By Maria A. Perri, D.C., D.A.C.R.B.
The American Academy of Family Physicians has estimated that up to two-thirds of all office visits to family doctors are for stress-related symptoms. Research over the last 2 decades has indicated that up to 60% of all HMO visits are made by people with no diagnosable disorder–the “worried well” (Sobel)–and that many of these presenting symptoms are related to the patient’s psychosocial functioning–things such as depression, anxiety, social isolation, overwork, etc. (Kroenke & Mangelsdorff ). At least one third of cardiology patients presenting with chest pain who have normal or near normal coronary arteries have been found to be suffering from panic disorder (Kusher).
Are you interested in improving your ability to co-manage your neuro-musculoskeletal patient’s who also suffer from these all pervasive psychosocial issues? The important question, “How do you alter your treatment protocols for special populations?” is asked during the skills section of the ACRB’s Oral Practical Examination. Those taking the test are asked detailed questions about the rehab program they would create for a geriatric or pediatric patient or for an elite athlete. How would you answer this question today if your patient’s condition was stress related? Do you presently have the skill set to effectively participate in the co-management of patients with high blood pressure, colitis, sleep disturbances, depression or anxiety disorders? A large percentage of your patients with NMS related complaints are also suffering with many stress related ailments. When you begin to delve into their history you will find that a majority of your patients have an “Upper Stress Syndrome”; Hypertonicity of the amygdala and adrenal glands and Inhibition of the diaphragm and pre-frontal cortex (Perri, 2010 – I just made this up!) Seriously, as Chiropractors, I believe we can do more for these patients than give a good referral.
At the annual ACRC’s Conference held this past March in LA, I presented a brief introduction to mindfulness and the neurobiology of well-being. Simply put, mindfulness is a way of focusing attention in the present moment and being fully present with the intension of experiencing rather than judging. Practicing mindfulness is recommended for anyone in a helping profession as it can lead to enhanced listening skills and a greater sense of health and well-being for the practitioner. Exposing patients to the concept of mindfulness can give them invaluable self care tools to better manage pain as well as stress with greater ease.
Many of us can recall times when we have experienced moments of mindfulness. Time stood still, our awareness was peaked and we were totally in the moment. When asked about these moments several in our group recounted unforgettable moments of near death experiences or readiness for winning a competition. All of us could also recall too many times when we were on automatic pilot; experiences of driving, eating, showering and (oh should we admit it) taking a patient’s history. During these moments we zone out and experience a time lapse so that when we come back to awareness we cannot recall what happened while we were “away”. These experiences are the antithesis of mindfulness.
There is a way to have moments of total presence more often and it is simple – practice! In fact, research has shown over the last 30+ years that the way we focus our attention can create actual structural changes in the brain that are measurable and reproducible. Dan Siegel describes in his groundbreaking book The Mindful Brain: The Neurobiology of Well-being the way mindfulness practice creates structural changes in the pre- frontal cortex and what effects these changes have on behavior, health and the experience of well-being.
Siegel describes the first function of the pre-frontal cortex as auto regulation of the autonomic nervous system. Patients with anxiety, high blood pressure, digestive disturbances or sleeping disorders can benefit greatly from a calmed sympathetic nervous system and a para-sympathetic nervous system that is supported and balanced.
Recent research has shown that mindful practices influence pain modulation and may be valuable in the treatment of central sensitization and chronic pain. Montreal University researchers from the lab of Pierre Rainville, PhD found that meditators experienced an 18% reduction in pain sensitivity compared to their non-meditating counterparts.
Building on this earlier study, researchers have found that Zen meditation can decrease sensitivity to pain by thickening brain matter. They measured thermal pain sensitivity of 17 seasoned meditators and compared them to that of 18 people who haven’t practiced any form of meditation or other relaxation techniques such as yoga.
The researchers placed a heated plate on the calf of participants and used Magnetic Resonance Imaging (MRI) to conduct brain scans. The results? Meditators had significantly thicker anterior cingulate, a region of the brain known for pain and emotion regulation. And with this thickening of the brain, pain sensitivity was decreased. The entire study can be found in a special edition of the American Psychological Association’s Journal Emotion.
The Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School is a visionary force and global leader in mind-body medicine. For thirty years, they have pioneered the integration of mindfulness meditation and other mindfulness-based approaches in mainstream medicine and healthcare. This includes patient care, research, academic medical and professional education, and into the broader society through diverse outreach and public service initiatives.
More than 18,000 patients have completed their 8 week Stress Reduction Program spearheaded by Jon Kabat Zinn called the MBSR (Mindfulness Based Stress Reduction) program. In addition, over 4,000 physicians as well as other healthcare providers have referred their patients to this program with exceptional results. Thousands of people worldwide have entered similar programs offered by practitioners trained by senior staff members at The Center for Mindfulness.
Their work over three decades has shown consistent, reliable, and reproducible demonstrations of major and clinically relevant reductions in medical and psychological symptoms across a wide range of medical diagnoses. This includes many different chronic pain conditions [Kabat-Zinn, 1982; Kabat-Zinn, Lipworth and Burney, 1985; Kabat-Zinn et al, 1986] as well as other medical diagnoses. [Kabat-Zinn and Chapman-Waldrop, 1988] Gains were also recorded in medical patients with a secondary diagnosis of anxiety and/or panic disorders. [Kabat-Zinn et al, 1992; Miller et al, 1995] A reduction of symptoms was shown over the eight weeks of MBSR intervention. The most significant finding is the maintenance of these changes in some cases for up to four years of follow-up.
Duke Integrative Medicine in Raleigh, North Carolina offers the 8 week Mindfulness Based Stress Reduction Program. The majority of people who complete the course report:
- Lasting decrease in physical and psychological symptoms
- An increase in ability to relax
- Reduction in pain levels and an enhanced ability to cope with chronic pain that may be permanent
- Greater energy and enthusiasm for life
- Improved self-esteem
- An ability to cope more effectively with both short and long-term stressful situations.
The new wave in progressive healthcare is called “integrative, participatory medicine”. It is a cooperative model of healthcare that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care. As early as 1946, The World Health Organization defined optimal health as “more than the absence of disease, involving mental, physical and social well-being.” Surprisingly familiar to what I learned on the first day of philosophy class in Chiropractic school. Duke University’s Department of Integrative Medicine offers the model below depicting the essential role of mindfulness in overall health and well being.
There is power and empowerment in participatory, integrative medicine. By adopting practices of mindfulness, patients can collaborate with providers to restore their own health, wholeness and balance and harmony within.
Duke Integrative Medicine
How to integrate mindfulness into your Chiropractic practice:
The pace of our lives is so fast with constant demands and never ending to do lists. Sometimes our well-intentioned, well documented, evidence based rehab program is just another thing on a patient’s never-ending list.
Even our patients with “balanced” and happy lives often take time for exercise, but rarely make time to really relax the mind and body and just “be”.
Mindfulness exercises are so easy to do and regular practice can produce profound health benefits. The instructions are very simple:
- Sit in a dignified position with a lengthened spine
- Focus on your breath
- Stay present
When thoughts arise as they inevitably do, return your focus back to the breath
There are many ways to practice mindfulness:
- formal sitting practice/Walking meditation
- Yoga/Tai Chi/Running (mindfully)
- Centering prayer
- Mundane activities done mindfully like walking the dog or washing dishes
If you are interested in learning mindfulness yourself or integrating mindfulness into your treatment approach I have several suggestions that will help you get started.
- Learn more about the Mindfulness Based Stress Reduction Program at UMass Medical School by visiting www.umassmed.edu/cfm/
- Visit www.Dukeintegrativemedicine.org to see a state of the art integrated program with mindfulness as the core operating principle
- Read these books:
- THE MINDFUL BRAIN –THE NEUROBIOLOGY OF WELL-BEING by Daniel Siegel MD
- HEAL THYSELF by Saki Santorelli (director of The Center for Mindfulness in Medicine, Health Care, and Society)
- Go to SoundsTrue.com – for free podcasts, books, audio & on line courses from the leaders: Zinn, Kornfield, Thich Nhat Hanh, Chodrin, Siegel and so many more
- Join the Natl Inst. for Clinical Application of Behavior Medicine and explore their many related offerings: www.nicabm.com
- Find a MBSR instructor in your area. Offer the 8 week course through your practice (and take it yourself).
The practice of mindfulness has a profoundly positive influence in my life, both personally and professionally. It is my intention to continue to share the depth and the wealth of this ancient knowledge, art and more recent science with our Rehab group. I hope that it inspires you and expands your skills to provide active care with the functional goal of well-being.
I leave you with the words of Sandy Wells, the founder of The Institute for Mindful Living:
Mindfulness is a way of learning to relate directly to your own experience with acceptance. It is a way to take charge of your life by developing the capacity to pay attention, moment-by-moment, without judgment, to the continuous stream of your experience.
It is a way of doing something for yourself that no one else can do for you — to consciously and systematically work with your own mind and learn to alleviate stress, pain, illness, and to relate to the challenges and demands of everyday life with awareness.
It is a way to develop sensitivity to all aspects of self: body and mind, heart and soul, and to restore within yourself a balanced sense of health and well-being.
The Institute for Mindful Living
Bibliography — Peer Reviewed Papers
Kabat-Zinn, J. An out-patient program in Behavioral Medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. Gen. Hosp. Psychiatry (1982) 4:33-47.
Kabat-Zinn, J., Lipworth, L. and Burney, R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J. Behav. Med. (1985) 8:163-190.
Kabat-Zinn, J., Lipworth, L., Burney, R. and Sellers, W. Four year follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance. Clin.J.Pain (1986) 2:159-173.
Kabat-Zinn, J. and Chapman-Waldrop, A. Compliance with an outpatient stress reduction program: rates and predictors of completion. J.Behav. Med. (1988) 11:333-352.
Ockene, J., Sorensen, G., Kabat-Zinn, J., Ockene, I.S., and Donnelly, G. Benefits and costs of lifestyle change to reduce risk of chronic disease. Preventive Medicine, (1988) 17:224-234.
Bernhard, J., Kristeller, J. and Kabat-Zinn, J. Effectiveness of relaxation and visualization techniques as a adjunct to phototherapy and photochemotherapy of psoriasis. J. Am. Acad. Dermatol. (1988) 19:572-73.
Ockene, J.K., Ockene, I.S., Kabat-Zinn, J., Greene, H.L., and Frid, D. Teaching risk-factor counseling skills to medical students, house staff, and fellows. Am. J. Prevent. Med. (1990)6 (#2): 35-42.
Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K., Pbert, L., Linderking, W., Santorelli, S.F. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am. J Psychiatry (1992) 149:936-943.
Miller, J., Fletcher, K. and Kabat-Zinn, J. Three-year follow-up and clinical implications of a mindfulness-based stress reduction intervention in the treatment of anxiety disorders. Gen. Hosp. Psychiatry (1995) 17:192-200.
Massion, A.O., Teas, J., Hebert, J.R., Wertheimer, M.D., and Kabat-Zinn, J. Meditation, melatonin, and breast/prostate cancer: Hypothesis and preliminary data. Medical Hypotheses(1995) 44:39-46.
Kabat-Zinn, J. Chapman, A, and Salmon, P. The relationship of cognitive and somatic components of anxiety to patient preference for alternative relaxation techniques. Mind/ Body Medicine (1997) 2:101-109.
Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Scharf, M.S., Cropley, T. G., Hosmer, D., and Bernhard, J. Influence of a mindfulness-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA) Psychosomat Med (1998) 60: 625-632.
Saxe, G., Hebert, J., Carmody, J., Kabat-Zinn, J., Rosenzweig, P., Jarzobski, D., Reed, G., and Blute, R. Can Diet, in conjunction with Stress Reduction, Affect the Rate of Increase in Prostate-specific Antigen After Biochemical Recurrence of Prostate Cancer? J. of Urology, In Press, 2001.
Abstracts and Poster Sessions
Kabat-Zinn, J. and Burney, R. (1981) The clinical use of awareness meditation in the self-regulation of chronic pain. Pain Supplement 1, p.S273 (abs). Poster presented at III World Congress on Pain, Edinburgh, August, 1981.
Kabat-Zinn, J., Lipworth, L., Sellers, W., Brew, M., and Burney, R. Reproducibility and four year follow-up of a training program in mindfulness mediation for the self-regulation of chronic pain. Pain Supplement 2 pg.S303 (1984) (abs).Poster presented at IV World Congress on Pain, Seattle, Sept, 1984.
Kabat-Zinn, J., Beall, B. and Rippe, J. A systematic mental training program based on mindfulness meditation to optimize performance in collegiate and olympic rowers. Poster presented at VI World Congress in Sport Psychology, Copenhagen, Denmark, June, 1985.
Bath, J., Alfred, H. Powell, P., Cohen, A., Baker., S. and Kabat-Zinn, J. Patient Education: Relaxation training via videotape reduces cramping in patients undergoing chronic hemodialysis. Paper presented at APHA, Washington, D.C., Nov.18, 1985.
Kabat-Zinn, J., Goleman, D., and Chapman-Waldrop, A. Relationship of cognitive and somatic components of anxiety and depression to patient preference for alternative relaxation techniques. Poster presented at SBM, San Francisco, March 1986.
Kabat-Zinn, J. Sellers, W. and Santorelli, S. Symptom reduction in medical patients following stress management training. Poster presented at AABT Meetings, Chicago, Nov. 15, 1986.
Kabat-Zinn, J. and Chapman-Waldrop, A. Compliance with physician referral for stress management training. Poster presented at AABT Meetings, Chicago, Nov. 15, 1986.
Kabat-Zinn, J. Six-month hospital visit cost reductions in medical patients following self-regulatory training. Poster presented at SBM, Washington D.C. March 22, 1987.
Chapman-Waldrop, A. and Kabat-Zinn, J. SCL-90-R symptom profiles for seven diagnostic categories of medical patients. Poster presented at SBM, Washington, D.C., March 21, 1987.
Chapman-Waldrop, A. and Kabat-Zinn, J. Patient evaluation of multiple relaxation techniques: relationship to compliance and treatment outcome. Poster presented at SBM, Washington, D.C., March 22, 1987.
Kabat-Zinn, J. and Chapman-Waldrop, A. Compliance with physician referral for cognitive/behavioral intervention in chronic pain patients. Pain Suppl 4, pg. S170 1987.
Kabat-Zinn, J., Tarbell, S., French, C., Santorelli, S., Dubois, J., Curley, F., Pratter, M., and Irwin, R. Functional status of patients with COPD following a behavioral pulmonary rehabilitation program. Poster presented at SBM Meetings, Boston, April 29 (1988).
Frid, D., Ockene, J., Kabat-Zinn, J., Tarbell, S., and Doefler, L. Training primary care physicians in behavioral medicine: graduate medical education. Paper presented at SBM Meetings, Boston, April 30 (1988).
Kabat-Zinn, J. The clinical uses of mindfulness in behavioral medicine. Paper presented at AABT Meetings, Washington D.C., November 5, 1989.
Curley, F.J., French, C.L., Tarbell, S., Kabat-Zinn, J., and Irwin, R.S. Do patients perceive and cope with dyspnea similarly to pain? Paper presented at the American Thoracic Society Meetings, Boston, May 21, 1990.
Weinberger, J., McLeod, C., McClelland, D., Santorelli, S.F., and Kabat-Zinn, J. Motivational change following a meditation-based stress reduction program for medical outpatients. Poster presented at the lst International Congress of Behavioral Medicine, Uppsala, Sweden, June 28, 1990.
Kristeller, J., Peterson, L., Massion, A., Pbert, L., Miller, J., and Kabat-Zinn, J. Mindfulness-based stress reduction in the treatment of anxiety disorders: effectiveness and limitations. Poster presented at the lst International Congress of Behavioral Medicine, Uppsala, Sweden, June 28, 1990.
Kabat-Zinn, J., Mumford, G., Levi-Alvares, D., Santorelli, S., and Skillings, A. A mindfulness-meditation based stress reduction clinic for low-income inner city residents: outcomes and receptivity. Poster presented at the 14th annual meeting of the Society of Behavioral Medicine, San Francisco, March 11, 1993.
Miller, J., Fletcher, K., and Kabat-Zinn, J. Effectiveness of a meditation-based stress reduction intervention in the treatment of anxiety disorders: Three-year follow-up. Poster presented at Society of Behavioral Medicine, San Francisco, March 11, 1993.
Kabat-Zinn, J. Some clinical and social applications of Buddhist mindfulness meditation in mainstream medicine and health care. Paper presented, First International Congress on Health Psychology, Tokyo, Japan, July 28, 1993.
Kabat-Zinn, J. Mindfulness: What it is and what it isn’t, and its value in mainstream medicine, health care, and daily living. Paper presented at International Symposium on the Comparative and Psychological Study of Meditation, Makuhari, Japan, August 2, 1993.
Kabat-Zinn, J. A fifteen-year experience using mindfulness meditation and yoga in the mainstream of medicine and health care. Paper presented at the Society of Behavioral Medicine Annual Meeting, Boston, April 14, 1994, and at the American Psychosomatic Society Annual Meeting, Boston, April 14, 1994.
Sobe,DS. Rethinking Medicine: Improving Health Outcomes with Cost-Effective Psychosocial Interventions. Psychosomatic Medicine (1995) 57:234-44
Kroenke, K, Mangelsdorff, AD. Common Symptoms in Ambulatory Care: Incidence, Evaluation, Therapy and Outcome. Am J Med (1989) 86:262-266
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Roth, B and Creaser, T. Mindfulness meditation-based stress reduction: Experience with a bilingual inner-city program. The Nurse Practitioner (1997) 22:150-176.
Shapiro, SL, Schwartz, GE, and Bonner, G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med (1998) 1:93-98.
Shapiro, SL and Schwartz, GE. Mindfulness in medical education: Fostering the health of physicians and medical practice. Integrative Med (1998) 21:581-599.
Shaprio, SL and Schwartz, GE. The role of intention in self-regulation: Toward intentional systemic mindfulness. In Boekaerts, M., Pintrich, PR, and Zeidner, M (Eds) Handbook of Self-Regulation, Academic Press, New York (1999, in press).
Randolph, PD, Caldera YM, Tacone AM et al. The long-term combined effects of medical treatment and a mindfulness-based behavorial program for the multidisciplinary management of chronic pain in West Texas. Pain Digest (1999)9:103-112.
Teasdale, JD. Metacognition, mindfulness and the modification of mood disorders. Clin Psychol Psychother (1999) 6:146-155.
Epstein, R.M. Mindful Practice. JAMA (1999) 262:833-839.
Marlatt, G A, and Kristeller, J. Mindfulness and Meditation. In: Miller, WR (Ed), Integrating spirituality into treatment(1999) 67-84.
Teasdale, JD, Segal, ZV, Williams MG, Ridgeway, VA, Soulsby, JM, Lau, MA. Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy. J. of Consulting and Clinical Psychology (2000) 68:615-623.
Speca, M, Carlson, LE, Goodey, E, Angen, M. A randomized, wait-list controlled clinical trial: the effect of a mindfulness-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med (2000) 62:613-622.
Mills, N, Allen, J. Mindfulness of movement as a coping strategy in multiple sclerosis: a pilot study. Gen Hosp Psychiatry (2000) 22:425-431.
Williams JMG, Teasdale JD, Segal ZV and Soulsby J. Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. J Abnorm Psychol (2001).