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