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The Therapeutic Alliance and Low Back Pain

Written by Kieran Macphail on . Posted in Uncategorized

The therapeutic relationship has been defined as;

“A helping relationship that’s based on mutual trust and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the gratification of your patient’s physical, emotional, and spiritual needs through your knowledge and skill” (Pullen and Mathias 2010).

All practitioners of the “healing arts” have experienced the importance of this relationship in helping to get the patient to comply with assessment, explain what they feel and want and helping them turn up for follow ups! In recent years more research has been conducted on the therapeutic alliance and just how powerful a positive one can be for improving care.

One systematic review has been conducted. However, Manzoni et al (2018) conducted their systematic review too soon, as by the author’s admission there is insufficient studies to date on the therapeutic alliance. All studies they reviewed examined low back pain patients. Two studies examined therapeutic alliance incentive measures and produced significant improvements in pain. The remaining four studies without alliance incentives showed no clear relationship.

Fuentes et al (2018) conducted an interesting four-arm trial on Interferential, sham interferential, with a good therapeutic alliance and poor therapeutic alliance with low back pain patients. Each session was thirty minutes. In the good therapeutic alliance during the first 10 minutes, each participant was questioned about his or her symptoms and lifestyle and about the cause of his or her condition. Therapists were encouraged to listen actively by repeating the patient’s words and asking for clarifications, tone of voice, nonverbal behaviors such as eye contact, physical touch, and empathy. For example saying, “I can understand how difficult LBP must be for you.” The therapist then stayed in the room during the entire treatment and during the measurement of outcomes. During this time, verbal interaction between the therapist and participant was encouraged. Finally, at the end of the session, a few words of encouragement were given. In the poor therapeutic alliance group, interaction was limited to about 5 minutes during which the therapist introduced herself and explained the purpose of the treatment. Participants were told that this was a “scientific study” in which the therapist had been instructed not to converse with participants. After setting up the interferential the therapist left the room and returned 15 and 30 minutes into the treatment to be present when the tester arrived to conduct outcome assessment. Mean differences on the post intervention NRS were 1.83 cm active interferential and poor therapeutic alliance, 1.03 cm for sham interferential and poor therapeutic alliance, 3.13 cm for the active interferential and good therapeutic alliance, and 2.22 cm for the sham interferential and good therapeutic alliance. Mean differences on PPTs were 1.2 kg, 0.3 kg, 2.0 kg, and 1.7 kg respectively. Thus therapeutic alliance was more effective at reducing NRS and pressure pain thresholds than the interferential. In looking at this study its remarkable how simple the instructions were to develop therapeutic alliance, and likely therapists went further naturally. Nonetheless the results are very impressive when you see sham interferential with good alliance outperform active interferential therapy and poor alliance.

The results of Fuentes et al (2018) suggest that by merely developing an effective therapeutic alliance, a sham treatment or very ineffective one may be beneficial. This may well be part of why many practitioners of methods established as ineffective can protest the effect of their method. They may be seeing the beneficial results of the therapeutic alliance they are developing and attributing their excellent results to their ineffective techniques. Although not discussed here it is likely a better therapeutic alliance will lead patients to over report on improvements in their symptoms as well.

Given that human interactions are difficult to quantify, there’s an argument qualitative research is especially useful in exploring the therapeutic alliance. Stenner et al (2018) conducted a qualitative investigation in to what matters most in physiotherapy consultations to patients. They interviewed 15 patients and physiotherapists. The key themes that emerged were that communication within physiotherapy is underexplored and frequently overlooked, understanding what is important to a person is vital to ensure a positive outcome, people’s issues are often simple but are sometimes voiced in an unstructured way, clinicians need to better support people to elicit ‘what matters to them’ and meaningful conversations may encourage an active role for people in their care.

Holopainen et al (2018) conducted a phenomenographic study to identify and describe the contextual nature of the conceptions of patients with low back pain of their encounters in the health care system. Seventeen patients with chronic or episodic low back pain classified as “high risk” were interviewed in open recall interviews, using videos of patients’ initial physiotherapy sessions that had been recorded previously. They classified themes in four levels: “non-encounters”, seeking support, empowering collaboration and autonomic agency. The key differences between the first and second categories were professionals “being present” and patients starting to understand their low back pain. Between the second and third category, the key aspects were strong therapeutic alliance and the active participation of the patient. Finally, the key differences between the third and fourth categories were the patient being in charge and taking responsibility while knowing that help was available if required. It’s possible to see this as a model for developing the therapeutic alliance as shown in figure 2. .

Figure 1. Based Holopainen et al’s (2018) Findings

In using this framework to evaluate clinical relationships some interesting practical insights can be attained. For example in shadowing a private pain consultant I saw a patient attend who was desperate for the consultant to give her an injection or a different medication to relieve her chronic sub occipital pain. She had an MRI, CT spect, botox, steroid injections and had tried various medications. In putting her through my interpretation of Holopainen’s et al’s (2018) findings it was clear she did not understand her condition and in many ways she was not really present in that she was not ready to listen and engage but knew what she wanted and did not want to hear anything else. There seemed to be no real positive therapeutic alliance between her and any of the many healthcare providers she had seen. She was clearly an active participant in that she was actively seeking out new specialists to try and find a solution but she was unwilling to do any exercises for herself as she had tried that and it did not “work”. She was very much in charge and had seeded no control elsewhere. In terms of locus of control she had an internal locus of control over care seeking but not in treatment. Interestingly though with her care seeking behaviour, she was very autonomous but not in a positive way. Thus with this example it was clear how much education was needed to help her understand her condition, her treatment options and give her a positive therapeutic relationship to help her manage symptoms. Thus Holopainen et al’s (2018) findings could be better constructed as a pyramid where education on the patient’s condition, prognosis and options is a key foundation for a healthy therapeutic alliance, which will lead to a positive autonomy versus an unhealthy autonomy.

Figure 2. Layered Approach To Developing The Therapeutic Alliance Based On (Holopainen et al 2018)

Further understanding of the nature of this education can be gleaned when considering a hypothetical example the patient who has seen a well meaning therapist that educated them on the importance of bracing their core and avoiding rounding or over extending their back. Furthermore their pain consultant had told them they had the spine of an 80 year old. This patient has been educated, may develop a “positive” therapeutic alliance with their therapist and become autonomous, a model patient, in applying this “faulty” model which may in some cases do more “harm” than good. Thus therapeutic alliance must be placed within an, evolving, evidence-based medicine, bio-psycho-social approach.

This understanding helps to shed further light on the findings of Trager et al (2018) who found no benefit for two 30-minute pain education sessions over placebo in acute LBP patients when added to usual care in their RCT. However, placebo was active listening for 30 minutes. It is likely this active listening was developing a strong rapport whereas the education sessions are less likely to. Both of these interventions are part of the process of developing the therapeutic alliance. It is hard to see either as individual isolated interventions when viewed within this context.

In my MSc research (Macphail 2018) I drew the distinction between the clinical reasoning of what is best for the chronic low back pain patient and getting the patient to do what is best for them. Part of this is the therapeutic relationship. Figure 3 shows the iterative cycle that emerged from my interviews with a variety of experienced physiotherapists when describing how they would manage a typical chronic low back pain patient with yellow flags. Building rapport is essentially developing the therapeutic alliance, whilst the whole cycle is the workings of the therapeutic alliance.

 

Figure 3. Iterative cycle to help patients do what is best for them

All interviews placed a strong emphasis on understanding the patient. There were two elements to this one more focused on the technical aspect and another more focused on understanding the patient’s expectations, beliefs and past experience so as to develop rapport and adapt the assessment and treatment to better suit the patient. For example interview 3 outlined how she would vary her treatment approach based on the patient’s previous experiences.

Interviewee 3: He would say, “I have been to 2 different physio’s and they all
manipulated my back and each time it was terrible afterwards.” So of
course I would go over what I need to do, so I guess again it has a
lot to do with what the patient tells me.

There was a wide range of styles displayed for building rapport. For example interview 5 placed particular emphasis on rapport using humour.

Interviewee 5: I would probably say, “You just keep going until I get bored”, or something like that, to make a bit of a joke of it. Because if I can get that kind of jokey link with him I always feel that I can get better compliance with things.

All physiotherapists interviewed mentioned re-assurance and using the patient’s language. Broadly these were all strategies under rapport building which helped the physiotherapist to get the patient to do what the physiotherapist felt was technically best for them.

The simplest example of interviewees adapting is that they frequently stated they may only give a patient one or two exercises to gain compliance, despite that fact they felt the patient would benefit from more. This same theme shows up through the assessment and treatment process. For example interview 3 explained how she adapted her approach to delivering questionnaires depending on the patient.

Interviewee 3: I would not just want to give them a questionnaire, I
would want to explain to them that I am interested to understand their
problems from a lot of different aspects.

Whilst interview 5 described using manual therapy if that was what the patient expected so that the patient would comply with his more active approach.

Interviewee 5: Just to see if I can get the jump on them in terms of if they expect a manual approach, and you don’t give it to them, then I feel like they don’t listen as well to my active approach.

There was a strong emphasis throughout the interviews on empowering patients to manage their own symptoms, for example.

Interviewee 1: The homework is the most important bit

In particular clinicians described using the clinical audit process to get buy in for a patient to complete their home exercises. Furthermore education was used to empower patients to understand their symptoms. For example interview 3 went as far as to state it was probably the biggest influence on the therapeutic outcome.

Interviewee 3: What I believe is that if I can manage this problem of pain
equals harm, if I can address this successfully then usually it can
be very successful in these patients. But it is probably mainly can I
get his trust and compliance. I guess this is the interaction between
myself and him. It is probably the main thing which I believe makes a
successful intervention or not.

Holopainen et al (2018) focused on understanding the patient’s experience of the relationship, whereas my research (Macphail 2018) focuses on the practitioner’s role. Between these two papers the issues raised by Stenner et al (2018) are addressed and a combined understanding of the two may be useful. Holopainen et al’s work provides a framework for assessing where the relationship with that patient is at, and where it should look to go next. My research provides aspects for the therapist to consider to develop this relationship and how to structure what to work on in a session. Furthermore this may stimulate therapists to consider other factors not covered that improve the therapeutic alliance. Practically this might mean that a session plan could involve, pain education, re-assurance, exercise and an aim for developing the therapeutic alliance. For example if the figures presented here are consulted before the session and you feel the therapeutic alliance is at the seeking support stage. You may then consult figure 3 and consider where you are lacking. For example, do you need to adapt your communication, assessment and treatment better to the patient? Were they expecting hands on treatment, and you “just sat and talked” about pain in the first session? In the second session you could adapt this to do an active manual therapy technique whilst discussing pain education. Alternatively you might feel you don’t fully understand the patient’s beliefs and expectations yet and look to understand this better. Tentatively I suggest a plan for developing the therapeutic alliance should be in the session plan for each patient.

There is a long way to go before we can really objectively assess the therapeutic alliance, understand it algorithmically and develop it optimally. It is clearly a powerful intervention in itself and may explain part of the benefit and success of some interventions based on clearly ineffective methods. Figure 2 based on Holopainen et al’s (2018) findings gives a method of evaluation of the therapeutic alliance. Furthermore this can be used as way of planning how to develop the therapeutic alliance in the clinical setting. Figure 3 outlining part of my MSc research (Macphail 2018) provides an overview of the different factors a therapist consider in improving their therapeutic alliances. It is tentatively suggested a combination of the two approaches is used to assess and plan the development of therapeutic alliance as part of session planning.

 

References

Fuentes, J., Armijo-Olivo, S., Funabashi, M., Miciak, M., Dick, B., Warren, S., Rashiq, S., Magee, D.J. and Gross, D.P., 2014. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy, 94(4), pp.477-489.

Holopainen, R., Piirainen, A., Heinonen, A., Karppinen, J. and O’Sullivan, P., 2018. From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system. Musculoskeletal care.

Macphail, K. (2018) The Why, How and What, Physiotherapist Management of Chronic Low Back Pain Patients with Yellow Flags. In Press

Manzoni et al (2018) The role of the therapeutic alliance on pain relief in musculoskeletal rehabilitation: A systematic review. Physiother Theory Pract. 2018 Feb

Pullen Jr, R.L. and Mathias, T., 2010. Fostering therapeutic nurse-patient relationships. Nursing made incredibly easy, 8 (3), 4.

Stenner, R., Palmer, S. and Hammond, R., 2018. What matters most to people in musculoskeletal physiotherapy consultations? A qualitative study. Musculoskeletal Science and Practice, 35, pp.84-89.

Traeger, A.C., Lee, H., Hübscher, M., Skinner, I.W., Moseley, G.L., Nicholas, M.K., Henschke, N., Refshauge, K.M., Blyth, F.M., Main, C.J. and Hush, J.M., 2018. Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain: A randomized clinical trial. JAMA neurology.

The Low Back Pain Diet

Written by Kieran Macphail on . Posted in Back Pain and Diet, For Everyone!, Low back pain

Nutrition

 

  1. Sleep
    1. Track with sleep cycle, try to average 8hrs
    2. Less sleep increase sensitivity to painful stimuli and is associated with the onset of chronic pain problems
    3. Most people start to move towards a more “pro-inflammatory” state at less than 7hrs sleep
  1. Aim for a 1g of protein a day for each kg of healthy body weight.
    1. 100g of meat, fish or nuts will give you approx 20g of protein as a rough guide.
    2. Look to get this from animal sources where possible. Nuts are an acceptable substitute for 1 portion a day.
    3. 3 eggs will provide approx 21grams
    4. Ideally you would split this across 3 smaller portions throughout the day.
  2. Increase fruit and vegetable intake to 8 portions a day
    1. Studies have shown that averaging 8 portions of fruit and vegetables can reduce all cause mortality and reduce inflammatory markers.
    2. A portion is roughly a handful
    3. Try 2 portions of fruit with breakfast
    4. Look for 2 types of leaves, 1 portion fruit e.g. pomegranate seeds or grated apple and couple more veg in salad for lunch
    5. Then you only need one more with dinner.
  3. Get 1g of omega 3’s in each day. Get this from fish 3 days a week and via chia or flax seeds on the other 4 days
    1. Chia seeds are an easy option, 1 small chia pot will provide up to 5grams
    2. Otherwise 100g of salmon will give you 2 grams
    3. 1 tablespoon of milled flax seeds provides over 2g of omega 3s. This can be added to yoghurt and in conjunction with a teaspoon of manuka makes a very useful and tasty addition to the diet.
  4. Consume probiotic foods
    1. A healthy gut flora reduces levels of systemic inflammation
    2. 100g a day of natural yoghurt/ kefir
    3. 200ml kombucha is another great option
    4. Sauerkraut, fermented salsa, kimchi
    5. Pickles/ cornichons/ pickled cucumbers (not made with vinegar as this kills the probiotic bacteria)
  5. Consume enough carbohydrate to make sure your energy levels are good.
    1. Add more bulk carbohydrates from sources such as brown rice, wild rice, oats, lentils and sweet potato until your energy levels are ideal.
    2. Limiting carbohydrate intake has been shown to reduce level of inflammatory markers that increase pain perception.
    3. As body fat produces inflammatory mediators that lead to increased pain sensation, and offers an additional load we will look to decrease your body fat levels. Reducing bulk carbohydrate intake is one of the simplest ways to achieve this.
  6. 30grams of dark 70% cocoa chocolate per day is associated with lower levels of inflammation
  7. Track your diet using an app like myfitnesspal
    1. On there go to more in the bottom right of the main screen, then goals, then calorie & macronutrient goals
  8. Fibre
    1. Add more fibre to your diet until your bowel movements try to float
  9. When to eat
    1. Again the timing of eating is quite variable. Generally speaking its best to get as many calories as possible in earlier in the day. I would suggest just generally keeping this in mind and aiming to eat more earlier in the day and lighter at the end of the day.
  1. Once you have all this in place CALORIES MATTERS
    1. Try not operate at more than a 10% calorie deficit each day if trying to lose weight
    2. Body fat produces pro-inflammatory cells, which increase the sensitivity of your threat detectors that contribute to us feeling mechanical pain.
    3. Below I’ve included my most frequently recommended videos for people interested in weight loss.
      1. This lecture is 1 hour and 15 minutes long. In it Christopher Gardener talks about the research he did comparing the different spectrum of diets from high carb to low carb. He discusses how well people actually follow the diets and how much weight people lost. He then links it back in with the interesting concepts of relative density and water content. http://www.youtube.com/watch?v=eREuZEdMAVo
      2. In this excellent 1 hour 10 minute presentation Gary Taubes explains why loosing weight is not just about calories in and calories out. Gary explains that having excess fat is not caused by eating too much or exercising too little. But by a dysfunction in the body’s fat storing mechanism. Fat storage is stimulated by the level of insulin in the system and this is raised when carbohydrates are consumed. http://www.youtube.com/watch?v=bTUspjZG-wc&feature=related

Liquids and Hydration

  1. Stay adequately hydrated
    1. A good rough guide is 0.333litres x your body weight in kg, e.g. 100kg =3.3 litres per day
    2. The key is to make sure your urine is clear
  2. Feel free to have 1 Cup of coffee per day at least 8 hours before bed
    1. Up to 4 shots of espresso per day appears to reduce levels of systemic inflammation
  3. Green Tea can reduce inflammation

Dietary Supplements

 

  1. Sun Warrior Vegan Protein – if needed
    1. https://www.revital.co.uk/sunwarrior-classic-protein-raw-vegan-vanilla-1kg-vanilla24753
  2. Omega 3’s if deficient or not consuming dietary sources. Get these via Eskimo fish oil capsules 8/ day with food
    1. https://www.revital.co.uk/eskimo-3
  3. 1 gram per day Turmeric, taken with black pepper and food
    1. https://www.revital.co.uk/pukka-herbs-wholistic-turmeric-30-capsules
  4. 400mg White willow bark (if on no medications) 1/ day
    1. https://www.revital.co.uk/viridian-organic-white-willow-90-vegetarian-capsules-400mg-2889
  5. 100mg Devils claw (if on no medications) 1/ day
    1. https://www.revital.co.uk/a-vogel-devils-claw-100ml-659

 

Ointments

  1. Arnica – applied to sites of pain up to every 4 hours.
    1. https://www.revital.co.uk/weleda-arnica-massage-balm-50ml-8336
  2. CBD oil – applied to sites of pain up to every 4 hours.
    1. https://provacan.co.uk/collections/cbd-topicals/products/provacan-cannabis-balm-infused-with-cbd

Menu

Monday Tuesday Wednesday- vegetarian day Thursday- vegan day Friday- fish Saturday Sunday
Breakfast Spicy scrambled eggs with 4 veg and 2 fruit Smoked salmon on toast strawberries & fresh squeezed orange juice Protein, chia pancakes with yoghurt and blueberries Overnight mango coconut yoatie Smoked mackerel on toast Porridge, chia, cocoa nibs, protein powder, banana, manuka, cinnamon Boiled eggs on gluten free toast, smoked salmon
Juice Anti-inflammatory carrot, apple & ginger Blueberry and cherry blast Spinach, celery and cucumber Nutty, blueberry & cherry blast Blueberry & hemp seed smoothie Pineapple, turmeric and cucumber Kale, grape, ginger and lemon
Lunch Super quick chicken, & veggie lentils with sauerkraut. Chicken salad with sauerkraut Lentil pasta passata with kimchi Tai green tofu curry with ramen and kimchi Salmon, and dill pickle Steamed cod with kimchi Roast chicken, veg and sauerkraut
Snack Humus & carrots Skyr yoghurt, Blueberries, raspberries/ strawberries Apple & nut butter Salted caramel bliss balls Cottage cheese with tomato & basil Devilled eggs with humus Flap jack
Dinner Turkey and tray baked vegetables Chicken and yoghurt tenders Crock pot beans Bolognese Rice & beans burrito Salmon and Cauliflower rice bowl Mediterranean Turmeric and Fennel Chicken Chinese chicken salad
Dessert Skyr yoghurt, honey & flax seeds Chocolate flax yoatie Avocado, cocoa & chia mousse Chocolate cherry chia pudding Berry Flax Freezer pops Chocolate flax seed, banana bites Hot chocolate

 

Using The Menu

You could eat the whole menu above as laid out. However, most likely you’ll like the sound of some meals and have specific dietary requirements, which will choose you to exclude some meals.

Thus most likely you might have one breakfast 3-4 times per week and another on the other days. Whilst using the grab and go do as a guideline for those times when you cannot prepare food at all.

When cooking it is often easier to cook a double portion for dinner and then have the left overs for lunch the following day.

Eating Out Grab & Go’s

 

Monday- Tesco Tuesday- Sainsbury’s Wednesday- Marks & Spencer Thursday- Pret Friday- Leon Saturday- Waitrose Sunday-

Whole foods

Breakfast Skyr yoghurt, Blueberries, raspberries Alpro coconut yoghurt with strawberries & cherries Natural yoghurt & blueberries & raspberries Egg, mushroom, beans power pot + coconut bowl Smoked salmon and avocado pot Unearthed Spanish omlette Qnola, almond and vanilla with plenish nut milk
Juice Green machine juice Innocent energise/ invigorate smoothie Apple & ginger juice Loads of good options! Almond protein, green juice etc Kombucha Wow Chia drink Nourish kefir
Lunch Cooked chicken breast, beetroot salad Cooked chicken breast, 4 bean salad Cooked chicken +kimchi coleslaw, waldorf salad Tuna nicoise salad Chicken satay hot box Ranoch smoked chicken breast, deli beetroot salad, Cosi organic chicken, BOL salad jar & beetroot salad, Laurie’s saurkrout
Snack Carrots & humus Apple & walnuts Dried mango & cashews Apple & almond butter bowl Cardamon and cranberry PaLeon bar Goldenberries & unsalted nuts Raw health zesty lemon chia balls
Dinner Pre-cooked Salmon fillet, spiced cauliflower & chickpea salad Deli roast turkey, organic salad & organic guacamole Cooked prawns & beetroot skinny slaw, super nutty whole food salad Sesame salmon and black rice Brazillian black bean Unearthed prawns, mixed bean salad Cosi organic Turkey, Mrs Renfro’s salsa, mixed leaves, bean salad
Pudding Fullfil bar Trek oat protein flapjack Hazelnut millionaire shortbread Mango chia pot Vegan billionaire shortbread Booja booja ice cream Raw health hemp protein balls

 

Grocery Delivery

Riverford Organics

Excellent organic meat, fruit, veg and more

https://www.riverford.co.uk/

Ready to Eat Meal Delivery Options

Soulmate food

https://www.soulmatefood.com/

Approx £23/ day+ , hello10 for a 10% discount

Good basic food, geared to support training, I recommend the snacks as well.

Note there admin can be bad and mistakes are quite common, just complain straight away and they will correct things very quickly.

 

PurePackage

https://www.purepackage.com/

Approx £40/ day+

Higher end and excellent quality meals delivered to you.

 

Snacks & Bars

UK

Organic Biltong

https://www.coombefarmorganic.co.uk/products/207-organic-beef-biltong

 

Organic food bar with added greens and good protein

https://www.planetorganic.com/organic-food-bars-active-green-probiotics-68g/23273/?sessionid=undefined

 

Macrobiotic bars

https://www.gomacro.com/shop/protein-bars/

 

US

Epic Bars

https://www.amazon.com/Epic-Natural-Bison-Uncured-Cranberry/dp/B00ET7LPK4?ref_=fsclp_pl_dp_4&th=1

RXBAR bars

https://www.amazon.com/RXBAR-Whole-Food-Protein-Blueberry/dp/B0143NQW2E?ref_=fsclp_pl_dp_8&th=1

Breakfasts

Spicy Scrambled Eggs with 4 veg and 2 fruit

Preparation time: 0 mins

Cooking time: 15 mins

 

Ingredients:

  1. 3 eggs
  2. 50g smoked salmon
  3. Tablespoon olive oil/ butter/ coconut oil
  4. ½ red onion
  5. 1 chilli- to suit your taste
  6. 50g tomatoes
  7. 1 huge handful of Spinach
  8. Salt
  9. Pepper
  10. Cumin
  11. Paprika
  12. Follow with 2 good handfuls of bluebberies & raspberries

Directions:

 

  1. Heat a little butter or other quality fat on a low heat so it lightly melts but does not burn.
  2. Chop the onion and chilli and sauté in the oil over a low heat .
  3. While the onion and chilli sauté chop the tomatoes and add these once the onion has gone slightly translucent.
  4. Let these gently sauté as well and then add the spinach.
  5. Stir the spinach around in the pan whilst whisking the eggs.
  6. Once the spinach has wilted season with salt, pepper, paprika and cumin, then add the whisked eggs.
  7. Let the eggs cook and mix around to ensure everything is combined. Leave to cook to suit your taste in terms of how cooked through you like your eggs.
  8. Serve with the smoked salmon.

 

 

Smoked salmon on toast followed by strawberries & fresh squeezed orange juice

Preparation time: 2 mins

Cooking time: 2 mins

 

Ingredients:

  1. 1 slice gluten free bread
  2. 50g smoked salmon
  3. 1 large orange
  4. Handful strawberries

Directions:

  1. Toast the bread
  2. Place the smoked salmon on top
  3. Season with pepper and possibly a little Himalayan salt, and chives to taste
  4. Follow with 1 good handful of strawberries and a freshly squeezed orange juice

 

Protein Pancakes (2 pancakes, good for 1 person)

Preparation time: 5 mins +10 mins wait

Cooking time: 3-12 minutes

Calories: 300

 

Ingredients:

  1. 1/4 cup coconut flour.
  2. 1 scoop vanilla vegan protein powder
  3. 1 tablespoon chia seeds.
  4. 1 large egg.
  5. 1/3 cup unsweetened vanilla almond milk.
  6. 1/2 tsp vanilla extract.
  7. 1/2 cup greek yogurt (any flavour)
  8. 1/2 cup blueberries.

Directions:

  1. Mix together coconut flour and protein powder.
  2. Add in almond milk, egg, vanilla and chia seeds.
  3. Set mixture aside for 10 mins.
  4. Place a non-stick skillet (or skillet greased with coconut oil) over medium heat.
  5. Cook each pancake for 2-3 minutes per side. Do not overcrowd skillet.
  6. Top with Greek yogurt and blueberries.

 

Overnight Mango Coconut Yoatie

Preparation time: 5 mins

Cooking time: Leave overnight in fridge

 

Ingredients:

 

  1. 1/2 cup Greek Yogurt
  2. 3/4 cup Coconut Milk
  3. 1/2 cup gluten free oats
  4. 1 tbsp Chia Seeds
  5. 1/2 tsp Vanilla Extract
  6. 1 tsp Manuka Honey
  7. 1/2 cup Mango Peeled and Cubed

Directions:

Mix all ingredients together in a bowl, cover and leave overnight.

 

 

Smoked Mackerel on Toast

Preparation time: 1 min

Cooking time: 5 mins

 

Ingredients:

  1. 1 fillet smoked mackerel
  2. Handful of tomatoes or 1 good big one
  3. Basil (handful fresh if possible)
  4. Oregano dired)
  5. 1 slice gluten free toast

Directions:

  1. Warm up the mackerel for 5 mins in the oven.
  2. Toast the bread.
  3. Slice the tomatoes on to the toast and cover with the herbs.
  4. Flake the mackerel on top and enjoy.

 

Porridge, Chia, Cocoa Nibs, Protein Powder, Banana, Manuka, Cinnamon

Preparation time: 5 mins

Cooking time: Leave overnight in fridge

 

Ingredients:

 

  1. 1 cup gluten free oats
  2. 1 tbsp Chia Seeds
  3. 2 tsp Manuka Honey
  4. 2 scoops or 20g of protein equivalent in protein powder
  5. 1 banana
  6. 1 tsp cinnamon

Directions:

Put 1 cup of oats and 1.5 cups of water in a saucepan and bring to the boil. Simmer for 5 minutes.

 

 

Poached Eggs on Gluten Free Toast with Smoked Salmon

Preparation time: 2 mins

Cooking time: 10 mins

 

Ingredients:

 

  1. 1 slice gluten free toast
  2. 2 eggs
  3. 50g smoked salmon
  4. Optional, serve with sauted spinach, tomatoes and mushrooms

 

Directions:

  1. Bring water to the boil, with a dash of vinegar
  2. Place bread in toaster
  3. Once water boils, stir water to create a vortex/ whirpool effect, then crack an egg in to the middle of the vortex and continue stiring. Remove egg was clearly cooked on the outside. Repeat for the other egg.
  4. Place eggs on the toast and serve with smoked salmon.

 

 

Juices

Apple, carrot, ginger & turmeric smoothie

 

Preparation time: 2 mins

Cooking time: 1 min

Ingredients:

1 Apple

1 carrot medium

½ thumb of ginger

2 teaspoons turmeric

black pepper

1 cup water

Directions:

Core the apple, chop the carrot in to 3-4 pieces and cut the skin off the ginger.

Add all ingredients to a nutribullet or food processor and blend/ blast for 1 min or until all ingredients are combined.

Blueberries & Cherry Blast

 

Preparation time: 2 mins

Cooking time: 30 secs

Ingredients:

1 Cup Kale

½ Cup Frozen Blueberries

½ Cup Frozen Cherries

10   Walnut Halves

1 Tablespoon Flax Seeds

½ Inch Turmeric

1 ½ Cups Coconut Water

 

Directions:

Place all ingredients in a nutribullet or similar and “blast” for 30 seconds.

 

Spinach, Celery and Cucumber Blast

 

Preparation time: 2 mins

Cooking time: 30 secs

Ingredients:

1 Cup Spinach

1 Stalk Celery

1 Cup Cucumber

½ Cup Pineapple

½   Lime

2 Tablespoons Flax Seeds

3   Ice Cubes *

1 ½ Cups Coconut Water

 

Directions:

Blast for 30 seconds.

 

 

Nutty Blueberry & Cherry Blast

 

Preparation time: 2 mins

Cooking time: 30 secs

Ingredients:

 

2 Cups Kale

½ Cup Blueberries

½ Cup Cherries

1 Tablespoon Flax Seeds

3   Walnuts

½ Teaspoon Turmeric

1 ½ Cups Water

 

Directions:

Blast for 30 seconds.

 

Blueberry & Hemp Seed Smoothie

Preparation time: 2 mins

Cooking time: 30 secs

Ingredients:

 

1 1/4 cup (140 g) frozen blueberries (or other frozen berry of choice)

2 tbsp (22 g) hemp seeds

1 serving (30 g) vanilla plant-based protein powder

1/2 cup packed (30 g), fresh spinach or kale

1 tsp spirulina or chlorella powder

1 1/4 unsweetened plant-based milk of choice

 

Directions:

Blend all together till smooth and serve

 

Pineapple, turmeric and cucumber

 

Preparation time: 2 mins

Cooking time: 30 secs

Ingredients:

Handful of pineapple

½ cucumbers

2 three-inch pieces of fresh turmeric root or

1 tablespoon of ground cinnamon

Black pepper

 

Directions:

  1. Juice the pineapple, cucumber and fresh turmeric and pour into a glass.
  2. Stir in the cinnamon and black pepper enjoy!

 

Kale, grape, ginger and lemon

 

Preparation time: 2 mins

Cooking time: 30 secs

Ingredients:

1 bunch kale

1 cup grapes

1 slice ginger, optional

Juice of one lemon wedge

 

Directions:

  1. Juice the kale, grapes and ginger and pour into a glass.
  2. Squeeze in the lemon juice and serve.

 

Lunches

Super Quick Smoked Chicken & Veggie Lentils with Saurkraut

Preparation time: <5 mins

Cooking time: 5-10 mins (30 mins if cooking the chicken)

Ingredients:

1 chicken breast – pre cooked e.g. Ranoch smoked chicken breast from Waitrose or cook a raw breast as below

1 tablespoon olive oil

1/2 onion

1 big handful of spinach

50g tomatoes

1 pack lentils, e.g. Merchant gormet Mediterranean lentils

Dried basil and oregano desert spoon each (even better fresh basil and oregano)

 

Directions:

If using a raw chicken breast heat oven to 190 degrees and choose an option below;

Cover chicken breast in chopped garlic, oregano, basil and olive oil

Rub 2 dessert spoons of paprika and olive, salt and pepper in to the breast

The chicken can be left plane.

Typically a breast will perfectly cooked if placed in the oven for 30 mins from heating up, or 25mins if the oven is preheated.

 

Heat the olive oil over a low heat.

While the oil heats chop the onion and then add.

As these sauté chop the tomatoes and then add these and the spinach.

Let the spinach wilt and then add the lentils with basil and oregano.

Chop the chicken up and emerse in the veggies and lentils.

Can be served with hummus or a basic lettuce based salad, but tasty, nutritious and easy as it is.

 

Large chicken salad with sauerkraut

Preparation time: 5 mins

Cooking time: 0 (30 mins if cooking the chicken)

Ingredients:

1 chicken breast – pre cooked e.g. Ranoch smoked chicken breast from Waitrose or cook a raw breast as per the recipe above.

1/2 grated red onion

1 grated carrot

1 grated apple

2 big handfuls of leaves

1 pepper chopped

50g tomatoes chopped

1 tablespoon sauerkraut

Vinaigrette

½ cup each of cyder vinegar and olive oil

Teaspoon manuka honey

Teaspoon mustard

1 clove of garlic crushed

Directions:

Mix all the salad ingredients together in a bowl, pour the vinaigrette over and serve with the sauerkraut on the side.

 

Lentil Pasta Passata with Kimchi

Preparation time: <5 mins

Cooking time: 20 mins to properly sauté the veg and let sauce sit

Ingredients:

100-200g lentil pasta e.g. https://groceries.asda.com/product/pasta-noodles-cous-cous/explore-cuisine-organic-green-lentil-penne/910002512341

1 Onion

1 tablespoon olive oil

1-3 cloves garlic depending on preference

200g tinned tomatoes

1 chilli if desired

1 yellow pepper

1 large handful + of spinach

1 tablespoon kimchi

Directions:

Heat a large pan of water with a little salt and oil and cook the pasta as per the instructions. (With non-gluten pastas you will not get the same al dente feel, it just wants to be cooked through).

Lightly heat the olive oil over a low heat and sauté the onion, and garlic lightly till translucent.

Then chop and add chilli and pepper to the pan. As this gets within a couple of minutes of being done, e.g. the peppers are lightly sautéed but still quite firm, add the tomatoes and spinach.

Stir the spinach till it is thoroughly immersed in the sauce and turn the heat down so that the sauce just lightly bubbles.

 

Tai Green Curry Tofu with Ramen and Kimchi (serves 2)

Preparation time: 5 mins max

Cooking time: 10 mins

Ingredients:

Ramen

  1. 100g rice ramen
  2. 1 cups red cabbage, thinly sliced
  3. 1/2 cup vegan kimchi
  4. 80 grams tofu
  5. Salt and pepper, to taste

 

Tai Green Curry Sauce

  1. 1 tablespoons cashew butter
  2. 1/2 tablespoon green curry paste
  3. 3 garlic cloves, pressed
  4. Splash of water to thin

Directions:

 

  1. Prepare the Thai green curry sauce by combining the cashew butter, curry paste and water, then add the garlic to it. Take 3 tablespoons of the sauce to marinate the tofu. You can either fry the tofu or bake it for around 10 minutes at 200°C.
  2. While the tofu is frying or baking thinly slice the red cabbage and cook your rice ramen according the manufactures directions.
  3. Assemble by mixing rice ramen noodles, red cabbage, tofu, and Thai green curry sauce. Season with salt and pepper.

Salmon and Dill Pickle

Preparation time: 10 mins

Cooking time: 10 mins

Ingredients:

  1. 1 tablespoons unsalted butter, softened
  2. 1/4 cup finely diced dill pickles (not made with vinegar as this kills the probiotic bacteria)
  3. 1 teaspoon minced tarragon
  4. 1/2 teaspoon Dijon mustard
  5. Salt and freshly ground pepper
  6. 1 salmon fillets, with skin
  7. Extra-virgin olive oil, for rubbing

 

Directions:

  1. Light a grill. In a small bowl, blend the butter with the diced pickles, tarragon and mustard and season with salt and pepper.
  2. Rub the salmon with oil and season with salt and pepper. Grill over moderately high heat, skin side down, until the skin is lightly charred and crisp, about 3 minutes. Using a metal spatula, turn the fillets and grill until barely done in the center, about 4 minutes longer. Transfer the salmon to plates. Top with the dill pickle butter and serve.

 

 

Steamed Cod with Kimchi

Preparation time: 10 mins

Cooking time: 15 mins

Ingredients:

  1. cod fillet(150g)
  2. Saltand pepper to taste
  3. ½inchginger(peeled and julienned) (45g)
  4. 4cupnapa cabbage kimchi(sliced) (100g)
  5. 1clove1garlic(minced)
  6. 1tbspvegetable oil
  7. 1tbsp tamari
  8. 1green onion(finely sliced)

 

Directions:

  1. Place cod on a shallow bowl. Sprinkle salt, pepper, and ginger all over the cod. Place sliced kimchi on the top.
  2. Fill a large pot with about an inch of water. Place in a metal rack or stand in the middle of the pot. Bring the water to a boil. Place the dish with the fish on the metal rack then place lid on the pot. Reduce heat to medium and allow fish to steam for 12 to 15 minutes. When cod is done, it should flake easily.
  3. Place minced garlic and vegetable oil in a small microwave safe bowl. Microwave on high for 1 minute 30 seconds. Remove and mix in soy sauce. Set aside.
  4. Remove fish from the pot and drain off some of the liquid. Drizzle garlic oil over the fish. Garnish with sliced green onions.
  5. Serve immediately.

 

Roasted Chicken and Sauerkraut

 

Preparation time: 10 mins

Cooking time: 90 mins

Ingredients:

  1. 1 x 1.6 kg higher-welfare chicken
  2. 2 medium onions
  3. 2 carrots
  4. 2 sticks of celery
  5. 1 bulb of garlic
  6. Olive oil
  7. 1 lemon
  8. 1 bunch of mixed fresh herbs , such as, thyme, rosemary, bay
  9. Sauerkraut

 

Directions:

  1. Remove the chicken from the fridge 30 minutes before you want to cook it, to let it come up to room temperature.
  2. Preheat the oven to 240°C/475°F/gas 9.
  3. Wash and roughly chop the vegetables – there’s no need to peel them. Break the garlic bulb into cloves, leaving them unpeeled.
  4. Pile all the veg, garlic and herbs into the middle of a large roasting tray and drizzle with oil.
  5. Drizzle the chicken with oil and season well with sea salt and black pepper, then rub all over the bird. Place the chicken on top of the vegetables.
  6. Carefully prick the lemon all over, using the tip of a sharp knife (if you have a microwave, you could pop the lemon in these for 40 seconds at this point as this will really bring out the flavour). Put the lemon inside the chicken’s cavity, with the bunch of herbs.
  7. Place the tray in the oven, then turn the heat down immediately to 200°C/400°F/gas 6 and cook for 1 hour 20 minutes.
  8. If you’re doing roast potatoes and veggies, this is the time to crack on with them – get them into the oven for the last 45 minutes of cooking.
  9. Baste the chicken halfway through cooking and if the veg look dry, add a splash of water to the tray to stop them from burning.
  10. When the chicken is cooked, take the tray out of the oven and transfer the chicken to a board to rest for 15 minutes or so. Cover it with a layer of tin foil and a tea towel and leave aside while you make your gravy.
  11. To carve your chicken, remove any string and take off the wings (break them up and add to your gravy, along with the veg trivet, for mega flavour). Carefully cut down between the leg and the breast. Cut through the joint and pull the leg off.
  12. Repeat on the other side, then cut each leg between the thigh and the drumstick so you end up with four portions of dark meat. Place these on a serving platter.
  13. You should now have a clear space to carve the rest of your chicken. Angle the knife along the breastbone and carve one side off, then the other.
  14. When you get down to the fussy bits, just use your fingers to pull all the meat off, and turn the chicken over to get all the tasty, juicy bits from underneath. You should be left with a stripped carcass, and a platter full of lovely meat that you can serve with your piping hot gravy and some delicious roast veg and sauerkraut.

 

Snacks

Humus & Carrots

Preparation time: 5 mins

Cooking time: 0 mins

Ingredients:

  1. 1 can chickpeas
  2. 1 clove garlic
  3. ¼ cup olive oil
  4. Juice of 3 lemons
  5. 2 tablespoons tahini
  6. 1 teaspoon Himalayan salt
  7. 1 teaspoon cumin
  8. 1 teaspoon paprika

Directions:

1.     Mix all ingredients EXCEPT the paprika in a food processor.

  1. Serve with the paprika on top, and a bag of raw carrots to dunk in.

 

Skyr yoghurt, Blueberries, raspberries/ strawberries

Preparation time: 5 mins

Cooking time: 0 mins

Ingredients:

  1. 150g Skyr yoghurt- chosen for it’s higher protein content compared with other yoghurts.
  2. Handful of blueberries
  3. Handful of either raspberries or strawberries

Directions:

  1. Pop the berries on top of the yoghurt.
  2. Devour at your leisure.

 

Apple & Cashew Nut Butter

Preparation time: 5 mins

Cooking time: 0 mins

Ingredients:

  1. 2 cups (240g) roasted lightly salted cashews
  2. ½ tsp salt, or to taste

Directions:

  1. Add the cashews to a high-speed blender, and blend on low for 8-10 minutes or until creamy, scraping down the sides with a spatula as necessary. Add the salt, and blend for 20-30 seconds. Transfer to a jar or airtight container, and store in the refrigerator.

 

Salted Caramel Bliss Balls

 

Preparation time: 10 mins

Cooking time: 1 hour in freezer to set

 

Ingredients

 

  1. Dates
  2. Tamarind
  3. Tahini
  4. Ground almonds
  5. Cashew nuts
  6. Coconut flour
  7. Cinnamon

 

  1. Sesame seeds or desiccated coconut to roll in

 

Directions

Mix ingredients 1-7 in a food processor for 3-5 minutes until fully combined. If not binding fully then add a little extra coconut flour.

Roll in either sesame seeds or dessicated coconut to coat the outside and then place in container in the freezer for 1 hr to set.

 

Tomato and Basil Cottage Cheese

 

Preparation time: 10 mins

Cooking time: 1 hour in freezer to set

Ingredients

10 Cherry Tomatoes (quartered)

  • 1/4 cup Low-Fat Cottage Cheese
  • 1/4 tsp Dried Basil
  • 1/4 tsp Pepper
  • 2 1/2 Tbsp Olives (sliced)

 

Directions

  1. Cut the cherry tomatoes in half.
  2. Put the cottage cheese in a small bowl and stir in the basil and pepper.
  3. Gently stir in the sliced olives and tomatoes.

 

 

Devilled Eggs with Hummus

 

Preparation time: 10 mins

Cooking time: 8 mins

 

Ingredients

  • 2 Eggs
  • 4 tbsps Hummus
  • Paprika – to taste

 

Directions

  1. Boil 2 eggs
  2. Slice the eggs in half, discard yolks, and fill each egg white half with one-fourth of the hummus.
  3. Top with paprika to taste.

 

 

Flapjack

 

Preparation time: 15 mins

Cooking time: 25 mins

Ingredients

225g Gluten Free Oats

100g Manuka honey

150g Coconut Oil

Pinch of salt

75g Dates, roughly chopped

50g Dried Cherries

50g Whole Blanched Almonds, toasted and roughly chopped

 

Directions

  1. Preheat the oven to 180°C and line a 7inch loose bottom square tin with greaseproof paper and set to one side until later.
  2. Usually you’d put a lot of butter into a flapjack but I use coconut oil as a substitute and works brilliantly.
  3. Before you’re ready to use the coconut oil you just need to melt 150g of it in a saucepan with 50g of honey because it comes in a solid form.
  4. After you’ve toasted 50g of almonds – roughly chop them all up and put them into a mixing bowl. Then add 225g of gluten free oats – make sure that they’re the gluten free and not the normal version, they can be found in every supermarket.
  5. Add a pinch of salt, 75g of dates, 50g of dried cherries and 100g of brown sugar into the bowl. Then give it a good mix before adding the honey and coconut oil.
  6. Mix thoroughly again until evenly combined and make sure that you cover all your oats with the liquid. Scrape the mixture into the prepared tin and press the mixture into all the corners evenly and bake in the oven for 25 minutes, until golden brown.
  7. Leave in the tin to cool completely before cutting into pieces. Store in an air-tight container and eat within 5 days.

Dinners

Lazy Turkey Breasts

 

Preparation time: 5 mins

Cooking time: 30mins

Ingredients

  1. 200g turkey
  2. 2 Garlic cloves
  3. 1 courgette
  4. 1 large carrot
  5. Handful of brocolli
  6. 1 large beetroot
  7. Handful baby sweetcorn
  8. Approx 5 sprigs of thyme
  9. 3 tablespoons coconut oil
  10. Salt & pepper to season

 

Directions

Preheat oven to 200 degrees C/ Gas mark 6.

Chop all the vegetables in to chunks the size of half a golf ball.

Stab the sprigs of thyme in the turkey, and place the garlic in the folds of the turkey, if there’s no folds chop the garlic in pieces and stab them in to the turkey as well.

Place the chopped vegetables in to a tray with the turkey and 3 tablespoons of coconut oil, and season with salt and pepper.

Leave for 30 mins.

 

Harissa & Yogurt Marinated Chicken Tenders (Serves 2)

 

Preparation time: 5 mins + overnight marinate

Cooking time: 30mins

Ingredients

  1. 2 tablespoons harissa paste
  2. ¼ cup plain Greek yogurt
  3. ¼ cup dry white wine
  4. 4 chicken breasts

 

Directions

  1. Mix together the harissa, yogurt, and wine. Place the chicken tenders in a shallow baking dish, and top with the yogurt mixture. Cover with plastic wrap, and refrigerate. Marinate for at least two hours, up to overnight.
  2. To cook the chicken: Fire up your grill! Remove the chicken from the marinade, allowing any excess to drip off. Place the chicken on the hot grill, and cook for approximately 5 minutes on each side.
  3. Serving ideas: with a side salad, rice or quinoa, topped with sliced vegetables and fresh herbs.

 

Crock Pot Bean Bolognese (serves 2-4)

 

Preparation time: 5 mins

Cooking time: 4-6 hours

Ingredients

  1. 1 medium-size onion, chopped
  2. 2 carrots, peeled and chopped
  3. 2 celery stalks, chopped
  4. 2 cloves garlic, minced
  5. 400g can white beans (such as Cannellini)
  6. 800g crushed tomatoes
  7. Gluten free pasta

 

Directions

  1. Place all ingredients in a crock pot set on low. Cook for approximately 4-6 hours until all ingredients are tender. Serve as a chunky stew (add a ½ cup water to the mix if you prefer a looser consistency!) or as a sauce on top of cooked pasta.

 

Burrito

 

Preparation time: 5 mins

Cooking time: 30 mins

Ingredients

  1. 1 cup whole grain brown/ wild Rice
  2. 2 teaspoons olive oil
  3. 1 medium onion, chopped
  4. 2 garlic cloves, minced
  5. 3 teaspoons chili powder
  6. 1/2 teaspoon ground cumin
  7. 1 can (15 oz) black beans, drained and rinsed
  8. 1 (11 oz) whole kernel corn with red and green bell peppers
  9. 8 (8-inch each) gluten free tortillas
  10. 2 green onions, thinly sliced
  11. 1 cup cheddar cheese, shredded
  12. 1/2 cup light sour cream
  13. 1/2 cup salsa

 

Directions

Prepare rice according to package directions, probably 30 mins. While rice is cooking, heat oil over medium heat. Add onion, garlic, chili powder, and cumin. Sauté 3 to 5 minutes until onion is tender. Add cooked rice, beans and corn; cook stirring 2 to 3 minutes or until mixture is thoroughly heated. Remove from heat. Spread 1/2 cup rice, beans and corn mixture in the middle of each tortilla. Top each with 2 tablespoons shredded cheese, 1 tablespoon green onion and sour cream. Roll up and top each with salsa.

 

 

 

Salmon and Cauliflower Rice Bowl

Preparation time: 15 mins

Cooking time: 60 mins

Ingredients

  1. 10 to 12 Brussels sprouts, chopped in half
  2. 1 bunch kale, washed and shredded
  3. ½ head cauliflower, pulsed into cauliflower rice (you can use a whole cauliflower head if you wish)
  4. 3 tablespoons olive or coconut oil
  5. 1 teaspoon curry powder
  6. Himalayan salt

For marinade

  1. ¼ cup tamari sauce
  2. 1 teaspoon Dijon mustard
  3. 1 teaspoon sesame oil
  4. 1 teaspoon honey or maple syrup (optional)
  5. 1 tablespoon sesame seeds

 

Directions

  1. Preheat oven to 180°C.
  2. Line a baking tray and add chopped Brussels sprouts. Coat with 1 tablespoon oil and season with salt. Add to oven and roast for 20 minutes.
  3. Meanwhile, make marinade by combining all ingredients in a bowl and whisking until combined.
  4. Remove Brussels sprouts after 20 minutes and add salmon fillets to the baking tray. Spoon marinade over salmon fillets and return to oven for a further 13 to 15 minutes, or until salmon is cooked to your liking.
  5. While salmon is cooking, heat a pan over medium-high heat and add 1 tablespoon oil. Add kale and sauté until wilted (2 to 3 minutes). Remove from pan and set aside.
  6. Heat remaining oil in pan and add cauliflower rice. Season with 1 teaspoon curry powder and salt and sauté until cooked (2 to 3 minutes).
  7. Remove salmon and Brussels sprouts from oven and divide into two bowls. Add sautéed kale and cauliflower rice to bowls.

 

Mediterranean Turmeric and Fennel Chicken (Serves 4-6)

Preparation time: 15 mins

Cooking time: 45 mins

Ingredients

  1. 1/2 cup extra virgin olive oil
  2. 1/2 cup dry white wine
  3. 1/2 cup orange juice
  4. 1 lime, juice of
  5. 2 tbsp yellow mustard
  6. 3 tbsp brown sugar, more for later
  7. 1 tbsp garlic powder
  8. 3/4 tbsp ground turmeric spice
  9. 1 tsp ground corriander
  10. 1 tsp sweet paprika
  11. Salt and Pepper
  12. 1 large fennel bulb, cored, sliced
  13. 1 large sweet onion, sliced into half moons
  14. 6 pieces bone in, skin on chicken (chicken legs or breasts, or a combination)
  15. 2 Oranges, unpeeled, sliced
  16. 1 lime, thinly sliced (optional)

 

Directions

  1. Make the marinade. In a large bowl or deep dish, mix together the first six ingredients: olive oil, white wine, orange juice, lime juice, mustard and brown sugar.
  2. In a small bowl, mix together the spices: turmeric, garlic powder, coriander, paprika , salt and pepper. Now, add about half of the spice mix to the liquid marinade. Mix to combine.
  3. Pat the chicken pieces dry and generously season with the remainder of the spice mix. Be sure to lift the chicken skins slightly and apply some of the spice mix underneath the skin.
  4. Add the seasoned chicken and the remaining ingredients to the large bowl of marinade. Work the chicken well into the marinade. Cover and refrigerate for 1-2 hours (if you don’t have time, you can skip the marinating).
  5. When ready, preheat the oven to 475 degrees F. Transfer the chicken along with the marinade and everything else to a large baking pan so that everything is comfortably arranged in one layer. Be sure the chicken skin is facing up. Sprinkle with a dash or salt and more brown sugar, if you like.
  6. Roast for 40-45 minutes, or until the chicken is cooked through and the chicken skin has nicely browned. Internal chicken temperature should be 170 degrees F.

 

 

 

Chinese Chicken Salad (serves 2-4)

 

Preparation time: 5 mins

Cooking time: 30mins

Ingredients

  1. ½ cup vegetable oil
  2. ¼ cup unseasoned rice wine vinegar
  3. 1 tablespoon Dijon mustard
  4. 1 tablespoon low-sodium soy sauce
  5. 1 teaspoon sesame oil
  6. 2 garlic cloves, minced
  7. ¼-inch piece of ginger, peeled and chopped
  8. Pinch of salt

 

Directions

  1. Place all of the dressing ingredients in a blender, and pulse until smooth. Set aside.
  2. Combine all of the salad ingredients in a large mixing bowl. Toss with the dressing. Top with wonton strips, if desired.

 

Desserts

Skyr yoghurt, honey & flax seeds

 

Preparation time: 1 min

Cooking time: 0

Ingredients

  1. 150g Skyr yoghurt (it has the highest protein content, but other yoghurt is fine)
  2. Teaspoon Manuka honey
  3. Tablespoon milled flax seeds

 

Directions

Mix ingredients in a bowl with a spoon and serve.

 

 

 

Chocolate Hazlenut Yoatie

Preparation time: 5 mins

Cooking time: Leave overnight in fridge

 

Ingredients:

 

1/4 cup Greek Yogurt

1 cup apple juice

1 cup gluten free oats

15g (1.5 squares Lindt)

handful hazelnuts

Directions:

Mix the yoghurt, apple juice and oats together in a bowl, cover and leave overnight, or at least 2 hours.

Mash the hazelnuts up with a pestle and mortar, and then melt the chocolate with the hazelnuts either in a microwave or over alow heat on the hob. Leave to set and store in fridge.

Mash the chocolate and hazlenuts back up with a knife and

 

Vegan Chia Chocolate Mousse

 

Preparation time: 5 mins

Cooking time: Leave overnight in fridge

Ingredients:

Makes 2 portions

1 large ripe avocado

¼ cup cocoa powder

¼ cup coconut milk

1 tspn vanilla extract

1 tablespoon maple syrup

1 tablespoon chia seeds

Directions:

Halve and stone the avocado and puree the flesh in a processor

Mix the milk and cocoa powder and mix with the avocado, and the other ingredients and process.

Leave in bowls/ ramakins to set over night.

 

Chocolate Cherry Chia Pudding (Serves 4)

 

Preparation time: 5 mins

Cooking time: 4hrs+ in fridge

Ingredients:

1 1/2 cup non-dairy milk (almond/ coconut/ hemp are my favourites)
1/4 cup chia seeds (look for powdered chia seeds if you want a smooth texture)
4 teaspoons raw cacao powder
2-3 tablespoons pure maple syrup or honey
1/2 cup cherries, pitted and sliced + extra for plating

additional toppings : extra cherries, raw cacao nibs, dark chocolate shavings (use 70% dark chocolate or higher)

Directions:

In a bowl or mason jar, stir together the first 4 ingredients: milk, chia seeds, raw cacao and maple syrup and refrigerate for at least 4 hours or overnight. (If using a Mason Jar, simply close the lid and shake!)

Just before serving, separate into 4 serving dishes, top with sliced cherries and garnish with raw cacao chips, dark chocolate shavings and extra whole cherries and enjoy!

 

Berry Freezer pops

 

Preparation time: 5 mins + overnight

Cooking time: 0

Ingredients

  1. 1 cup strawberries
  2. 1 tbsp milled flax seeds
  3. ½ tbsp almonds
  4. 3 cups plain low flat yoghurt

 

Directions

  1. Put strawberries, flax seeds and almonds in a food processor and mix until very small pieces.
  2. Add yogurt and pulse a few times.
  3. Equally divide yogurt mixture in 6 small paper cups.
  4. Place a Popsicle stick in the middle of the yogurt.
  5. Put in the freezer and freeze overnight.
  6. Before eating, peel off the paper cup.

 

 

Berry Freezer pops (serves 3)

 

Preparation time: 10 mins + overnight

Cooking time: 0

Ingredients

  1. 100g 70% dark chocolate
  2. 1 tablespoon coconut oil
  3. 3 large bananas, cut into thirds
  4. Popsicle sticks
  5. Milled flax seeds
  6. Cocoa nibs

 

Directions

Melt chocolate over a double boiler (or in the microwave, if you prefer) with the coconut oil.  Stir until smooth, glossy, and entirely melted.

Insert a popsicle stick into one end of each banana piece.

Dip each banana into the warm melted chocolate.  Shake off excess chocolate as best you can.

Place dipped bananas on a parchment lined baking sheet.

Sprinkle generously with milled flax seeds, or cocoa nibs.

Place in the freezer to harden and set.

When frozen through wrap individually or enjoy immediately.

 

Hot Chocolate

 

Preparation time: 2 mins

Cooking time: 3-5 mins max

Ingredients

  1. 1 cup non-dairy milk of choice (I use coconut but hemp or almond are great)
  2. 1 teaspoon raw cacao
  3. 1 tsp maca powder*
  4. 1/4 tsp ground turmeric
  5. 1/4 tsp of ground cinnamon
  6. 1 desert spoon manuka honey
  7. 1 desert spoon coconut oil

 

Directions

  1. Add milk of choice to a medium-sized sauce pot and bring to a boil.
  2. Lower to a simmer and add cacao powder and stir.
  3. Add in maca powder, turmeric and cinnamon and continue to stir.
  4. Stir in honey until well combined.
  5. Add coconut oil and whip in until all chunks are melted and mixture becomes thick.
  6. Serve immediately.

 

Gratitude and Low Back Pain

Written by Kieran Macphail on . Posted in For Health Professionals, Low back pain

Gratitude is frequently stated to be useful to improving health within alternative health circles. However is there any evidence that improving our focus on gratitude can be useful to improving low back pain?

There have not been any studies examining the benefits of gratitude interventions on pain. However, gratitude interventions have improved positive affect, inflammatory markers and specifically depression and anxiety.

Emmons and McCullough (2003) were the first to examine the effects of focusing on gratitude or hassles on psychological markers. They assigned patients to focus on either gratitude, hassles or neutral events or social comparison. Patients kept either weekly or daily records of their moods. In a third arm patients with neuromuscular disease were randomly assigned to either a gratitude intervention or control. The gratitude intervention was as follows;

“For the next eight weeks you will be asked to record 3-5 things for which you are grateful on a daily basis. Think back over your day and include anything, however small or great, that was a source of gratitude that day. Make the list personal, and try to think of different things each day”.

The results showed that a focus on gratitude improved emotional and interpersonal markers.

Redwine et al (2016) found that a daily gratitude practice reduced inflammatory markers and improved heart rate variability in heart rate failure patients. Patients were instructed as per Emmons and McCullough (2003). Interestingly sleep appears to play a mediating role in the effects of gratitude on depression and anxiety (Ng and Wong 2013). The mediating effect exists for depression but appears stronger with anxiety. Thus interventions should look to target sleep and gratitude together for best results.

To date there are no studies showing direct effects of a gratitude practice on pain. However as inflammation levels decrease the nociceptive threshold and mean we feel more pain there is a plausible mechanism for an impact on pain. Similarly positive affect is associated with better outcomes in low back pain patients and thus the suggestion is it may be beneficial low back pain patients.

A practice of writing down 3-5 things each day that you are grateful for is a free, quick and potentially useful adjunct to the management of chronic low back pain.

 

References

Emmons, R.A. and McCullough, M.E., 2003. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. Journal of personality and social psychology, 84(2), p.377.

Ng, M.Y. and Wong, W.S., 2013. The differential effects of gratitude and sleep on psychological distress in patients with chronic pain. Journal of health psychology, 18(2), pp.263-271.

Redwine, L.S., Henry, B.L., Pung, M.A., Wilson, K., Chinh, K., Knight, B., Jain, S., Rutledge, T., Greenberg, B., Maisel, A. and Mills, P.J., 2016. Pilot randomized study of a gratitude journaling intervention on heart rate variability and inflammatory biomarkers in patients with stage B heart failure. Psychosomatic medicine, 78(6), pp.667-676.

Psychosocial Symptoms, Chronic Low Back Pain and Inflammation

Written by Kieran Macphail on . Posted in Back Pain and Diet, For Diet and Lifestyle Professionals, For Everyone!, For Health Professionals, Low back pain, Mindfulness, Nutritional therapy, Orthopaedic Medicine

Highlights

 

  • Psychosocial symptoms are important predictors of those that do worse with chronic low back pain.
  • Currently the prevailing view is that psychosocial symptoms drive systemic inflammation.
  • Psychosocial problems increase inflammation, and inflammation increases psychosocial symptoms.
  • Psychosocial treatments decrease inflammation and reducing inflammation improves psychosocial symptoms.
  • The relationship is bidirectional and we should remember this when dealing with patients with psychosocial symptoms.
  • Explaining this relationship to patients may reduce the stigma associated with psychosocial symptoms.

 

Background

 

Since the turn of the century there has been an increased awareness of psychosocial symptoms in chronic low back pain (CLBP) patients. It’s well established that CLBP patients with psychosocial, psychological and social, risk factors have poorer outcomes and increased management costs (Grimmer-Somers 2006, Nicholas et al. 2011). The term “yellow flags” was originally used to describe psychosocial risk factors that predict disability in LBP patients. Yellow flags are now included in most LBP guidelines although there is wide variation in suggestions in how to assess and manage these patients (Koes et al. 2010). This is discussed elsewhere on this site, see article on Yellow flags and CLBP. These risk factors are predictors of return to work and disability in CLBP patients (Glattacker et al. 2013). They can be identified using a questionnaire or a clinical diagnosis (Watson and Kendall 2000). Questions cover beliefs that are associated with delayed return to work and disability. These include fears about pain, injury, recovery and being despondent or anxious. It is suggested that having a few strongly held negative beliefs or several weaker ones could be used to identify at risk patients (Nicholas et al. 2011). These beliefs can be viewed as “thought viruses” (Butler and Moseley 2013) and increase a patient’s perception of threat and modern neuroscience suggests that pain is the conscious interpretation that tissue is in danger (Moseley 2007).

 

Inflammation and Psychosocial Symptoms

Inflammation and psychosocial symptoms are intimately related. Those with higher levels of systemic inflammation have more psychosocial symptoms (Hänsel et al. 2010) and Miller at al (2014) found that psychosocial treatment reduces levels of inflammation. Generally this relationship has been viewed top down, e.g. the brain affecting our systemic inflammation level. However, systemic inflammatory molecules signal the brain to induce sickness behaviours and negative affect (negative emotions and a negative view of self) (Walker et al. 2014). It’s also well established that anti-inflammatories improve psychosocial symptoms such as depression (Gallagher et al. 2014, Iyengar et al 2013). Thus perhaps we should consider this as a bidirectional relationship.

Peripherally cytokines, proteins of the immune system that communicate with other cells, interact with afferent nerves which send signals to their primary projection area. For example the nucleus of the tractus solitarius for vagal afferents. From here it propagates to secondary projections including the paraventricular nucleus of the hypothalamus and the central nucleus of the amygdala, where it can contribute towards negative affect. This partially occurs, as there is some active transport of cytokines across the blood brain barrier. With increased levels of systemic inflammation, active transport of cytokines across the blood brain barrier is increased further.

Tissue damage in the body is responded to by two main systems, pathogen associated molecular patterns (PAMPs) and damage associated molecular patterns (DAMPs). In a cold it is PAMPs that give rise to the illness behaviour associated with having cold symptoms. We all tend to withdraw from activity, feel a bit ugh, and have a kind of minor low level depression with a cold. With back pain it is DAMPs that give rise to the illness behaviours. Yet with CLBP we treat patients as if they are making conscious decisions to withdraw from activity. Potentially if we understand these underlying mechanisms and view the behaviours that arise secondary to this condition as like that of an infection we might have more empathy towards understanding the CLBP patient.

The association between peripheral inflammation and depression was initially established in patients undergoing cytokine therapy. Immune stimulating therapies such interferon therapy in those with hepatitis C or malignant melanoma produced initial sickness behaviour and then a transition to depression in many patients (Raison et al. 2007). Capuron et al. (2002) established that the anti-depressant paroxetine only reduces sickness behaviours and not the cognitive and affective aspects of depression. It appears that it is prolonged elevated levels of inflammation that are required for the transition of sickness behaviour in to depression. Obviously there are multiple mechanisms interacting here and to focus on one to the exclusion of others would be negligent clinically.

In healthy individuals typhoid vaccination induces negative mood post-vaccination (Wright et al., 2005), stops the normally occurring improvement in mood as the day progresses (Strike et al., 2004), increases brain activity in depression-related regions such as the subgenual cingulate cortex, and decreases its connectivity to the amygdala, medial prefrontal cortex, and nucleus accumbens (Harrison et al., 2009). Similarly, in healthy mice increasing levels of inflammation induce initial sickness behaviours, which subside, and transition to depressive symptoms following prolonged increased inflammatory levels (O’Connor et al. 2009).

Inflamamtion is closely linked to the pain experience. Peripheral inflammation can propogate signals to key brain areas involved in pain such as the central nucleus of the amygdala. Pro-inflammatory cytokines also lower nociceptor thresholds throughout the body decreasing the temperature, pressure or pH stimulus required for nociception. Further low levels of anti-inflammatory cytokines, such as Il-10 may also lower nociceptor thresholds (Uceyler et al. 2006).

Norman et al (2010) investigated the effects of social isolation on depressive symptoms in mice post nerve injury. Only the socially isolated mice developed depression and increased inflammation in the brain seven days later as measured by Interleukin-1β. Mice that underwent social isolation but received oxytocin did not develop increased inflammation or depression. Conversely, mice that were socialising but received an oxytocin antagonist developed depression and elevated brain Interleukin-1β. This, at least in mice, very clearly demonstrates the importance of social interaction, a positive psychosocial input, on inflammation; and points to the central role of oxytocin, at least as a marker, in this process.

Tryptophan is required for the production of the “happy” neurotransmitter serotonin. Decreases in tryptophan have been theorised to cause depressive symptoms and there is some support for this (Dell’Osso et al. 2016). Under increased levels of systemic inflammation there is increased activity of indoleamine 2,3-dioxygenase, an enzyme that converts tryptophan in to kynurenine, Thus there is less available for serotonin production. In animal studies the induction of inflammation has been shown to produce increase indoleamine 2,3-dioxygenase activity, decreased circulating tryptophan and a progression from sickness behaviour to depression (O’Connor et al. 2009).

Increased activity of indoleamine 2,3-dioxygenase ultimately leads to an increase in the NMDA receptor agonist quinolinic acid. Increased glutamate and its receptor subtypes including NMDA have been implicated in the development of both chronic pain and depression (Mitani et al 2006). Glutamate is primary neurotransmitter in nociceptor afferents.

This evidence clearly indicates the role of peripheral inflammation to directly impact our behaviour. This needs to be viewed within a broad context and the central process contributing to illness behaviours must also be considered. Nonetheless this information can be powerful for patients in taking the pressure off themselves to change these behaviours under the illusion that they are 100% under our control. This can be quite empowering in a perverse way and allows for a more open and honest discussion of these behaviours with patients as the pressure for responsibility and feelings of being judged are decreased.

 

What does this mean for treatment?

Psychosocial interventions such as CBT, pain neurophysiology education and mindfulness are still useful when viewing this relationship as bidirectional. In my clinical experience when they are offered these treatments patients often feel like they are being judged, it’s in their head, they should think positively and pull themselves together. Explaining this relationship to patients removes some of the stigma associated with psychosocial symptoms and pain. When patients view these changes in mood as similar to when you have a cold it is easier for us to discuss these symptoms and patients often feel like it becomes more manageable.

 

If this article has been useful at all please feel free to donate to help with the running of the site. Donations of £1 are really appreciated and help me keep the site add free, many thanks.




References

Butler, D.S., Moseley, G.L. (2013) Explain Pain. London: Noigroup Publications.

Capuron, L., Ravaud, A., Neveu, P.J., Miller, A.H., Maes, M. and Dantzer, R., 2002. Association between decreased serum tryptophan concentrations and depressive symptoms in cancer patients undergoing cytokine therapy. Molecular psychiatry, 7(5), 468.

Dell’Osso, L., Carmassi, C., Mucci, F. and Marazziti, D., 2016. Depression, Serotonin and Tryptophan. Current pharmaceutical design, 22(8), 949-954.

Gallagher, P.J., Castro, V., Fava, M., Weilburg, J.B., Murphy, S.N., Gainer, V.S., Churchill, S.E., Kohane, I.S., Iosifescu, D.V., Smoller, J.W. and Perlis, R.H., 2012. Antidepressant response in patients with major depression exposed to NSAIDs: a pharmacovigilance study. American Journal of Psychiatry, 169(10), 1065-1072.

Glattacker, M., Heyduck, K., Meffert, C. (2013) Illness beliefs and treatment beliefs as predictors of short-term and medium-term outcome in chronic back pain. Rehabilitation Medicine45(3): 268-76.

Grimmer-Somers, K., Prior, M., Robertson, J. (2008) Yellow flag scores in a compensable New Zealand cohort suffering acute low back pain. Journal of pain Research, 1:15-25.

Hänsel, A., Hong, S., Cámara, R.J. and Von Kaenel, R., 2010. Inflammation as a psychophysiological biomarker in chronic psychosocial stress. Neuroscience & Biobehavioral Reviews, 35(1), 115-121.

Harrison, N.A., Brydon, L., Walker, C., Gray, M.A., Steptoe, A. and Critchley, H.D., 2009. Inflammation causes mood changes through alterations in subgenual cingulate activity and mesolimbic connectivity. Biological psychiatry, 66(5), 407-414.

Iyengar, R.L., Gandhi, S., Aneja, A., Thorpe, K., Razzouk, L., Greenberg, J., Mosovich, S. and Farkouh, M.E., 2013. NSAIDs are associated with lower depression scores in patients with osteoarthritis. The American journal of medicine, 126(11), 1017-e11.

Koes, B.W., van Tulder, M., Lin, C.W.C., Macedo, L.G., McAuley, J., Maher, C. (2010) An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal, 19(12): 2075-2094.

Miller, G.E., Brody, G.H., Yu, T. and Chen, E., 2014. A family-oriented psychosocial intervention reduces inflammation in low-SES African American youth. Proceedings of the National Academy of Sciences, 111(31), 11287-11292.

Mitani, H., Shirayama, Y., Yamada, T., Maeda, K., Ashby, C. R., & Kawahara, R. (2006). Correlation between plasma levels of glutamate, alanine and serine with severity of depression. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30(6), 1155-1158.

 

Moseley, G.L. (2007) Reconceptualising pain according to modern pain science. Physical Therapy Reviews, 12(3): 169-178.

Norman, G. J., Karelina, K., Morris, J. S., Zhang, N., Cochran, M., & DeVries, A. C. (2010). Social interaction prevents the development of depressive-like behavior post nerve injury in mice: a potential role for oxytocin. Psychosomatic medicine, 72(6), 519-526.

Nicholas, M. K., Linton, S. J., Watson, P. J., Main, C. J. (2011) Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Physical Therapy, 91 (5): 737-753.

O’Connor JC, André C, Wang Y, Lawson MA, Szegedi SS, Lestage J, Castanon N, Kelley KW, and Dantzer R

(2009) Interferon-γ and tumor necrosis factor-α mediate the upregulation of indoleamine 2,3-dioxygenase and the induction of depressive-like behavior in mice in response to bacillus Calmette-Guerin. J Neurosci 29:4200–4209.

Raison, C.L., Woolwine, B.J., Demetrashvili, M.F., Borisov, A.S., Weinreib, R., Staab, J.P., Zajecka, J.M., Bruno, C.J., Henderson, M.A., Reinus, J.F. and Evans, D.L., 2007. Paroxetine for prevention of depressive symptoms induced by interferon‐alpha and ribavirin for hepatitis C. Alimentary pharmacology & therapeutics, 25(10), 1163-1174.

Strike, P.C., Wardle, J. and Steptoe, A., 2004. Mild acute inflammatory stimulation induces transient negative mood. Journal of psychosomatic research, 57(2), 189-194.

Üçeyler, N., Valenza, R., Stock, M., Schedel, R., Sprotte, G., & Sommer, C. (2006). Reduced levels of antiinflammatory cytokines in patients with chronic widespread pain. Arthritis & Rheumatology, 54(8), 2656-2664.

Walker, A.K., Kavelaars, A., Heijnen, C.J. and Dantzer, R., 2014. Neuroinflammation and comorbidity of pain and depression. Pharmacological reviews, 66(1), 80-101.

 

Watson, P., Kendall, N. (2000) Assessing psychosocial yellow flags. Topical issues in pain, 2: 111-129.

Wright, C.E., Strike, P.C., Brydon, L. and Steptoe, A., 2005. Acute inflammation and negative mood: mediation by cytokine activation. Brain, behavior, and immunity, 19(4), 345-350.

Mindfulness and Chronic Low Back Pain; Why and How To.

Written by Kieran Macphail on . Posted in Acute Low Back Pain, Corrective Holistic Exercise Kinesiology, For Diet and Lifestyle Professionals, For Everyone!, For Health Professionals, For Movement Therapists, Low back pain, Mindfulness, Nutritional therapy, Orthopaedic Medicine, Sacro-iliac joint

Mindfulness is basically the western term for meditation. The practice has moved from weird hippies only, to being used by CEOs and professional sport, and is now being studied fairly extensively. This blog will focus on the relevance of mindfulness to chronic low back pain. Outlining the benefits and how to start a mindfulness practice.

Psychological stress can directly influence the musculoskeletal, endocrine, immune and nervous systems through the limbic system modifying chronic pain (Macphail 2014). Psychosocial risk factors for low back pain (LBP) chronicity are well known to lead to worse outcomes (Grimmer-Sommer 2008). Indeed the assessment of psychosocial factors is included in most guidelines for the management of LBP worldwide (Koes et al. 2010). Childhood abuse is associated with an increase in peripheralising of low back pain later in life (Leisner et al. 2014) suggesting psychological processes can modify the pain experience even later in life.

Cherkin et al. (2017) conducted an interviewer blinded, randomized controlled trial comparing mindfulness based stress reduction (MBSR), cognitive behavioural therapy (CBT) and usual care in 342 chronic low back pain (CLBP) patients aged 20-70. MBSR and CBT were both delivered as eight weekly two hour group sessions. Treatment effects were seen at 26 months and 2 year follow up. At 1 year and 2 years, Roland Morris Disability Questionnaire (RMDQ) scores were similar between groups. At 2 year follow 55.4% of the mindfulness group had clinically significant improvements in RMDQ and 41.2% in pain bothersomeness. In contrast usual care produced 42% and 31.1% of patients with clinicially significant improvements respectively, and CBT 62% and 39.6%. Follow-up rates were 78% for MBSR, 75% for CBT, and 89% for usual care. This may reflect lack of adherence to MBSR and CBT compared with usual care, but among those who did respond it appears the MBSR produced the greatest percentage of people with improvements in pain bothersomeness and it outperformed usual care on RMDQ. These results are startling given the limitations of the intervention, only eight two-hour sessions over eight weeks. The 8-week MBSR programme has also been shown to outperform the 10-steps to health aging programme in 282 community dwelling adults with CLBP (Morone et al. 2016). Thus there clearly seems to be benefit for mindfulness in patients with CLBP. So how do you or your patients get started with mindfulness?

Whilst the evidence discussed above strongly suggests some benefit from mindfulness interventions they can be very difficult to deliver. Therapists need to be confident in their value to be able to “sell” it to patients. Personal experience of the benefit is particularly valuable. In addition there will likely be personal benefit to the therapist.

The sequence of progression below is based on the mindfulness based stress reduction courses, with this authors own tweaks to make it easier to fit in to everyday life. In my experience its much easier to start with what personal development speaker Tony Robbins calls NET time, no extra time, activities. For example the first stage is doing one task each day mindfully.

 

1. One task daily done mindfully

e.g. brushing your teeth

2. Add one meal a day eaten mindfully

3. 5-10 minutes walking meditation

e.g. as part of your walk in to or out of work

4. 10-30 minutes mindful stretching

5. 10-30 minutes body scan done each day mindfully

6. 10-30 minutes seated meditation

 

From the very limited research we have in this area it appears seated meditation for about 30 minutes five times a week should be our goal with patients. This is very generic and non-specific. In reality we should look to help our patients develop a mindfulness practice that works for them, their personality and their schedule.

Establish if the patient has any experience of meditating. If not explain to them that mindfulness is being in the moment, the present. Often this is considered being in a “flow” state or in the zone. Flow occurs when our perceived ability meets the perceived demands of an activity. Much more on this can be gleaned by reading Flow by Mihaly Csikszentmihalyi who popularised this concept. Very simply anxiety occurs when we focus on the future and depression when focus on the past. Positive emotions like gratitude occur when looking in the past, and excitement when looking to the future. So the purpose is not to forgo looking forward or back but to develop an ability to be in the moment and to take ourselves back to the present when we find ourselves in a negative state.

With all these tasks its important to try. Some days will be tougher, the mind will be all over the place and concentration will be poorer. Other days a lot of negative thoughts may arise. There are real benefits though to being able to become aware of the fact that you cannot find the time to meditate, or you were so busy you got distracted and forgot or just could not fit it in. Becoming aware of this is the first step and then you can work improving the factors that lead you to miss sessions.

 

One task done mindfully daily

To start with pick a simple task that is done every day. The task I recommend is brushing teeth as we do this twice a day, it last about two minutes, and is very low concentration. It’s handy to pick a task you do multiple times a day so that if you miss it once you still have another opportunity. Other tasks, like ironing, washing up or even showering can be used. The key is that the patient will try to do this task mindfully. Instruct them just to focus on sensory cues in the moment. Breathing, tastes, smells, the feeling of the tooth brush on the teeth, their feet on the floor, any cues that bring them in to present and take them away from “monkey mind” thoughts in the past or present.

 

Eat one meal mindfully daily

The next progression is to eat a meal mindfully each day. The great thing with this task is you likely have three opportunities so if you miss one, then you’ve still got two opportunities. You can do this while eating with other people but it’s much tougher as it’s very easy to get in to conversation and being mindful in conversation is tricky. So to start focus on doing this activity during meals you are eating alone, even a snack if necessary.

Just focus on your breathing, the food, the tastes the smells. You will get distracted, just bring your mind back to a cue in the present each time, e.g. the smell, the tastes of the food, the feeling of your feet on the floor.

 

Walking meditation

This is another task that takes no extra time and is usually quite easy to get buy in from clients. As with the others the application is challenging but clients usually report acute benefit. Discuss the patient’s typical schedule with them and find a walk of around ten minutes they do most days. Often this is best to do on the way to work so they turn up to work in a good mindful state. If they don’t have an obvious way to fit this in to their schedule currently they can be encouraged to park 10 minutes further away from work or to go out for a short walk.

During the walk the client should focus on the steps and the sensory experience. Go through it once with them if possible and see which cues they prefer. Focusing on breathing in for four steps, pause for one, out for four. This can be adjusted to 3-1-3 if this suits the patient better. Just feeling the sensations in the feet and keep the walk as even as possible, maintaining a steady flow to the walk.

 

Mindful stretching

Mindful stretches is the first time we ask a patient to set aside extra time for their mindfulness practice. Many patients may never reach this point. The key here is that for a task to be done mindfully it needs to be very easy, unlike a true flow state, when mindful we are doing something very easy for us and being completely present. Thus it’s important the client is very comfortable with all stretches chosen and that none carry an injury risk.

Thus positions like sitting cross-legged, hands and knees, quad stretching in side lying, hamstring stretching in sitting and gentle trunk rotation may be useful. The stretches need to be tailored to the individual so that they are comfortable with them and for optimum efficiency they should also help mechanically.

 

Body scan

A body scan is a good transition from stretching to relaxation before fully transitioning towards a traditional meditative practice.

To start a body scan the patient should find a comfortable position. Common positions are lying down with a pillow for the head, or seated in a chair, on the floor or bed cross-legged with pillows under the hips and knees as needed.

The patient should start by focusing on their breath and settling in to relaxed diaphragmatic breathing. After a minute of settling in to this, the patient should begin getting an overall feel for the tension throughout the body. Then sequentially work down from the head, down the arms, the shoulders trunk and down the legs. In each area 3-5 breaths can be used to get an awareness of the tension in that area specifically and become aware of any sensations or emotions attached. Then 3-5 breaths can be used to relax to let go of the tension in the area.

The patient should be made aware that some areas will be easier than others. Thoughts will come in to the mind, just return to the breath and focus on becoming aware of the tension and feelings in an area and then letting it go.

 

Seated meditation

Seated meditation is our goal for most patients. With the aim of 30 minutes five times a week appearing to have significant anti-inflammatory effects.

By this stage patients should be comfortable at this point with the basics of mindfulness practice. Patients can be encouraged to;

  • Listen to guided meditations
  • Use various apps. My experience is that patients adhere to headspace for a few weeks and a few have stuck with it long term.
  • Progress through a sequence of focusing on the body, then the breath, then sounds and then thoughts.
  • Listening to meditative music, such as Anugama.
  • Using mantras, such as breathing in with a “yang” phrase such as strength or discipline and then a “yin” word on the exhalation such as humility or grace.
  • Progress from focusing on the breath, to areas of discomfort and then trying to focus on these areas on the inhalation and let go of the discomfort on the exhalation.

By the time the patient reaches this stage they will likely have their own thoughts on how they want to develop their practice. Walking meditation, mindfulness during a meal and a couple of daily tasks may be a really useful practice for one. Whilst another may do well with a daily mindful stretching programme. The practice should not be a means to an end in and of itself but should give the patient tangible benefits and if they are not seeing this it should be modified.

 

 

If this article has been useful at all please feel free to donate to help with the running of the site. Donations of £1 are really appreciated and help me keep the site add free, many thanks.





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