I think before we delve into this compassion is a word that people thrown around a lot. Self-compassion is even another layer deeper into that. Can you start us out by explaining what self-compassion is?
Self-compassion is made up of three different facets. It’s self-kindness, common humanity and mindfulness are the three facets that we look at when we’re looking at self-compassion. Self-kindness specifically is essentially what it says, being kind to yourself during instances of difficult experiences when you’re experiencing setbacks. When you’re experiencing any failure or there’s any setback. What we look at is that it’s different than self-criticizing, so it’s the opposite. They’re self-criticizing and self-kindness. There’s common humanity which is understanding one’s own experience as connected to the larger human experience.
Seeing yourself as part of the larger human body that I’m experiencing something that a lot of other people experienced too, that I’m not alone in what I’m feeling. Mindfulness is also one of those words that’s thrown around a lot that we use often. In the context of self-compassion, mindfulness is thought of as holding and staying in contact with painful experiences, not avoiding them, not pushing them away and also not over-identifying with them. Over-identifying with them can be looking at them as part of your identity or saying “This is going to be around forever. I’m not going to be able to get out of this.” It’s those three facets that make up self-compassion.
A lot of that was started by Kristin Neff?
Yes, she was the first one to move it into more of a psychological construct that could be studied.
As well as from probably centuries of contemplative work and lots of different areas. I guess that influenced your work. Did you study mindfulness and contemplative approaches at all?Self-compassion is associated with better functioning across multiple pain-specific outcomes, with the strongest associations among measures related to psychological functioning and valued living. Click To Tweet
I do actually. I study mindfulness-based relapse prevention, so that’s in the context of substance use, but certainly we use mindfulness a lot in acceptance and commitment therapy, in acting what I practice a lot also in chronic pain.
How and why is self-compassion related to chronic pain?
That gets at the heart of that study that you were talking about that I published. What we wanted to look at is that there’s a lot of work in self-compassion in a lot of different chronic health conditions, but we don’t see a lot of that in chronic pain specifically. That’s where this paper came in. I wanted to look at the role of self-compassion in these important markers of treatment outcomes for people with chronic pain. What we looked at in this paper is we took self-compassion scores and saw are they associated with better treatment outcomes? Things like depression, pain anxiety or how afraid you are of your pain, pain acceptance if you’re accepting of your pain.
Even as far as engagement in meaningful activities, things that are valuable to you and pain coping strategies. Based on both pain control and relaxation. Also, on acceptance-based approaches, allowing and noticing your pain for what it is. What we did is even controlling for pain intensity. What people were feeling in the moment as they were filling out these assessments and also controlling for pain duration. How long was pain sticking around for this person? We saw that higher levels of self-compassion were associated with lower levels of depression, pain anxiety, physical and psychological disability, higher levels of pain acceptance and engagement and meaningful activities and use of pain coping strategies.
What this study was looking at is laying the groundwork, “Is self-compassionate associated with better outcomes?” What we found is it is associated with better outcomes. The interesting part of the findings was that we saw that self-compassion was related more to psychological distress. Those are depression, pain anxiety, psychological disability and engagement in meaningful activities. Where it was less related to things like physical disability and strategies you use for pain control, reducing pain intensity. That was the interesting part that came out of all of this.
I found that interesting too. I was reading through your research. I was probably a little disappointed on some level. I was hoping that there was a little bit of positive shift toward some of the physical disability and that there may be if we measure in a different way and population might see more of that. The coping part, I also found interesting in the study. It can be a little challenging to work with patients with regard to pain coping skills from the lens of an acceptance-based approach because they may and especially depending on how a practitioner also utilizes the intervention. They may look at it as a way to control or eliminate pain versus cope with pain. Can you talk about that a little bit and how that added a different layer to the study? I don’t usually see in most of them.
We did see a little bit of bump in physical disability or these pain control. It’s not to say that it’s not adding nothing. There’s some additive effect there, but certainly not as big as we see in the other areas. You’re exactly right that it’s hard when people are in the room with you to say, “We’re going to focus on acceptance-based things,” and they’re like, “How can you make my pain go down?” I think when we’re looking at self-compassion specifically. I like to think of it as two different categories. One is focusing on primary suffering and secondary suffering.
Primary suffering is what we think of as those difficult times in life that we can get rid of, grief, loss, pain is certainly in that category for people with chronic pain. There’s more secondary suffering looking at ways in which we respond to those things. How we talk to ourselves, the behaviors we engage in on a day-to-day basis. Self-compassion is helpful in aspects of secondary suffering. How can I even with all of this stuff going on still continue in a way that I’m living my best life even with all this other stuff going on? In the aspect of a physical disability that physical disability is hard no matter what intervention you’re using to eliminate and pain I would say falls in that category for chronic pain folks.
That primary and secondary, if you follow contemplative approaches, they would call out the second-hour effect. The ACT looks at things like clean and dirty pain. I was never crazy about the word dirty pain, but it’s an interesting way to look at it. Self-compassion is helping with the second-hour if you’re following contemplative approaches or the dirty pain if you’re following the ACT. We look at it as the psychosocial aspects of it. With regard to the secondary aspect of the suffering, one of the things that I’m curious about is how does its practitioner start to apply that. Mental health professionals probably will pick up on this faster, maybe it’s a nurse, a physician, a physical therapist or an occupational therapist. How did they start to look at that?
Sometimes the farthest is modeling. For people to in the room with physicians, nurses, psychologists or whoever’s in the room taking care of the patient, modeling, self-compassion for them. Both from your own experience saying like, “I’ve had a tough day and I’m a little bit exhausted but I’m doing okay.” Also, on the flip side of that, catching patient language. When they’re beating up on themselves and they’re saying, “I had a rough day. Everything sucks. Pain is the worst.” Using that as an opportunity to reframe their language can be helpful for patients to see, “Someone else is being caring and compassionate towards me that might be a better response than maybe beating myself up.” That continual shaping of language and modeling can be helpful for patients to hold up a little bit of a mirror to themselves and say, “I’m beating myself up a lot. Maybe there’s a more compassionate view I can take.” That’s definitely stepping one and it’s easy for lots of people to implement no matter what profession you’re in.
I want to come back to that because language is so important, especially when you work with people with chronic pain, but not just pain. Any type of chronic elements, whether it’s physical or mental. Does someone need to have a seated meditation practice? I’ve had some people say ten minutes is fine, some people say no, you need 40 minutes. Do we have to develop a seated meditation practice to either cultivate compassion in ourselves or to help our patients and clients cultivate self-compassion?
It’s a tough line to walk. Sitting down to meditate is not going to hurt anyone, so I definitely recommend it to clients if they’re able to sit down. Even if they can just get one minute down, that is so much better than zero and two is better than one and etc. I don’t think there’s any magic number. I don’t think it’s 10 minutes or 40 minutes. I think any sitting formal meditation practice is going to be helpful. That said, at least in the realm of self-compassion, even quick on the go mindfulness practices can be helpful too that don’t necessarily require you to sit down. Take five minutes out of your day. I know for some people they don’t have five minutes. These quick informal practices are helpful when you don’t have a lot of time to sit down. What that looks like is just checking in with yourself. Taking a quick moment to say, checking in with maybe body sensations, “Why my heart’s racing. I’m feeling a little sweaty.” Checking in with emotions, “I’m feeling a little anxious and tightness in my chest.” Checking in with thoughts, “My thoughts are racing,” and moving forward with the rest of your day. Just allow you to regroup and it only takes a couple of seconds. That’s usually where I start with clients is, can we work in just a little bit of informal practice throughout your day and then maybe work our way up to sit for five minutes or ten minutes?
Just taking a moment to notice what’s happening in your mind and in your body. Obviously, those two things are intimately connected. When I reflect back on some clients I’ve had, at times there’s a lot of behavior change that has to happen with someone who has chronic pain. We have all the tools to help people, but the behavior can be tough. With that, people can be tough on themselves sometimes. How do they start to cultivate self-compassion themselves?
One aspect of that is meditation. Even though it’s quick informal practices and checking in with yourself, can give you a picture of where am I at? There are other little things that you can maybe cue yourself and ask yourself after you’ve done that small little check-in. Something along the lines of the common humanity piece wholeheartedly believes that I’m not alone in what I’m feeling. I think what that does is breaks down that isolation, especially people with chronic pain feel a lot. They often find themselves socially isolated, not feeling they’re connected to a community. Even if a lot of people experienced chronic pain, I’m not alone in this, but I think that goes a long way to feel like, “I’m not the only one in the entire world that’s feeling this.”
Along the lines of thinking about how can I cultivate self-compassion is asking yourself, “How would I treat a friend in this situation? If someone came to me and said, I’m a lot of pain. I wasn’t able to get out of the house. What would I tell my friend?” I’d probably tell my friend, “It’s okay. It was a tough day, maybe try again tomorrow,” rather than, “I have the worst and pain dictates my whole life.” That’s an easy question to ask yourself. At the heart of it too is noticing in our language coming back to that those shoulds and have tos. Whenever you find yourself talking to yourself in the sense of, “I have to do this or I should do this.” Those are always little cues for me, especially as a clinician when I’m in the room with patients to say, “Is that true? Do you have to?” Take a moment and assess that because usually it’s not true. Usually, there’s not a have to or should.
Breaking down and catching those little nuances in languages is helpful. Lastly, I think something that Kristin Neff who talked about creating self-compassion as we know it in the more Western world talks about that love is more powerful than fear. I think what she’s getting at there is that when we are motivated by love, that is so much more sustainable than when we are motivated by fear. Fear can be, “I’m scared of what pain’s going to do and I’m scared of putting myself out there in a new situation versus, I’m ready to connect. I’m interested in getting my health a little bit better, whatever the decision is that we as humans are much able to sustain important activities when it’s fueled by love, whether it be for ourselves or for others, rather than this more fear-based decision making.
Not a lot of people talk about love on my podcast, which surprises me. I probably need to focus on it a little bit more. The field of psychology is so huge, but when you have someone break it down into those two things, love and fear and someone can look at it and say, “I have two things that I can look at or focus on or relate to.” It is important within the worlds of chronic pain that I think that word should be used more and more, so I thank you for using it. Do values work tie into that over theme?
I think values definitely fall into the love piece. It falls in there in the sense that values are usually things that are important and meaningful to us that when we engage in those activities that they fuel us. They get us going and lightness up and bring meaning to our lives. Whatever word you choose to use, love, values, positive reinforcement if you’re more behavioral analytics. Those are what is sustainable and that more fear-based decisions or things that all into, I have to or I should, usually fall in there too. Usually, it motivates us, but they’re not self-sustainable. They’re more negative reinforcement. The research tells us that that is much less sustainable and keeping up behaviors, but certainly values are more driven in that love field for sure.
Are we at a place yet where we can pre and post-tests measure compassion in clinical practice where let’s say something we want to measure, whether we know if our intervention is working and targeting self-compassionate?
There have been a few studies, specifically one I’m thinking of in ACT where they looked at the mediating mechanism of self-compassion. Meaning changes in self-compassion during treatment are those related to good treatment outcomes. An ACT specifically, we’ve seen that changes in self-compassion lends itself to better treatment outcomes in chronic pain and that ACT a specific intervention can target self-compassion quite well. There’s only been one study to my knowledge that’s looked at that. We certainly need more and I’d be interested in looking at other mindfulness-based interventions to see if that pre, post self-compassion and changes and self-compassion lends itself to better treatment outcomes. That is the direction that we’d like to start moving for sure.
Is there research that traditional forms of CBT may have that in there somewhere that we maybe haven’t measured or looked at specifically?
Not to my knowledge. I’m sure your audience is familiar with CBT relatively, but that’s what we aimed at is going afterthoughts. Changing thoughts and behaviors to line up and it is very effective for lots of people. Also, it’s different than ACT though where we’re aimed at more acceptance-based approaches and persisting in behavior even when the stuff is tough, even when thoughts are all over the place. I don’t think we have a good sense yet if CBT builds up self-compassion in the same way that ACT is, but that would be a great study to carry out because I don’t think there’s been a lot of work in that.
I hear a little voice in my mind wanting to ask. You’ve mentioned CBT doesn’t have it in there necessarily, but ACT does. There are some flavorings of that in ACT, probably in all the processes and psychological flexibility. Does someone then need to study compassion-focused therapy or empathy-focused therapy? There are lots of different types of therapies out there. Is ACT enough or is mindfulness enough if I can phrase it in that way?
I don’t think we have an answer to that yet. Research is just starting to get going in compassion-focused therapies. Even looking at things as small as a brief intervention. Can we have someone have one or two sessions of self-compassion focus and it’s not enough to get some people up and moving and in a better place? I think that’s definitely a direction that the research is going. There’s not a lot of work yet in chronic pain in that area. I’d like to see more and hopefully I might carry out more of that. Definitely, there’s room to grow there and coming back to the CBT piece. The intervention might not specifically have empathy or compassion written in the manual, but I think that’s where the provider can model self-compassion. It’s not to say that because the intervention doesn’t have self-compassion written in that that’s not getting translated to the patient. That potentially by the provider being empathic, listening, and correcting patient language that that’s still coming across. I don’t think it’s written as clearly in CBT as it may be as an ACT or mindfulness. There’s still room to understand self-compassion more in a CBT framework and to look at that, is it more provider-based or is it more treatment-based? I don’t think we know yet.
Interesting thoughts because if it is provider-based, then how do we cultivate that in providers so that they can leverage that more and more in treatment? You mentioned brief interventions. Maybe if you look in the research, the average cognitive intervention, no matter what type of therapy looking at is maybe between seven and fourteen sessions. The brief would be as far as a number of weeks, as far as the time. It could it be brief as far as the first ten minutes of your intervention might be compassionate? What does all that look like?
What’s being looked at is a few different brief interventions. There’s one that’s like a web-based that’s not delivered by a provider. That’s even interesting to think about as we were talking about this might be translated by the provider or maybe we don’t even need the provider and a web-based intervention can do it. Looking at web-based, there are a few modules a person who can complete. Maybe three to four hours over the web. There have also been brief interventions to look at maybe like an hour for two weeks is the other one. Two hours of your time once per week that would come in with a provider. Something that would be interesting that I would like to move the field in is looking in to see if we can train providers to do what you’re saying a brief ten minute intervention with someone before they jumped into maybe their medical appointment or before they jumped into their PT appointment or to see if that also might get us some outcomes or movement in these important outcomes too.
I’d be curious to see that because I think we know from contemplative approaches that it’s wrapped up in there. I’d love to see someone like, “What’s going on in that closed eye practice and take that and figure it out?” “Here’s between a 10-minute and 30-minute intervention that you can work into practice.” We’ve talked a lot about self-compassionate and its importance for people with chronic pain. How important is it for the providers that treat them?
I would say it’s important in burnout. That is something that we talk a lot about in these more helping professions, whether it’s PT, psychology, nurses or doctors. Self-compassion is starting to grow a lot specifically when we’re looking at burnout in those careers. I think for caregivers it’s sometimes almost important, but it’s certainly as important as it is in the patients. What we know is that when we take care of ourselves, we’re able to better take care of others as well. I think of it as I use it with clients sometimes like a cut metaphor. I have to fill my cup before I can fill yours. Often that clicks with people to say, “If I have an empty cup, I’m not going to be able to help my fellow whoever I’m with.” Thinking about filling your cup before you’re able to go out and help others. Not only helps the people that we’re helping and making sure that they get the best care, but also taking care of ourselves and not running ourselves into the ground.
Karlyn, I know you’re still in training and there’s a whole couple of years ahead of you still, but what’s in the near future for you?
In the near future, I’ll be finishing up my graduate training at the University of New Mexico. I am moving into the field of chronic pain and substance use and looking at interventions to see if we can target both of those things at once. Because we know chronic pain, there’s often a hand in opioids and we see substance use also. Also, career trajectories, I’d love to work in interdisciplinary care. I think that that is important, especially when we’re working with folks with chronic pain who have a lot of complex needs that psychology can fill all the time. We need lots of other providers on hand. Working in some interdisciplinary setting where I can be in a pain clinic and implementing this research that we’re talking about and looking at little brief interventions and self-compassion would be helpful.
I want to thank you for your time and for the great study that you did. If people want to learn more about you and what you’re up to, where can they read all about you?
Look me up on Google Scholar. I’m Karlyn Edwards at ResearchGate and at the University of New Mexico on their Grad student website.
I want to thank Karlyn for being on the show to discuss self-compassion and chronic pain. It’s an important topic that we have not talked about a lot in this episode. Please make sure to share it out with your friends and family on social media. If there’s a Facebook group where people are involved in mindfulness and compassion or chronic pain, drop it in the group there so they can share and they can check it out. It’s a pleasure being with you and we’ll talk to you next time.
- Karlyn Edwards
- The Relation of Self-Compassion to Functioning Among Adults with Chronic Pain
- Kristin Neff
- ResearchGate – Karlyn Edwards
- www.IntegrativePainScienceInstitute.com/146Download – free gift
About Karlyn Edwards
Karlyn was born and raised in Seattle, Washington, and completed her undergraduate degree at the University of Puget Sound. She is now currently a clinical psychology graduate student at the University of New Mexico, working with Drs. Kevin Vowles and Katie Witkiewitz.
She studies important psychological factors that impact chronic pain as well as psychological interventions that can improve the lives of those with chronic pain. She also studies opioid and another substance misuse in the context of chronic pain, specifically how pain impacts medication treatment for those with co-occurring opioid use disorder and chronic pain.
In her spare time, Karlyn enjoys travel, snowboarding, surfing, and yoga. She plans to pursue a career where she can continue carrying out research examining important psychological factors and effective interventions for chronic pain and substance misuse.
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Welcome back to the Healing Pain Podcast with Ronald D. Siegel, PsyD
We are talking about how to use mindfulness to treat or alleviate chronic pain. Our expert guest is Dr. Ronald Siegel. He’s an Assistant Professor of Psychology at Harvard Medical School where he has taught for over 35 years. He’s a longtime student of mindfulness meditation and serves on the board of directors and faculty of The Institute for Meditation and Psychotherapy. He teaches internationally about the application of mindfulness practice in psychotherapy and maintains a private clinical practice in Lincoln, Massachusetts. Dr. Siegel is co-editor of the critically acclaimed text, Mindfulness and Psychotherapy, author of a comprehensive guide for general audiences called The Mindfulness Solution: Everyday Practices for Everyday Problems, co-editor of Wisdom and Compassion in Psychotherapy, co-author of the professional guide, Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy and co-author of the sub-treatment guide called Back Sense, which integrates Western and Eastern approaches for the treatment of chronic low back pain.
Dr. Siegel is also co-director of the annual Harvard Medical School Conference on Meditation and Psychotherapy. We will discuss how mindfulness helps chronic pain, Dr. Siegel’s own personal journey of finding mindfulness, as well as overcoming chronic low back pain and how mindfulness fits into clinical practice, whether you are a mental health professional or a physical medicine professional. Dr. Siegel also created a free download to accompany this called How Mindfulness Works, Avoiding Avoidance. This download goes over how mindfulness helps with anxiety, helps with chronic pain, helps with depression as well as how mindfulness is the antidote to avoidance. To access this free gift, all you have to do is text the word, 144Download, to the number 44-222 on your smartphone. If you’re on your computer, you can open up a browser and type in the URL, www.IntegrativePainScienceInstitute.com/144download. I know you’re going to enjoy this as much as I did. We go through a ton of information on mindfulness and how mindfulness works to alleviate chronic pain and the suffering that’s associated with it. Dr. Siegel’s a master at mindfulness and psychotherapy. I learned so much from him, so I recommend that you follow his work and take notes. Let’s begin and let’s meet Dr. Siegel.
Watch the episode here:
How Mindfulness Works For Chronic Pain with Ronald D. Siegel, PsyD
Ron, thanks for joining me.
Thanks so much for having me.
I was excited when you decided to join and talk about mindfulness, specifically for chronic pain. It’s a topic we’ve talked about before, but not one that we’ve really delved into. With some substantial evidence as well as both the psychotherapy perspective as well as more of a contemplative perspective, you’ve been doing this for a long time, over 35 years. You’ve written five books on mindfulness, both for people who are interested in practicing mindfulness, as well as practitioners integrating mindfulness into their practice. Tell me how you first got started in mindfulness.
The way I first got started in mindfulness practice, there’s the old story and then there’s the newer story. I’ll share with you the newest story, which I’m only sharing because times have changed somewhat culturally. I got involved with them as a kid experimenting with psychedelic drugs, encountering certain states of mind, particularly transpersonal states, states of openness, states of access to unconscious materials that were fascinating to me and seemed very important. At the time as a kid, I thought, “Who has a map for these? Who understands these? Who’s explored and written about these?” It turned out that it was folks with deep meditative practices and wisdom, traditions and contemplative practices that knew something about these transpersonal states. They knew something about their contours and how one might live the lives that incorporate them or at least that is aligned with some of the insights that come from them.
The reason why I’m telling that story instead of it was just in the Zeitgeists at the time, which it was when I was growing up because I grew up in the countercultural era, is because now the use of these psychedelic substances is in phase two and phase three FDA approved clinical trials at major medical centers throughout the US and in many studies in Europe. We’re finding that they’re very useful for treating everything from trauma and intractable depression to things like end of life issues. Now that it’s become a little bit more mainstream to talk about the effect of the substances on consciousness, you can know the true story.
We appreciate truth and I’m sure that story was harder to tell maybe in the ‘80s when it wasn’t as widely accepted. There’s more and more research on controlled psychedelics, let’s call them, versus people just experimenting with street drugs on treating different types of psychopathology. I appreciate you bringing it to the forefront. It’s not something we’ve talked about, but I’m curious to know, did you find that mindfulness enhanced those types of experiences? How did you use mindfulness as part of that?
It was more that I discovered certain states of awareness and certain capacities to access emotion using the substances and then thought you don’t have good executive functioning when involved in these substances. One also needs to be able to go to graduate school and know your ZIP code. What are alternate means of pursuing some of these insights that don’t impair executive functioning? It turns out that mindfulness practice is one such means. In fact, that was largely its role. Traditionally, its role was not things like chronic pain treatment. Its role traditionally was to examine how we construct our sense of self and by seeing clearly how we construct our sense of self, we can identify the patterns that create psychological suffering across the board, emotional suffering as well as physical suffering and seeing those mechanisms. How might we free ourselves from them?
The sense of self is interesting. We’ve talked about it a little bit on this more than the context of ACT because ACT talks about self as context or self as process. They have a couple of different terms in ACT. Can you talk to us a little bit about how mindfulness can be used as a tool to increase our awareness?
Even though probably most of your readers are somewhat familiar with it, a lot of people have a little bit of confusion about what we mean when we talk about mindfulness. As I’m using it here, I’m talking about any awareness of present experience with loving acceptance. It means being alert, being in the present moment and having this open attitude of loving acceptance toward whatever is occurring right now. As it turns out, most of what we see when we start doing mindfulness practices, which are activities such as following the breath or walking in and noticing the sensation of the feet touching the ground. When we do these practices that involve stepping out of the thought stream and coming back to moment to moment sensory experience, one of the things that happen is we develop metacognitive awareness. We develop the ability to see thoughts as thoughts rather than as realities that we identify with. A principle found, for example, in most ACT approaches to treatment.
We also start to notice certain phenomena such as every time I resist some experience, whether it be a sensation of pain, a thought, an image, a memory, the very act of constricting and resisting that experience amplifies it. It turns it from being a transient event that arises and passes to being some event that your organism becomes stuck in. Where we get caught in some recursive pattern in which we’re resisting it so much, the very resistance fuels it and then we resist more and we get stuck in that pattern. Mindfulness practices give us insight into those kinds of mechanisms, but they also give us insight into how we construct our sense of self by talking to ourselves all day long. When we practice stepping out of the thought stream a lot, we start to notice that when the thoughts do arise, most of the thoughts are about me and about what I want, what I’m hoping will go well, what I’m hoping won’t go well. Right now thinking, “Am I staying on the theme? Am I remembering what your question is? Is this going to be useful to readers?” This is what’s going on the background even as I’m speaking at this moment.
Mindful awareness is noticing that this is occurring and also noticing that all of this chatter about ourselves is, as the court pointed out years ago, “I think, therefore I am,” how our sense of me is constructed out of all of this talk. It’s constructed out of the way in which we build what we might call a narrative self where I say, “I’m Ron. I’m a father and a psychologist. I treat chronic pain disorders. I’m participating here.” As opposed to a moment to moment experiential self, which is simply noticing my heart rate’s a little bit elevated because I’m doing public speaking. I’m noticing that it’s a little warm in the room now because it happens to be summertime in New England, feeling my feet on the ground, this kind of thing. There are many elements to this. There’s the developing metacognitive awareness. There’s the noticing what we resist persists. There’s this seeing how we’re constructing the sense of self. The more clearly we see this, the main advantage to this is all of the self-esteem preoccupations we have. “How am I doing? What do people think about me? Am I successful or not? Am I loved? Am I popular? Am I pretty? Am I ugly?” All that stuff which preoccupies us and fills a lot of our emotional landscape, that stuff starts to loosen up.
There’s another component to it, which I think we’ll drill into what I’m talking about chronic pain, which is simply practicing being with discomfort moment to moment on a sensory level. Whether that’s an itch or an ache or a feeling of hunger or the feeling of sadness in the heart or the feeling of fear in the chest. Being with the sensations is moment to moment sensations and learning that by doing that and by not fighting them, they arise and pass. This greatly increases both our affect tolerance, our ability to be with emotions, including difficult emotions, as well as our capacity to be with physical pain. When we dig into the physical pain side of this, what I’m going to propose is that mindfulness practices aren’t about reducing physical pain, not as a first-order intervention. They’re about increasing our tolerance for physical pain so that we can break the recursive loops that maintain most physical pain syndromes. Once we’ve broken the loop by no longer getting caught in resistance, then the syndrome has a way of resolving on its own.Mindfulness meditation improves pain, stress, anxiety, depression symptoms, and improves quality of life! Click To Tweet
I want to talk about both the cognitive and affective aspects of pain as well as the more physical pain aspects of chronic pain. The first time you had it, how did you segue from the more mindfulness psychotherapy into helping people with chronic pain?
I did it by getting caught in one of these loops myself. I was a patient years ago. I spent four and a half months flat on my back with a herniated disc diagnosis. In those days, the prevailing opinion on the part of orthopedics and neurosurgeons was if you have a bulging or herniated disc, you need to remain horizontal as much as possible and hope that this heals and wait for three, four months. If it doesn’t, have surgery, which had very iffy statistics and still do. Maybe you’ll get lucky and it will heal. I was following their advice because I was quite frightened of this. Day after day, week after week, I totally wasn’t getting better. I thought, “There must be a more active approach.” I went to see a sports medicine doc and he took one look at my CAT scan. This was before we were using MRIs clinically. There was such an era for younger folks. He said, “If you don’t stay off your feet, you’re going to be begging me for surgery in six months.” I stayed off my feet.
Bad medical advice.
Right, but very much the prevailing advice at the time. I wasn’t getting better. At a certain point, I thought, “I’m a psychologist. I’ve got a pretty sedentary profession.” I began a bizarre parody of the classical psychoanalytic scene. I had folks construct like a platform bed in my clinical office and in my private practice office. I would be lying down while my patients are sitting up wondering about my pathology and my prognosis. This went on for months. I finally got work. A fellow named John who happen to be a social worker said, “You’ve got to talk to Linda.” Linda was another social worker. I knew she ran a residential treatment facility for kids. I thought, “Linda is very nice. She’s a good clinician. She runs a great program. What does she know about chronic back pain that these orthopedists and neurosurgeons at Harvard Medical School don’t know?” He kept pushing me. I called up Linda and I said, “Hi, Linda.” She said, “Hi, Ron. I heard you had a back problem.” I said, “Yes.” She said, “What are you doing?” I said, “I’m lying down. It’s all I ever do.” I was a real peach at the time. She said, “You get up and buy groceries. Your wife will appreciate it.” I thought, “What?”
I’m completely unable to move. I thought this is some feminist cabal. I’m a postmodern guy. I go to the supermarket but it’s like, “No, I can’t do anything. How could I possibly groceries?” She said, “Just do it. Go back to your life.” At that point, I had an appointment scheduled with a well-reputed surgeon because I hadn’t gotten better. It was months into this. I thought, “Before I go for the surgical consult, I’m going to do what Linda suggested. Linda’s rationale for this was saying this is essentially a psychophysiological disorder. These disorders are often created and certainly very often perpetuated by in essence, our fear of the disorder and the behavioral adjustments we make in response to the disorder. If we go back to our lives, the chances of recovery are increased. I thought, “I’ll at least try walking.” At that point in my life, I could walk about a city block and I’d get serious sciatic pain shooting down my leg. I thought, “I’m going to push it a bit.” I walked my city block, right on cue, got the sciatic pain down my leg. I thought, “Courage, Ron. Just try it. Linda seemed convinced. She apparently got out of one of these disorders.” I walked in another city block.
To my utter surprise, in addition to the pain shooting down one leg, I developed pain shooting down the other leg. I thought, “That was great advice.” It was because according to the CAT scan report, the disc was herniated laterally, as they often are. I’m supposed to have pain down one leg, but I wasn’t supposed to have pain down the other leg. The reason I knew this was I read the radiology report pretty much every night before bed. I was obsessed and terrified of this disorder. If I’m having pain down the other leg, what does this mean? My first hypothesis is I’ve shattered my spine entirely and it’s all over. My second thought was, “Could Linda be right? Could it be that the pain is being caused by some mechanism other than the herniation? If I were to understand that, might I get out of this?” I thought, “Go for broke. For the next couple of weeks before you see the surgeon, just treat it like a sack of physiological disorder. Treat it as though your fear of this and your behavioral adjustments and your psychological reactivity to the pain is what’s perpetuating it and see what happens.” Two weeks later, I was done. I was sitting up in my chair seeing patients. I was starting to do yoga again. I was exercising. It was like, “This was all a bad misunderstanding. How could that be?”
A year later, I’m still fine. I started communicating with people who had been writing about this. It was a very small group of people many years ago who were talking about this. They started connecting with physicians in the Boston area who were not so much taking the psychophysiological angle, but they were doing aggressive rehabilitation to get people back into their lives. Together we started developing programs based on this. Mind you, in this entire miraculous story of recovery. I didn’t mention mindfulness. I’d been doing mindfulness practice since I was seventeen. Frankly, when I was in this disorder, I felt so depressed, frustrated and frightened that I’d practice a little bit but it was like, “I’ve got to cure my body.”
Once I got over this thing and once I understood the mechanism of it, at least in my case, I started realizing the principles and practices that come from mindfulness traditions would have been extremely useful had I had them in the right cognitive context. Had I understood the disorder differently and saw that it was my reactivity to my fear that was the engine driving this. I could have used mindfulness practices to see my fear more clearly, to tolerate the pain more readily and to move toward re-engagement in a full life. That’s how I got into treating this and that was 30-odd years ago and I’ve been seeing patients ever since.
It’s a beautiful story, Ron, and I know it’s not beautiful to be in pain. It’s nice to be out of it. It’s a beautiful story because what Linda did for you in the world of pain, there’s not only one thing cognitive that usually helps people with pain. She helped you with reconciling that your scan has little to do with the pain you’re experiencing. Now the pain switched sides and moved around. It was unpredictable. If it was just purely of a musculoskeletal origin, pain is not unpredictable like that. She helped point you toward things that are meaningful to you and valuable like your relationship with your wife and doing activities that support whatever it was your marriage or relationship. Having you do the activity is a good way to alleviate pain. Probably the biggest thing you mentioned, and I want to talk to this in the context of mindfulness, is fear and fear avoidance specifically enough. There’s a lot of research around fear avoidance of pain. Talk to me about avoidance in general as far as human beings and how mindfulness can help alleviate some of that.
My pal, John Briere, who’s a trauma researcher and a clinician at the University Southern California, he likes to say, “The only thing you need to avoid in life is avoidance.” It’s simple. Avoidance is this posture. Another colleague of mine, a fellow named Jud Brewer, who’s doing wonderful research on the neurobiology of mindfulness and its relationship to addictions at Brown these days. Jud boils it down to something very simple. Are you in a posture of constriction or are you in a posture of openness? Every time we move into avoidance, we move into this posture of constriction. If we look at the emotions that are most problematic to us, and even you might join me in this and our readers, take a moment to pantomime fear and fear as quintessential avoidant reaction like, “I’ve got to get out of here.” Just do it. Pantomime it like you were scared for a moment in your body. If you were to do anger, which is another avoidance of sorts because it’s about getting rid of the bad threat. If we pantomime anger, what do we get? What’s happening to our musculature in both of those conditions?
Everything is tensing and constructing.
What we call psychological constriction is the same thing as musculoskeletal or muscular constriction. It is what occurs when we’re angry and when we’re frightened, when we’re saying no to an experience in some way. We call it the fight and flight response. We’re either running or repelling, but they’re both highly avoidant states. The opposite of avoidance is allowing, being with, accepting, feeling. In that state, we don’t have the same levels of muscular tension and we have an additional super important asset, which is we don’t get stuck. Emotional states and pain states get stuck when we fight them. When we don’t fight them, they arise and they pass like all other phenomena. One of the insights that come to mind from this practice is impermanence. Noticing that all phenomenon, constant flux.
The Buddha pointed this out some 2,500 years ago, but you don’t have to be a rocket scientist or a saint to get it now. Just notice, does any experience they have the same? Do any phenomena stay the same? No. The closest thing to things staying the same that we can get is getting stuck in one of these avoidance cycles. The way this plays out quite simply or the most skeletal outline in terms of chronic pain disorders. Let’s take the back pain that I was in. What was happening was I was so terrified of this pain that I was, one, avoiding activity, which would have allowed me to use my musculature normally but even more, I was so tight. I was so scared and I was constricting, trying desperately to get this to stop. As soon as I’m frightened, that’s going to tense muscles. As soon as muscles become tense, there’s going to be pain.
Tense muscles simply hurt after a while. We know this. When these muscles tighten up, we know that if we’ve ever had a Charley horse in our calf, the only difference is when it’s these muscles on our calf, we typically think it’s harmless. It’s okay, it’s just tension. When it’s our back and we live in a society that has an epidemic of chronic back problems, we think it’s something serious. My mom, when I was thirteen, spent practically a year on her back. I remember her using a bedpan. As a thirteen-year-old boy, your mom with a bedpan is not exactly an image that’s easy to reconcile. Her symptom was sciatica, so when I got my sciatic pain, I interpreted it with a level of fear that was probably greater than the average bear I would have had because I had this memory. Others have other associations to back pain from people we’ve seen who have had their lives derailed by this.
When we have the sensation of pain, it brings up all sorts of thoughts about our structural damage and how badly injured we are and how really in danger we are because this can derail our life. Those thoughts lead to more of the fear, leads to more of the tension and you could easily see how this becomes a perpetual loop that we get caught in. It’s exacerbated because we lose strength, endurance and flexibility because usually we stop using our body normally. Our muscles are more vulnerable even though they may have not been when we first got into the cycle. If we can use mindfulness practice to simply observe the fear and observe these frightened thoughts and have an increased tolerance for the pain sensations without being reactive to it. To approach all of this with an attitude of loving acceptance, it’s not easy but that’s what we try to cultivate. You could see how that would interrupt the cycle quite nicely.
Your colleague, Linda, also said something or what she did for you. With regard to chronic pain, ACT talks about rulemaking. The rule you had in your mind at that point was, “If I rest, then my pain will go away, then I can get back to my life.” What Linda helped you with it sounds like one maybe quick phone conversation. Once you return to life, once you get moving again and get back to life, then your pain starts to subside. How do you reconcile that through the lens of a mindfulness contemplative approach?
Let me talk about it in that context but let me talk about in another context for us because you’re raising an interesting and important point. As I’ve encountered them, the majority of pain treatment programs, at least in the United States, have as their metric in their goal, reduction of the sensation of pain. To my mind, that’s problematic because of precisely the mechanism that you just outlined. Linda’s approach was different. Linda’s approach was if you can re-engage fully in your life, you will be less afraid of your pain. You will not be fearful of disability. You will be less inclined to get into one of these fear pain avoidant loops and that will walk you out of it. Where you begin is critically important. Frankly, some of the mindfulness, there’ve been quite a few research studies on the use of mindfulness to work with chronic pain and they show what I would consider modest effectiveness. They work. They’re helpful about at the same level at CBT of various sources.
Most of the psychosocial interventions seem to be on par with one another. What has distressed me as a clinician working in this field for many years is they have very rarely paired with aggressive rehabilitation. They’re very rarely paired with something that says, “No, let’s get you back into your lives.” Once you’re able to see that you can have a full life, even though the pain is there, you will be less frightened of the pain. You will have less impulse to restrict and the thing will resolve by itself, which is the course that I’ve seen the vast majority of my patients follow. The role of mindfulness in this then is to make it so that we’re less frightened of the pain when it arises. It’s best paired with a rehabilitation program. Let’s say I start walking again and I haven’t been walking because I’ve been afraid it’s going to hurt my back or I start lifting things.
A woman who I worked with said, “I started emptying the dishwasher myself instead of having my husband do it because I’m ready to face my fears and get back into life.” When the twinge comes, when the spasm comes, when the fearful thought of, “What if I become incapacitated and can’t work or can’t lift my child?” When those thoughts come, we use mindfulness practice to work with that. We simply feel the sensations of the muscles tightening. We simply notice the catastrophic thoughts arising and passing. We use our mindfulness practice to allow us to tolerate the difficult aspects of resuming a normal and full life. The mindfulness practice supports that. As we get into our life more normally with less fear and constriction, these disorders tend to take care of themselves.
I’m going to flip hats. I’m going to put on my strong clinician hat. There are a couple of things coming to mind as you’re talking that I’m noticing come up for me. One is in the realm of physical therapy as well as some pain psychology. There are pain education approaches that helped people re-conceptualize what pain is. Instead of them thinking that it’s a problem in their body that they’re not damaged, that it’s a problem in the nervous system. There’s great evidence on it very similar to CBT and minimal to moderate effects. When you combine it with other physical rehabilitation, then you see moderate to larger effects.
That approach does leave you at times grappling with changing someone’s thoughts or beliefs. Similar to the fact that traditional CBT, you would take someone’s thoughts in essence and again, help reframe them or restructure them. What are your thoughts on things? I know you’ve studied both. Obviously, you’re a trained psychologist. How does that or does that not fit in with mindfulness? As a psychologist who’s reading this or another mental health professional may say, “I love mindfulness. I recommend mindfulness all the time for my clients, but I have a hard time fitting it into my CBT practice or I have a hard time fitting it into my DBT practice.” What are your responses to those types of questions?
As I understand it, mindfulness is the experience of mindfulness practice on the part of many practitioners that has helped open up what is often called the third wave in behavior therapy. The movement from straight behavioral interventions, whether through classical conditioning and paradigms or changing reinforcement contingencies in an operant paradigm, what we call behavior modification broadly. People think in ways that rats probably don’t. Let’s address cognitions. We have the whole realm of CBT, which as you put quite clearly, is about changing maladaptive, irrational thoughts into adaptive rational ones. There’s this third wave of which ACT is a significant component, which is about, “Can we see thought as thought? Can we notice?” As I understand that, and I’ve run this by several researchers in the field of cognitive science, non-clinicians, as I read their cognitive science literature, it’s two big findings that have come out of the last fifteen years.
The first is we are holy and hopelessly irrational in our thinking. Our thinking is driven by our feelings. All we need to do is glance at the political arena to see this. Whatever side of the divide any of us might be on, think of the way you view the people on the other side of the divide. Notice the way all of their thoughts are shaped by their feelings. You can see it quite clearly when looking at the other people, which ties into the second major finding in cognitive science. We all believe ourselves to be rational actors. We don’t believe that our feelings are influenced by our emotions, even though all the data says that they are. Putting these together, thought becomes extremely unreliable, particularly in contexts that are emotionally charged. When we’re in pain, it is highly emotionally charged.
Our belief that we’re damaged, our belief about what’s going to happen becomes quite powerful. There are different ways to work with that. You could work with it with traditional CBT and argue against the premise that you’re damaged. I think that plays a role in treatment. Even though I’m not big at arguing with patients in general in my life, I will argue with folks. I will point out the fallacies in some of their logic about their pain disorders. I’ve had people literally tell me that their back went down and I asked them what’s their model, what’s their understanding of what happened. “It was a week ago I drove over a pothole.” The person had a Mercury, one of these boats, like all the American cars. You drove over a pothole a week ago on your Mercury and that’s what caused it. I must avoid potholes. I’ll do traditional CBT and take on that to examine how plausible is that really? More often from a mindfulness-oriented perspective, the task is to notice the connection between affect and thinking.
Notice the way this changes. We see this quite clearly in other disorders like depression. If you talk to somebody who’s not always deeply sunk in depression but struggles with it, you ask them how do they view the world when they’re feeling depressed? They’ll tell you it’s hopeless, it’s negative, all of this. You say, “How did you view it a couple of weeks ago when you weren’t so depressed?” “I was fooling myself back then. My more optimistic vision was diluted back then. Now I see reality.” You flip that and you talk to somebody who’s come out of depression and they’ll say, “Back then when I was depressed, that was my depression talking. That’s why I saw it so negatively. Now I see things more clearly.” Helping people to see that the way we construct our universe is so deeply dependent on our emotional state at the time. That becomes very powerful for loosening this up. There’s a mindfulness-oriented approach, which is a more contextual approach. It is much more about developing metacognitive awareness. There is a role for sometimes challenging people’s belief systems, particularly when they have belief systems that lead to, “I mustn’t lift, bend, participate in my life.” Listening to those beliefs is such a powerful factor in maintaining the disorder that it’s worth challenging them directly.
I love the way you folded all that together. Often, it’s easy for everybody to pick a camp, “I’m in the CBD camp. I’m in the mindfulness camp, I’m in the ACT camp.” When you’re able to fold, and very few practitioners can do what you just did, and hurdle all different aspects and know when to apply it. I appreciate that. I think it shows your skill and your years of expertise because some of these things can be difficult to start to implement with people if you’re holding onto that one approach.
Wilhelm Reich, who you know was in a sense the original mind-body therapist who’s Freud’s follower, who spoke about character armor. Everything came out of Reich’s work, he arguably got into some pretty crazy territory at the end with his Orgone box. Before going off the deep end in that way, he said, and I thought it was brilliant, “I’ve never come across a psychological model that wasn’t true to some degree and wasn’t useful to some degree in giving us some explanatory value.” That’s my sense we’re all looking at this amazingly multi-barrier complex being a bigger human being. There are so many different ways to story this, all of which are somewhat useful and all of which give us a slightly different perspective.
There is a myriad of different ways to help people with their mind and of course their body as well because they are highly interconnected. I think mindfulness is important for practitioners who treat pain, as well as other chronic health conditions. How can a practitioner who trains in mindfulness improve themselves as a practitioner and in turn help their outcomes with their patients?
Mindfulness practice is one of those things. I sometimes joke with audiences, “What do the following three things have in common: swimming, making love and eating a gourmet meal?” What would you say?
They’re all pleasurable.
It probably depends with whom you make love potentially. Anything else come to mind?
Not particularly, no.
My thought from my peculiar mind is those are three things in which doing them is very different from talking about them. Mindfulness practice is very much in that camp. There are people who say, “I want to teach my patients mindfulness practice.” It’s a little bit like saying, “I want to be a cello teacher.” “Do you play the cello?” “No, I don’t.” “Have you played the cello?” “No, I never have but I want to teach it.” It’s very hard to do it. You can read the scripts, but as soon as people start having interesting and challenging experiences, which means very early on in the process of teaching this, you have to have personally experienced a lot of those challenges yourself, struggled with them some, found ways through some of them. You have to have lived it to teach it. The first place to begin as I see it, is pick up the practices. Try this yourself. These practices were not originally designed to treat particular disorders that show up in the DSM. They were designed to treat the fact that we evolved brains and minds. They didn’t talk about in terms of brains 2,500 years ago. They talked in terms of minds, but we evolve minds that inherently bring a tremendous amount of psychological distress.
Our minds are constantly complaining. They’re constantly wanting things to be other than as they are. They’re constantly self-preoccupied with how am I doing. Mine’s doing it right now and I’ve been doing this stuff for years. They have these propensities that lead to psychological suffering. These practices are designed to help eliminate those and give us pathways through. They’re of use to us even if we’re not treating patients but they’re particularly of use to us as clinicians if we want to share these practices with folks. That’s where it begins. The second thing which is quite important is to understand that anything powerful enough to be useful is powerful enough to make trouble. Fire being the most commonly used example of this principle. It’s great when it’s contained in an internal combustion engine or a stove, not so good when it gets out into the living room.
What we know from mindfulness practices is that they’re like this. They are quite powerful change agents. They can shift how we understand ourselves. They can soften the repression barrier and give us access to all sorts of emotions that where we otherwise weren’t in contact with. Let’s start that because that’s another important function of them. These are the chronic pain we can come back to. They help us to be present. They help us to be more related, all sorts of positive things. What we’re finding, and I credit my friend and colleague, Willoughby B. Britton at Brown University, has done a ten-year study on the adverse effects of mindfulness practices.
She’s a serious mindfulness student. She’s not a hostile person who thinks what we should be doing is all watching television all the time. She’s been cataloging the things that go wrong and people get stuck in states of dissociation. They encounter states of high anxiety. They encounter all sorts of difficulties. The second thing is to be aware of whom these practices are most suited when. To have something of a differentiated clinical understanding of when they would be useful and when they would not be useful so that we don’t inadvertently help people connect with thoughts, feelings, experiences that they’re not equipped to work with right now and re-traumatize people and overwhelm them. The two first orders of business are, do the practice ourselves and learn about indications and contraindications and then we move into their various applications.
You had a star there. Do you want to get to that star?
Let me mention that. To step back and look at an approach to chronic pain and we package this into something we call the Back Sense program and wrote a book several years ago on this. At that time, the research was based on like a little bit novel. It wasn’t the mainstream. Now it’s all become quite mainstream. It’s been quite heartening to see this. We had four steps to this. The first was the obvious one. You want to rule out dangerous, treatable medical conditions. Some people have back pain because they’ve got a kidney infection. Some people have cancer of the spine. We don’t want to start treating those things like psychophysiological disorders. We want to rule out the dangerous stuff. The second part is the cognitive restructuring that you’ve spoken of. How can we come to understand this differently? If I can answer one of your questions a little bit more thoroughly.
Mindfulness practice has also helped with cognitive restructuring because as we develop metacognitive awareness and see thoughts arising and passing, we become less attached to each individual thought. We become a little bit more flexible and a little bit better able to entertain new thoughts, novel ways of looking at situations, to think outside the box. The more we practice mindfulness, the better for that. The third component that I haven’t addressed so far is sometimes people will get back into their lives. They will develop the courage to start moving normally and their pain persists. One hypothesis is, “There is a structural issue going on that needs to be addressed or perhaps can’t be addressed and the person has to live with it. Another hypothesis, which very often seems to be operative in my clinical experience, is there’s some emotional state, some emotions that are difficult to integrate, that are difficult to allow into awareness. What’s happening is the person is chronically tensing up, is chronically in a fight or flight state, not fearing the tigers out there or even perhaps at this point fearing their pain so much because they worked this through.
They’re afraid of the sadness or they’re afraid of the anger or they’re afraid of some sexual feeling, which in their particular cultural or family context is unacceptable. For me, having grown up as a guy, I learned not to cry publicly pretty early on by seeing what happened to other guys who did that. I learned not to cry it all shortly after that. When I’m generally anxious, stressed and tight, if I’m a bit mindful and I turned inward and I asked myself the question, “What feeling might be under this?” There’s almost always a wave of sadness. There’s almost always some unintegrated sense of loss, vulnerability or tenderness. If I can connect with that, very often the whole fight or flight stress response lets go. I’ll share one of the stories on that. I know I’m rolling a little bit. I had an incident of chronic back pain on a family vacation in Turkey and it was our last vacation, I have twin daughters before they were going to go off to college. It’s a point in time in our lives in the sense that we were going to face the empty nest.
I love my kids. It was like, “What’s that going to be like? Will I miss them?” I’m climbing out of the Bosporus in Turkey and suddenly my back goes out and it’s horrible. It’s one of these can’t tie my shoelaces back episodes. I’ve been doing this work for quite a long time. I remember, I forget the guy’s name, but the orthopedics who used to edit spine, who was at Dartmouth-Hitchcock. His wife’s back had gone out the same way, like couldn’t tie your shoelace and she said, “Honey, what should I do?” He said, “You should go for a run.” She said, “Are you nuts? I can’t go for run. I can’t tie my shoelaces.” “Just go for a run.” I was moved by that. This is along the same lines we’ve been talking and I thought, “I’m in Turkey. I can’t tie my shoelace, but I jog for exercise. I’m going for a run.” I went for a run, but I did it. I kept doing it. I flew back home and kept active. About a week later, it’s hanging on for a long time. I’m thinking, “This is weird,” because I am fully back to activity, but it’s still hanging on. I didn’t think there was something structural. I just climbed over some rocks in the Bosporus.
I was in the basement and doing laundry, a further example of living your life normally despite this thing. Suddenly this wave of sadness comes up about my kids leaving home like, “They’ve grown up. I can’t believe it. Everything does change. I’m going to miss them so much.” This powerful wave of sadness. There was a release associated with that wave of sadness. By that evening, it was gone. I thought, “What an important lesson here.” Having learned not to cry in junior high, carrying that through as a life character posture. Here, sometimes you can get over the fear of movement and get over all that and you have to address these other emotional things. There are many pathways to doing that. Mindfulness practice isn’t the only one. Mindfulness practice is one way to tune in, notice what emotions are happening of felt sense in the body and open to them. That too becomes a very important component of this treatment process.
When I first started doing loving-kindness practices, I was amazed at how much anger would come up in these practices when I thought I would be sitting down and feeling good and wishing everyone in loving this and kindness. I was like, “Why is there anger, frustration and rage and all these other things that are in there that I didn’t know were in there?” When you sit with yourself for a certain period of time and you’re guided through those practices, other things come up and you start to see the different colors of those rainbows that you hope are going to be all loving. They’re not always like that. Once you get beyond that or you just learn to be with that and notice it, it does get better. Things do start to change from that.
Sometimes these heart-centered practices are very powerful in this way. A good friend of mine that we’ve done a lot of writing and work together. Chris Germer, who’s with Kristin Neff, developed the Mindful Self-Compassion program. He coined this term backdraft. He didn’t coin, he borrowed it from firefighters who when they enter a room, they feel the door first before opening. Before entering the room, they feel the door to see if it’s hot because if it’s hot, there are smoldering embers in there. You open the door, the oxygen comes in and you have this conflagration. That’s exactly how we operate. You see the little kid who skinned his or her knee frozen on the ground until a loving adult comes up and gives them a hug and that’s like it’s all out. We’re all that way. When we do these loving-kindness practices, whether it be, “Wah or argh or ow,” or whatever it might be that we’ve locked away, it comes to the floor. I’d argue that is extremely important for treating these chronic pain disorders. That’s what allows us not to chronically hold our muscles always in this state of contraction because we’re trying to block out the tigers within.
When people tell me, “I love loving-kindness practice. I do it all the time. I feel great 100% of the time,” I’m like, “Something’s wrong.” You’re not doing it right or you’re not approaching it with what you think it should be doing. It’s not working in that sense. You mentioned the book, Back Sense, which of course is a book that talks about mindfulness from a chronic pain perspective with regards to back pain. You also have a course coming up with Praxis in September. If people want to check that out, you can go to www.PraxisCET.com and the course is called Clinical Applications of Mindfulness and Compassion, which fits perfectly with a lot of the things we’ve talked about. Can you tell us what the aim of that course is, what practitioners can learn from that?
The aim of that course is to take this integration of mindfulness practices to talk about what I think is the growth edge of this. When we first wrote back in 2005, we wrote Mindfulness and Psychotherapy. It was one of the early texts about integrating mindfulness practices into psychotherapy. It was all quite novel back then. Years later, a lot of clinicians are familiar with this but there are some implications of these practices that I’ve alluded to in our talk here that have tremendous therapeutic potential. Like the way in which they can get us to reconsider our whole sense of self and what is all this self-preoccupation about? How do I construct it and how do I to put it in an ACT framework, limit my psychological flexibility by believing that I am this self and not that self? In many ways, we are made up of a constantly changing kaleidoscope of selves and how mindfulness practice can help eliminate that.
The course also delves in some depth to how do you tailor these practices to meet the different needs of different clients or patients because these are not one-size-fits-all practices. We’ve already mentioned two in the course of our discussion. You’ve emphasized the loving-kindness practices and when I was talking more about mindfulness is awareness of present experience with acceptance. It’s more about the awareness of wisdom practices. These practices, in many of the traditions from which they derive, are designed to create wisdom, clear seeing, clear cognition and compassion and open, vulnerable, quivering, loving heart. How to use these practices to develop both for different people who may be stuck in different ways as well as people from different cultural backgrounds in the light. The course delves in a lot to what are the basic mechanisms of action? We’ve touched here on a few of the mechanisms of action. These are the chronic pain, but there are similar mechanisms of action for anxiety, for depression, for relational difficulties and the likes. The course tries to take what’s developed over many years and talk about what at least I see as some of the growth edges to the field.
You can learn all about Ron by going to his website directly, which is Mindfulness-Solution.com. Ron, it’s been great having you. Let us know what you’re up to in the future because we’d love to have you back on, talk about mindfulness and chronic pain, all the different things you have to talk about. It’s been a pleasure working with you.
Thanks so much and thanks for your thoughtful questions. It’s so clear that you’ve been doing this work yourself, in which you ask your questions and the perspectives you have. I appreciate that. Thank you so much for having me.
Thank you. Make sure to share this with your friends and family on Facebook, Twitter, LinkedIn or drop it in a Facebook group where there are people who are interested in mindfulness and CBT, pain education and chronic pain. They’ll definitely get something from this and all around, it’s great resources.
- Mindfulness and Psychotherapy
- The Mindfulness Solution: Everyday Practices for Everyday Problems
- Wisdom and Compassion in Psychotherapy
- Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy
- Back Sense
- How Mindfulness Works, Avoiding Avoidance
- Mindful Self-Compassion program
- Clinical Applications of Mindfulness and Compassion
- Ronald Siegel on Twitter
- Ronald Siegel on Facebook
About Dr. Ronald D. Siegel, PsyD
Dr. Ronald D. Siegel is an Assistant Professor of Psychology, part-time, at Harvard Medical School, where he has taught for over 35 years. He is a long-time student of mindfulness meditation and serves on the Board of Directors and faculty of the Institute for Meditation and Psychotherapy. He teaches internationally about the application of mindfulness practice in psychotherapy and other fields and maintains a private clinical practice in Lincoln, Massachusetts.
Dr. Siegel is co-editor of the critically acclaimed text, Mindfulness, and Psychotherapy, 2nd Edition; author of a comprehensive guide for general audiences, The Mindfulness Solution: Everyday Practices for Everyday Problems; coeditor of Wisdom and Compassion in Psychotherapy; coauthor of the professional guide Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy; coauthor of the self-treatment guide Back Sense, which integrates Western and Eastern approaches for treating chronic back pain; and professor for The Science of Mindfulness: A Research-Based Path to Well-Being produced by The Great Courses.
He is also a regular contributor to other professional publications and is co-director of the annual Harvard Medical School Conference on Meditation and Psychotherapy.
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Rheumatological and musculoskeletal symptoms (RMS) are a main cause of chronic pain in people with type 2 diabetes mellitus (T2D). Some RMS, such as limited joint mobility syndrome (diabetic cheiroarthropathy), neuropathic arthritis, tendinopathy, diabetic amyotrophy, and diabetic muscle infarction, are considered specific complications of T2D. For other RMS, including osteoarthritis, low back pain, carpal tunnel syndrome, gout, adhesive capsulitis of the shoulder (frozen shoulder), diffuse idiopathic skeletal hyperostosis (DISH), and widespread chronic pain, T2D is considered a predisposing condition (1, 2).
Shared risk factors between T2D and RMS are thought to influence high comorbidity. These include hypertension, hyperlipidemia, inactive lifestyle, older age, and obesity. More than 90% of people with diabetes are overweight or obese, which greatly increases the risk of developing conditions associated with chronic pain (3). Indeed, irrespective of diabetes, a large-scale survey of over 1 million people in the USA demonstrated that chronic pain increases linearly with BMI: compared with people with normal weight (BMI < 25), the rate of recurring pain was increased 20% in overweight people (BMI 25-<30), 68% in people with class I obesity (BMI 30-<35), 136% in people with class II obesity (BMI 35-<40), and 254% in people with morbid obesity (BMI ≥40) (4).
The pain associated with RMS can make it difficult or painful to exercise; this leads to sedentarism, which exacerbates the problem. Not surprisingly, RMS and chronic pain in T2D can be also promoted by psychosocial factors such as depression, fear of injury, and impaired quality of life (5).
Regular exercise may prevent or delay the development of T2D, and is the key lifestyle strategy recommended for weight loss and control of glucose blood levels in those affected. But can exercise effectively alleviate RMS-related chronic pain in people with T2D?Regular exercise may prevent or delay the development of T2D, and is the key lifestyle strategy recommended for weight loss and control of glucose blood levels in those affected. Click To Tweet
Treating RMS with Exercise in Type 2 Diabetes: What Helps and What Doesn’t?
Exercise and diet modification are initially advised before medication initiation for T2D management. Many studies demonstrated that exercise provides clear benefits to people with diabetes, by improving insulin sensitivity and preventing diabetes-related complications (6). There is however much less evidence available for the risk vs benefit of exercise interventions for chronic pain related to RMS in T2D.
The authors caution that most studies addressing the efficacy of exercise on diabetic symptoms usually exclude potential participants based on the presence of RMS, and that’s why adverse effects may be underestimated.
Nevertheless, the few studies available suggest that exercise does improve RMS symptoms in diabetic patients, although adverse events occur in some cases, depending on exercise modality, frequency, and intensity:
Low to moderate aerobic exercise. A systematic review recently published in Diabetes/metabolism Research and Reviews that evaluated 11 studies concluded that aerobic exercise is well tolerated and may improve nerve function and reduce neuropathy-related symptoms in people with T2D, with minimal adverse events (7). Although not focused on T2D, several studies also showed that weight reduction, a key benefit of aerobic exercise, reduces joint load and can provide relief from osteoarthritic pain (8, 9).
Strength Training. Although investigations on the effects of strength training on diabetic RMS are lacking, evidence that it helped T2D patients improve glycemic control and muscle function has been presented (10, 11).
Resistance training. Like strength training, resistance training can help build muscle mass and strengthen soft tissues. Resistance training however is more low-impact, uses the body’s own weight, and because it’s gentler on the joints is often preferred to manage joint problems. A Diabetes Therapy report on 8 published studies concluded that resistance training, especially of high intensity, may improve glycemic control and muscle strength in elderly T2D patients (12).
Flexibility training. Improving range of motion and decreasing stiffness are the main benefits of flexibility training. Low intensity activities like yoga and Tai Chi combine flexibility, balance, resistance, and endurance, and have shown to improve metabolic function, reduce pain interference, and increase limb strength and balance in T2D patients (13, 14). Both are also good therapies to reduce stress, anxiety, fear of movement and pain cognitions, thus helping overcome mental barriers to exercise.
Combined exercise training. Evidence shows that multisensory exercise (an approach that evokes the stimulation and use of various senses) and functional programs combining balance and strength training can improve gait speed and balance and increase muscle strength and joint mobility in patients with diabetic peripheral neuropathy (6).
A clinical trial in T2D showed that a combined regimen that included progressive balance, flexibility, strengthening, and aerobic exercise improved walking ability when it was conducted standing and walking (weight-bearing exercise; WB) rather than sitting or lying (non-weight-bearing exercise; NWB). While this outcome was perhaps predictable, glycated hemoglobin levels (a measure of the amount of blood glucose attached to hemoglobin) were reduced only in the NWB group. Because this group spent more time than the WB group exercising, it was proposed that the volume of exercise (rather than the intensity) accounted for this improvement. Predictably too, the NWB group reported fewer complaints of lower extremity musculoskeletal pain during exercise sessions (15).
In a recent position statement, the American Diabetes Association provides concise exercise training recommendations for exercise class (aerobic, resistance, and flexibility and balance), intensity, duration, frequency, and progression. These new guidelines emphasize the “inclusion of flexibility exercise to improve range of motion around joints in individuals of all ages and balance activities to improve gait and prevent falls in older adults” (16).
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Exercise Caution With Exercise
While regular exercise offers clear benefits for chronic pain, too strenuous and high-load exercise can instead aggravate musculoskeletal symptoms in people with T2D. The literature offers some examples of adverse effects caused by intensive exercise interventions for T2D:
- Clinical trial results published in JAMA showed that 50% of the T2D patients randomized to an intensive lifestyle intervention (5 to 6 weekly aerobic training sessions of which 2-3 included resistance training) experienced adverse events (most commonly musculoskeletal pain or discomfort and mild hypoglycemia) compared to just 14% of those that received only standard care (medical counseling, education in type 2 diabetes, and lifestyle advice). Moreover, 1 in 5 participants in the exercise intervention group (and none in the control group) reported RMS or discomfort that prevented them from exercising for 7 or more consecutive days (17).
- In a Diabetologia study that assigned 92 T2D patients to 12-months of endurance interval training that included either brisk walking (three 60-min sessions per week) or a medical fitness program (exercise on a home trainer, elliptical trainer or rowing ergometer 3 times a week), 45% and 30% of participants in each group dropped the study after 6 months. At 12 months, the dropout rate increased to 63% and 56%, respectively, with orthopaedic-related comorbidities, such as overuse injuries and/or subclinical osteoarthritis of the lower extremities as the main reason for dropout in ~50% of the cases (18).
RMS in Diabetes, a Challenge for Physical Therapists
As the rates of obesity and diabetes continue to rise, knowledge of the exercise modalities best suited to specific musculoskeletal problems in the T2D population is essential in Physical Therapy practice. Of importance also is knowing which assessment tools are more appropriate for initial evaluation and treatment follow-up. Unfortunately, no specific questionnaires are available that capture the range of symptoms experienced by people with T2D. The Nordic Musculoskeletal Questionnaire is a useful instrument that addresses the prevalence of musculoskeletal symptoms throughout the body, but does not evaluate their impact on function. A combination of this and other self-report measures such as the BPI, SF-12, and NTSS-6 is suggested to assess more thoroughly the burden of RMS and chronic pain in T2D patients.
1- Serban, A. L., & Udrea, G. F. (2012). Rheumatic manifestations in diabetic patients. Journal of medicine and life, 5(3), 252–257.
2- Sözen, T., Başaran, N. Ç., Tınazlı, M., & Özışık, L. (2018). Musculoskeletal problems in diabetes mellitus. European journal of rheumatology, 5(4), 258–265. doi:10.5152/eurjrheum.2018.18044
3- Okifuji, A., & Hare, B. D. (2015). The association between chronic pain and obesity. Journal of pain research, 8, 399–408. doi:10.2147/JPR.S55598
4- Stone, A. A., & Broderick, J. E. (2012). Obesity and pain are associated in the United States. Obesity, 20(7), 1491-1495.
5- Cox, E. R., Coombes, J. S., Keating, S. E., Burton, N. W., and Coombes, B. K. (2019) Not a Painless Condition: Rheumatological and Musculoskeletal Symptoms in Type 2 Diabetes, and the Implications for Exercise Participation. Current Diabetes Reviews, 15. doi:10.2174/1573399815666190531083504
6- Gelaw, A. Y. (2018). Exercise and Diabetes Mellitus. Diabetes Food Plan, 167.
7- Gu, Y., Dennis, S. M., Kiernan, M. C., & Harmer, A. R. (2019). Aerobic exercise training may improve nerve function in type 2 diabetes and pre‐diabetes: A systematic review. Diabetes/metabolism research and reviews, 35(2), e3099.
8- Messier, S. P., Gutekunst, D. J., Davis, C., & DeVita, P. (2005). Weight loss reduces knee‐joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism, 52(7), 2026-2032.
9- Aaboe, J., Bliddal, H., Messier, S. P., Alkjaer, T., & Henriksen, M. (2011). Effects of an intensive weight loss program on knee joint loading in obese adults with knee osteoarthritis. Osteoarthritis and Cartilage, 19(7), 822-828.
10- Cauza, E., Hanusch-Enserer, U., Strasser, B., Ludvik, B., Metz-Schimmerl, S., Pacini, G., … & Dunky, A. (2005). The relative benefits of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus. Archives of physical medicine and rehabilitation, 86(8), 1527-1533.
11- Brooks, N., Layne, J. E., Gordon, P. L., Roubenoff, R., Nelson, M. E., & Castaneda-Sceppa, C. (2007). Strength training improves muscle quality and insulin sensitivity in Hispanic older adults with type 2 diabetes. International journal of medical sciences, 4(1), 19.
12- Lee, J., Kim, D., & Kim, C. (2017). Resistance training for glycemic control, muscular strength, and lean body mass in old type 2 diabetic patients: a meta-analysis. Diabetes Therapy, 8(3), 459-473.
13- Schmid, A. A., Atler, K. E., Malcolm, M. P., Grimm, L. A., Klinedinst, T. C., Marchant, D. R., … & Portz, J. D. (2018). Yoga improves quality of life and fall risk-factors in a sample of people with chronic pain and Type 2 Diabetes. Complementary therapies in clinical practice, 31, 369-373.
14- Ahn, S., & Song, R. (2012). Effects of tai chi exercise on glucose control, neuropathy scores, balance, and quality of life in patients with type 2 diabetes and neuropathy. The Journal of Alternative and Complementary Medicine, 18(12), 1172-1178.
15- Mueller, M. J., Tuttle, L. J., LeMaster, J. W., Strube, M. J., McGill, J. B., Hastings, M. K., & Sinacore, D. R. (2013). Weight-bearing versus nonweight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial. Archives of physical medicine and rehabilitation, 94(5), 829-838.
16- Colberg, S. R. (2017). Key points from the updated guidelines on exercise and diabetes. Frontiers in endocrinology, 8, 33.
17- Johansen, M. Y., MacDonald, C. S., Hansen, K. B., Karstoft, K., Christensen, R., Pedersen, M., … Ried-Larsen, M. (2017). Effect of an Intensive Lifestyle Intervention on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial. JAMA, 318(7), 637–646. doi:10.1001/jama.2017.10169
18- Praet, S. F., van Rooij, E. S., Wijtvliet, A., Boonman-de Winter, L. J., Enneking, T., Kuipers, H., … van Loon, L. J. (2008). Brisk walking compared with an individualised medical fitness programme for patients with type 2 diabetes: a randomised controlled trial. Diabetologia, 51(5), 736–746. doi:10.1007/s00125-008-0950-y