Meditation for Chronic Pain

by Renée Ostertag DPT MPhysio (Sports and Musculoskeletal)

So who has ever prescribed meditation as a Physical Therapy exercise or home instruction program? I suppose it's fair to say that it is not a traditional practice and somewhat "off-the-beaten-path". Most of us are very familiar with posture training, home exercise programs, stretching and strengthening- but meditation is not something that readily comes to mind when developing treatment plans for our patients.

Before I had the opportunity to study with David Butler at University of South Australia, meditation would have never entered my mind. Since gaining more in-depth knowledge of pain physiology and the brain, beginning a meditation practice of my own, and seeing the positive changes it's made in my own life- I began to wonder if this could be applied to the physical therapy setting. That led me to do what any evidence-based practitioner would do: investigate the research.

Before I review the research with you, let's just do a brief summary of pain physiology. Pain is always produced by the brain when it perceives a threat (actual or potential) to the body. Pain is an output from the brain's processing mechanism that is associated with the sympathetic nervous system (SNS), or "fight or flight". Some fight or flight responses- in addition to pain- include elevated levels of cortisol, increased heart rate, blood pressure, respiratory rate, global muscle tightness and increased alpha waves in the brain (Butler 2007). Since SNS activity is predominant in a pain state, it makes logical sense that a tool to decrease sympathetic activity would be a helpful adjunct to treatment of pain. So, the question at hand- does the research show meditation to decrease sympathetic activity and decrease pain?

Herbert Benson, a cardiologist and professor at Harvard Medical School and pioneer of meditation research, discovered "the Relaxation Response" which is a physiological response associated with decreased sympathetic nervous activity. His original research shows a reduction in blood pressure, muscle tension, and sympathetic nervous system activity in hypertensive patients (Benson et al 1974). The meditation these subjects participated in required a brief introduction to learn the technique, followed by twice-daily practice lasting 10-20 minutes for 6 weeks. The Benson Method is a simple meditation technique, independent from any religious dogma or spiritual philosophy, and is ideal for beginners; thus appears more likely for us to be able to use in the clinic. Unfortunately, no research that I am aware of has been done on using this specific form of meditation for subjects with pain.

Many studies have been done on meditation and pain, specifically utilizing mindfulness training as a clinical intervention (Baer 2003). Jon Kabat-Zinn's studies focus specifically on "mindfulness meditation" and its effect on pain. His research subjects underwent a 10 week intervention of mindfulness meditation, and those with chronic pain showed statistically significant improvements in ratings of present-moment pain, negative body image, and inhibition of activity by pain. In addition, the number of medical symptoms reported and psychological symptoms such as anxiety, depression also showed significant improvements (Kabat-Zinn 1982, 1985, 2003). Mindfulness meditation has been shown to be effective at treating pain, but it appears to be more complex to learn and current research (Baer 2003, Kabat-Zinn 2003) demonstrating these benefits require participation in a 10 week Stress Reduction and Relaxation Program. This seems like a promising intervention for the appropriate patient to decrease pain, but are most of our general musculoskeletal patients going to be compliant with a 10 week time commitment which requires substantial effort and lifestyle changes? In addition, most of us do not have the skills appropriate to be able to teach this method.

That brings me to my next point- it poses challenges on many levels for a PT to suggest meditation to a patient having never done meditation themselves. If you are interested in the possibility of using meditation as an adjunct tool to your current skills, it may be worth a 6 week daily trial of meditation yourself. Not only would it be easier for you to teach someone how to meditate having done it yourself- there are gains in it for you as well. As many of us know, stress inherent within the health care professions can negatively impact us and lead to increased depression, decreased job satisfaction and burnout. Shapiro et al (2005) demonstrate reductions in perceived stress and job burnout and greater satisfaction with life after 8 weeks of mindfulness meditations in health care practitioners. If you are inclined to achieve those benefits and be a better instructor for your interested patients, why not participate in an 8 week trial of meditation for your own research purposes?

Meditation research, on the whole, has poor methodological quality and it is difficult to draw firm conclusions on its effectiveness for pain management in a physical therapy setting. But there does appear to be trends in the evidence that are suggestive of mindfulness meditation to benefit pain management, as well as anxiety, depression and other health benefits (Baer et al 2003, Kabat-Zinn 2003). My own personal experience would suggest the Benson Method over Mindfulness Meditation to start with, despite having less evidence for it, because it is a simpler technique, ideal for beginners without in-depth instruction required, and a good place to start for those with a curiosity or interest in learning how to meditate.

As much as I wanted to find evidence that meditation is a wonderful adjunct and tool that could help us in the clinic, I have to report that the recent research falls somewhat short of my hopes. However as an eternal optimist, I believe more evidence will be produced in the near future and will hopefully show the benefits of meditation on health and pain management. Until then, we can continue to rely upon trends in the evidence and on our own clinical experiences. For more information, specific instructions on the Benson Method, questions or discussions please feel free to e-mail me.

For instructions on the Benson Method refer to www.relaxationresponse.org.

References

Baer RA (2003) "Mindfulness Training as a Clinical Intervention: A Conceptual and Empirical Review" Clin Psychol Sci Prac 10: 125-143.

Benson H, et al. (1974) "Decreased blood pressure in borderline hypertensive subjects who practiced meditation" J Chron Dis 27: 163-169.

Butler DS (2007). Class Lecture Notes: "Chronic Pain Management". University of South Australia, Adelaide.

Kabat-Zinn J (1982) "An outpatient program in Behavioural Medicine for chronic pain patients on the practice of mindfulness meditation: Theoretical considerations and preliminary results" Gen Hosp Psych 4: 33-47.

Kabat-Zinn J (1985) "The clinical use of mindfulness meditation for the self-regulation of chronic pain" J Behav Med 8: 163-190.

Kabat-Zinn J (2003) "Mindfulness-Based Interventions in Context: Past, Present, and Future" Clin Psychol Sci Prac 10: 144-156.

Shapiro SL, et al. (2005) "Mindfulness-Based Stress Reduction for Health Care Professional: Results From A Randomized Trial" Int J Stress Manag 12(2): 164-176.