Hi! I'm Dr Andrea Furlan, a physiatrist and pain specialist in Toronto.
In another video that i made i mentioned that the five
Ms of treatment for chronic pain include
medications, mind, movement, modalities and manual therapy.
Today, i will explain what the mind-based therapies are. Some examples are cognitive behavior, therapy
mindfulness meditation, hypnosis, and acceptance and commitment therapy.
So, let's talk about mind-body therapies for pain.
The World Health Organization defines health has a stage of complete
physical, mental, and social well-being. And it's not merely the absence of
disease or infirmity. I conceptualize diseases as infirmities
using a bio-psychosocial spiritual model.
In pain medicine, we use this model to treat the individual as a whole,
and that's why we recommend an interprofessional team
to assess and treat individuals with chronic pain.
Some professions will focus on the biological aspects of pain. like doctors
and pharmacists. The physiotherapist may work with fear
of movement, which is a very common psychological challenge for people with
chronic pain. The nurse may work with them on
increasing their social supports. And our social worker may help the
person to reconnect with a faith-based group,
and help them find purpose in life and meaning to their suffering.
The mind is where our feelings, thoughts, and desires are processed. Our minds are
always telling us: I feel. I think. I want. We feel pain,
we think about pain, and we want something,
usually we want the pain to go away. Unfortunately,
the more we think about pain the more memories
we are creating in our mind, and it's really hard to get rid of memories,
especially memories of pain. Therefore we need to learn
how not to think about pain and distract our minds
with other more interesting things. There is research that shows that our emotions
determine how much pain we feel, so the same
painful stimulus or injury will seem worse when we are sad, and it
will seem less intense when we are happy. If our brain is
distracted with other tasks, we may be less aware of
our pain than if our attention is focused on it,
especially if we are frightened or angry about the pain.
Our brain may also get overwhelmed with feeling pain all the time,
and stay in a constant state of hyper- vigilance.
And it's very common in some chronic pain syndromes like fibromyalgia,
and CRSP. I have another video that i explain fibromyalgia,
and one on CRPS that you can access. There are aspects of our personalities,
the way we were raised has a child, and previous
experiences in our lives that make us all different. These
differences also affect how we perceive, how we
communicate, and how we cope with pain. For example
some people are more optimistic in general. They are the kind of people who
are able to always see the bright side of
things in life. We know that people who have this kind
of personality tend to have a better recovery from
acute pain. If they develop chronic pain they
are less likely to have disability, or the chronic pain
should be very debilitating. On the other hand, people who are more
pessimistic, who worry more, or even imagine the worst
are more likely to develop chronic pain, but also to suffer more from their pain.
There is a questionnaire to assess this personality trait.
I don't like the name they gave to the trait,
because it says the people who are more pessimistic,
they are catastrophizers, which means they tend to see the potential for a
catastrophe in the events in their lives.
Well, the good news is that there has been research
over the past 50 years, conducted by psychologists and psychiatrists from all
over the world, and who have developed a number of
treatments that can help the mind aspect of people with chronic
pain. We are now very fortunate to have
various options for improving the "I feel, I think and I want"
functions of our mind. I will summarize some of these strategies that have
the most evidence of effectiveness from research studies.
Cognitive behavior therapy or CBT. The cognitive part
is about what we think, the interpretation that we give to the
things we are feeling. Sometimes what we think about is not
correct or helpful. I see people with chronic
pain all the time who have wrong thoughts and need someone
to help them to think about what they are thinking. This is the
cognitive part. The behavior part of CCT the "B"
in CBT is about what you do when you have chronic pain.
Such as activity pacing versus overdoing. Now if you're now thinking differently
you're ready to do things differently and get more enjoyment and less pain in
what you do. CBT is often offered by psychologists
or trained mental health counselors. Unfortunately,
this can be very expensive therapies. However,
more recently, therapists have developed online groups for CBT,
and computer-based CBT. Many of these are free or very low cost. Research
indicates that they are as effective has CBT delivered by
a professional face to face. I recommend CBT
to many of my patients. Let's talk about biofeedback. Biofeedback involves a
device or a machine that measures the stress response of the
body, like the hand sweats, the heart rate, or
the blood pressure in real time. Then these measures
are transformed into a visual scene or a auditory sound that is presented to the
person as a marker of their stress at the moment. Then, the person learns
techniques to reduce their stress levels, and they see or hear the feedback from
the machine or device in real time. It's not only about
relaxation, but it's also about shifting attention
and promoting an objective and precise understanding of what is
going in both the body and the mind, and how
they influence each other. Biofeedback
treatment has been shown to be effective for pain in children
and for phantom limb pain, which is a pain in the limb that has been amputated,
and is therefore very hard to treat. The main problem with biofeedback is that
these sessions are usually very expensive.
Let's talk about mindfulness. Now mindfulness is
sometimes referred to as mindfulness meditation,
or mindfulness based stress reduction. This group of therapies are focused on
building awareness and accepting of here and now
experiences, including pain and emotions. The person
is trained to feel these body sensations and emotions
in a non-judgmental way. The benefits of mindfulness for pain
are usually achieved in people who practice meditation
every day. The meditation training sessions
are usually done in a group and may involve
three components: a body scan to pay attention to the entire body, from
feet to head, and all the sensations coming from the body.
Then a sitting meditation usually involving breathing exercises,
and then, finishing with some stretching or posture
exercises. I have many patients who are able to reduce the use of painkillers
just with doing meditation, and they tell me
that one session of meditation is similar to taking one tablet
of their medication. So I tell them just to change one letter: change
medication by meditation. Again there is research from around the
world that supports the effectiveness of
mindfulness-based therapies. So now, let's talk about yoga. Yoga
is very similar to mindfulness-based therapies.
It places emphasis on mental fitness, as well as physical fitness. It combines breath control, meditation, and exercises to strengthen and stretch
and exercises to strengthen and stretch the muscles. There are many research studies showing
that yoga is helpful for people with low back pain,
fibromyalgia, arthritis, and migraines.
The main advantages is that there are many resources on the
internet teaching yoga, and my patients can access this from home.
I tell them that they need to practice for at least 45 minutes
a few times a week to notice the benefit for chronic pain.
But there are so many types of yoga these days, some are more vigorous
and done in a heated environment. I tell my patients to be careful,
and really talk to the instructors, and ask
if that type of yoga is appropriate for people with chronic pain.
Let's talk about hypnosis and guided imagery. There is evidence from medical
research studies demonstrating that hypnosis is helpful
to reduce the perceptions of pain in our mind.
It's also helpful to reduce pain and unpleasantness,
and use of opioids. There are many studies showing that in surgical
procedures or acute pain, the perceptions of pain were much
reduced with hypnosis. Hypnosis involves entering an altered
state of consciousness through a focused attention and helpful
suggestions. The component of suggestions help
changing thoughts, emotions and sensations, which is
basically using suggestions to change what our mind is saying "I feel, I think,
I want". I remember a young patient that I had.
I saw him many years ago who. He told me that he had stopped
using his opioids for chronic pain. So, when I asked him how he did it,
he showed me an app on his cell phone. It was installed
an app for self-hypnosis. He told me that every time he had
the pain and an urge to take his opioid, instead of
taking his short acting opioid, he turned the app,
and did a self-hypnosis. He does not need to use the opioids anymore.
I was amazed, but not entirely surprised, since the research supports what he told
me. Guided imagery involves active
imagination of visual, auditory, and body sensations
and perceptions. Both hypnosis and guided imagery aim at
reducing pain by using a focused attention and
imagination to superimpose sensations that are
pleasurable on the painful body areas. It seems that these two therapies work
better for acute pain condition, but clearly can be helpful for some
people with chronic pain. Acceptance and commitment therapy or ACT
I recommend many of my patients to go
to ACT. This therapy emphasizes the importance of accepting pain,
and focusing on goals that are important to that person.
I like this type of therapy because it is very goal-oriented and personalized.
Each person has a different goal, or many goals they want to achieve,
they want to achieve now, next week, next month, next year.
I see many of my patients with their lives on hold
because of the pain. And I feel so sorry for them because
they are missing out on important functions.
They are missing a nice family reunion, or
the graduation of their children, the vacation trip,
or postponing their careers. ACT has been transformative
for many of my patients. They finally accept
that their pain is here to stay, and they move on
with their life goals because they are in control
of what they can and cannot do. Not the pain.
I remember one patient that finished her ACT sessions,
and returned to see me for a follow-up visit.
She was so different and happier. She didn't even want to talk about her pain
with me. She only talked about her life. And when I asked her "How is your pain"?
She said: It's still here, but I don't pay attention to it anymore.
So it's not bothering me. I have so many other things in life to do.
I don't have time to marinate in the misery juice anymore.
ACT is a fairly new treatment but it has grown
a number of research studies supporting its effectiveness,
for helping people with chronic pain to get on with their lives.
So, to summarize. Pain physicians like me, we need to understand these
mind-based therapies and recommend them to our patients with
chronic pain. And for patients with chronic pain, when
I send you to a mind-body therapist, or a psychologist, please, do not
interpret this as me saying "I don't believe you have
real pain" or "I think you're inventing this pain"
because there's nothing wrong with your body that I can detect.
I'm trying to help you, and need to treat you as a whole.
I believe we are spirits, with minds, living in a temporary body, and that's
why I use a holistic approach. Now please,
remember that this video is not intended to provide medical advice.
It's only for educational purposes, if you have pain and you think you need
any type of mind based therapy please consult your doctor,
or a psychologist to get professional advice and a treatment plan for you.
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there. Bye for now.