Alternative Therapies for Pain Conditions

Introduction

Traditionally Physical / Physiotherapists are taught to be 'hands on' therapists and use traditional methods such as manipulations and soft tissue mobilisations, whether your in the camp of McKenzie or Maitland can be influenced upon your training. There is a lot of evidence to suggest that our traditional methods of treatment aren't effective at managing persistent pain long term, so is it time to look outside the box at alternative methods? [1]

Mindful Meditation

Pain is not just a pathophysiological process which was once though, it is an experience that is individual and unique to everyone. Pain is linked to experiences and memory, emotions and perceptions and social experience, therefore when treating persistent pain that is as complex as this, are 10-15 minutes of 'hands on' treatment going to be effective? 

Studies have shown a positive effect when looking at the effect of Mindful Meditation and persistent pain. Mindfulness / Mindful Meditation is defined as influencing the styles of thinking and emotional coping strategies, which aims to change unhelpful beliefs and catastrophising thoughts. [2]

Mindfulness is said to involve moment - moment attention to stimuli, whether this is external or internal, such as thoughts and feelings. It is acknowledgement of these stimuli with a non-judgemental view. This is a skill, which needs to be practised.[3] Studies of Buddhists and Monks have been shown to display changes in the brain which is thought to be related to their Mindful Meditation, but as stated this is a skill in which they develop and practice for months and years, so how can this be effective with our persistent pain population? [4]

There are many different types of meditation which can argue different techniques but it can be suggested that the Phases of Mindful Meditation are:[5]

Initial Phase:

This is concerned with the focused attention which can have effect of the selective and executive attention. This phase can involve focusing on the breath and the sensation of the air entering and exiting the body. [6]

Intermediate Phase:

Acknowledging the wandering mind and distractions, making note of them and bringing the mind back to focus. At this stage this is an effortful practice [7]

Advanced Phase:

This phase is a continuum of the intermediate phase, where this process become less effortful. [8]

Working with this theory on different phases /stages of meditation and given the length of time it takes to become an advanced meditator (like the Buddhists and Monks) and the criticism through out the literature on the short duration of controlled trials we can come to the conclusion that our patients have the capacity to enter the initial / intermediate phases. 

Research that is available does suggest that the less mindful the individual the more they catasthrophised, which involves the attention on the painful stimuli and is interpreted as a potential dangerous and harmful experience, in comparison to the mindful individual who catastropises less and each sensation / stimuli is observes as a non-judgemental sensation. [9][10]

So how do we empower our patients with theses skills? There are groups they could attend or simple online programmes to follow: 


Yoga 
Yoga pose.jpg

The NICE guidelines have been updated and recommend the best treatment for low back pain is exercise and not hands on treatment.[11] Anecdotally we known that a large proportion of persistent pain sufferers have back pain, and have tried many different treatment options previously, including hands on physiotherapy and have been given exercises at some point. So what is the best form of exercise for these patients? Some research has suggested that Yoga may be beneficial. [12]

So what is Yoga? It is an ancient practice that dates back over 5000 years. There is much more to Yoga than aiming to achieve those distorted and extreme positions that are associated with Yoga. It is also about harmonizing the body and mind with the breath (similar to the focused attention in the early phases of meditation). [13]

Studies have shown that Yoga can help decrease pain in musculoskeletal conditions[14][15]. Given the complexity of persistent pain Pearson 2008[16] has suggested that unless the individual with persistent pain has established acceptance of their pain and the clinician has a good foundation of knowledge of persistent pain then Yoga will not be beneficial at managing and decreasing the symptoms. Once this has been established then studies have proven to have a positive effect on pain and function. 

A relativity old study now, which has formed a platform for research into the area of Meditation, Yoga and Mindfulness looked at the Mindfulness-Based Stress Reduction Program in patients with persistent pain. This program included Meditation, Yoga, and breath and body awareness. This combined treatment of non conventional therapy proved beneficial immediate after the programme and up to a year post intervention.[17] Maybe it is time to consider thinking out side the box of conventional therapy?

Virtual Reality

The history of Virtual Reality (VR) in the clinical setting began with assisting patients who had suffered severe burns, to enable them to have dressings changed without experiencing significant levels of stress and discomfort, as research has suggested that a standard does of opioid medication was not sufficient to control pain levels. Hunter Hoffman and David Patterson started looking at the development of the use of VR with this patient group. With the collaboration of the University of Washington a VR game / world was created to use with this patient population. This game / world is called Snow-world with the idea that patient's experience excruciating burning fire like sensations when having their dressings changed, the aim of Snow-world was to make the patient feel encompassed in this icy cold world to help alleviate some of the symptoms along side the standard opioid medication. This research group have done studies on the burns patient population using functional MRI scans which have shown a decrease in pain-related brain activity when undergoing wound and dressing care whilst using VR.[18]

Research has shown to be very promising in the field of VR and acute pain, an area which is lacking in research is the use of VR in chronic / persistent pain[19]. A small group at Firsthand Technology have taken the idea of VR and are using it with the therapy of mindful meditation to help patients with persistent pain. They are combining the use of VR with biofeedback to provide the patient's with feedback to how well they are doing with their mindful meditation.[20] Take a look at the two videos below.


This may seem like this technology is too far away from our grasp working in clinics, but many people now have access to smart phones, and with a small cardboard device a smart phone with the right app can be transformed into a VR device.

References

  1. Griensven HV, Strong J, Unruh AM. Pain: A Textbook for Health Professionals. 2nd ed. Churchill Livingstone, Elsevier. London; 2014.
  2. Cassidy EL, Atherton RJ,Robertson N, Walsh DA, Gillett R. Mindfulness, functioning and catastrophising after multidisciplinary pain management for chronic low back pain. Pain. 2012; 153: 644-650
  3. Cassidy EL, Atherton RJ,Robertson N, Walsh DA, Gillett R. Mindfulness, functioning and catastrophising after multidisciplinary pain management for chronic low back pain. Pain. 2012; 153: 644-650
  4. Esmer G, Blum G, Rulf J, Pier J.Mindfulness-Based Stress Reduction for Failed Back Surgery Syndrome:fckLRA Randomized Controlled Trial. The Journal of the America Osteopathic Association. 2011; 111(1):646-652
  5. Cassidy EL, Atherton RJ,Robertson N, Walsh DA, Gillett R. Mindfulness, functioning and catastrophising after multidisciplinary pain management for chronic low back pain. Pain. 2012; 153: 644-650
  6. Chiesa A, Malinowski P. Mindfulness-based approaches: are they all the same? Journal of Clinical Psychology. 2011; 67: 404–24
  7. Tang, YY, Rothbart MK, Posner MI. Neural correlates of establishing, maintaining and switching brain states. Trends in Cognitive Sciences. 2012;16: 330–7
  8. Tang, YY, Rothbart MK, Posner MI. Neural correlates of establishing, maintaining and switching brain states. Trends in Cognitive Sciences. 2012;16: 330–7
  9. Schutze R, Rees C, Preece M, Schutze M. Low Mindfulness Predicts Pain Catastrophising in a Fear-Avoidance of Chronic Pain. Pain. 2010; 148: 120-127
  10. Peters LM, Vlaeyen JWS, Kunnen AMW. Is pain-related fear a predictor of somatosensory hypervigilance in chronic low back pain patients? Behav Res Ther 2002;40:85–103
  11. NICE. Exercise not acupuncture for people with low back pain says NICE in draft guidance. https://www.nice.org.uk/news/press-and-media/exercise-not-acupuncture-for-people-with-low-back-pain-says-nice-in-draft-guidance (accessed 24 April 2016)
  12. Pearson N. Yoga Therapy in Practice. Yoga for People in Pain. International Journal of Yoga Therapy. 2008; 18:77-86
  13. What is Yoga? http://www.artofliving.org/yoga (accessed 24 April 2016)
  14. Sherman KJ, Cherkin DC, Erro J, et al. Comparing yoga, exercise, and a self-care book for chronic low back pain. Annals of Internal Medicine.fckLR2005;143:849-56
  15. Williams KA, Petronis J, Smith D, et al. Effect of Iyengar yoga therapy for chronic low back pain. Pain. 2005;115:107-17
  16. Pearson N. Yoga Therapy in Practice. Yoga for People in Pain. International Journal of Yoga Therapy. 2008; 18: 77-86
  17. Kabat-Zinn J., Lipworth L. and Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioural Medicine. 1985;8:163-190.
  18. Virtual Reality Pain Reduction. http://www.vrpain.com/ (accessed 24 April 2016)
  19. Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Journal of Pain Management. 2001; 1(2):147-157
  20. VR Pain Control. http://www.firsthand.com/portfolio/pain.html (accessed 24 April 2016)