In the Moment

Physios are tuning into a pain management technique based on Buddhist principles. Louise Hunt finds out more

It may seem strange that instead of aiming to stop pain, physiotherapists should focus on helping patients learn to live with it, but one technique does just that and it is beginning to earn its stripes. Mindfulness as a clinical intervention is relatively new, but its roots lie in ancient Buddhist belief. In Buddhist tradition, by being aware of what causes suffering and by abandoning expectations of the way things should be, it is possible to develop an awareness of how things really are. Mindfulness as a healing technique began to take off in the late 1970s in the US (see panel: Meditation and medicine). Fast forward 30 years or so, and in the UK the concept is rapidly gathering pace. Doctors, psychotherapists, physiotherapists, occupational therapists and others are all sitting up and taking note of the concept described as the 'third wave of pain management' (following on from cognitive behavioural therapy and, before that, behavioural therapy). In chronic pain intervention, mindfulness involves using meditation to create moment-by-moment awareness of the body and thoughts. The aim is to make a distinction between primary and secondary suffering. Similar principles can be applied in managing depression, anxiety or long-term conditions. The distinction between primary and secondary suffering is fundamental to mindfulness. Primary suffering is, for example, the unpleasant sensations of back pain, whereas secondary suffering is all the negative reactions associated with pain that can lead to fear, depression and further tension producing additional pain. Vidyamala Burch is the founder of the not-for-profit firm Breathworks, which provides courses in mindfulness. She says: 'With mindfulness you can learn to accept the primary pain and reduce the secondary suffering, which can sometimes radically reduce pain. A lot of secondary pain is about resistance, we say to ourselves “I don't want this” and everything gets worse. Mindfulness can pull you out of the pit of chronic suffering.' Patients are taught pain is not only an unpleasant sensation, but a flow of changing sensations. 'Mindfulness teases apart the perception that pain is the enemy. People on the course find it a great relief to confront their pain. It is very stressful running away all the time.' Ms Burch adds: 'Mindfulness is not about making pain go away, which is why it is more suitable for chronic conditions. Obviously, if you can get rid of pain, great, but if you can't this is a profound way of getting your life back. The pinnacle of mindfulness is choice rather than reactivity.' She points to the small but growing number of physiotherapists, particularly those working with long-term conditions, who are interested in or have started using the approach. 'For practitioners, it is helpful if they can incorporate mindfulness training alongside other interventions, such as exercise,' she says. Breathworks offers introductory weekend courses for health professionals and also a longer course for practitioners to qualify as certified mindfulness trainers. Becoming a mindfulness trainer is not something to be done on a whim: professional courses, such as that run by Breathworks or the one at the centre for mindfulness research and practise at the University of Wales, Bangor, require experience of meditation. Trainers are expected to practice mindfulness for themselves to stay in tune with their patients' experiences. Physiotherapist Rosie Passingham took the Breathworks introductory course and has been learning and using mindfulness as part of a multidisciplinary team at the pain management unit at the Royal National Hospital for Rheumatic Diseases in Bath. The technique is used in contextual cognitive behavioural therapy as part of the unit's intensive three-week residential programmes for adults and adolescents with chronic pain.

Exercising with mindfulness 

 In physiotherapy sessions, patients learn to exercise with mindfulness and become more aware of their body sensations, thoughts, moods and urges, as well as learning how to notice their pain or fear of pain and make a choice as to an appropriate action. Patients are encouraged to learn from their experiences – if they have overdone an activity or avoided something because of fear, they are encouraged to talk through how to make a better decision. 'The patients we see are often very stuck; their lives have become smaller and less satisfying as they have struggled to reduce their pain and anxiety and other unpleasant thoughts,' says Ms Passingham. 'Unfortunately, many people with chronic pain aren't able to lead lives free of pain no matter how hard they try, how many treatments they have or experts they see. The idea of mindfulness is you don't have to feel better before you “do better”. The main message is to help people to take action in their lives with the presence of their pain.' Physio Bill Banks-Jones is also taking the Breathworks course and well on the way to becoming a certified practitioner after practising meditation for 15 years. He is using the approach in varying degrees with his work at Norfolk and Waveney mental health partnership trust in the older people's service and at a GP practice under South Norfolk primary care trust. In his mental health work he uses mindfulness with acupuncture to help patients become more aware of their bodies and where they hold tension. This can also be helpful with patients who have difficulty sleeping. He notes that National Institute for Health and Clinical Excellence guidelines have picked up on research at Bangor university showing that mindfulness-based cognitive therapy is effective in preventing relapses in depression. Stress reduction is the focus of an eight-week mindfulness-based programme in occupational health at Torbay hospitals trust, Devon. Physio Lynn Hunnable, who trained in mindfulness at Bangor university, says the scheme was introduced following a successful pilot last year. It is aimed primarily at staff who have been absent from work due to stress. While the long-term impact on work absence is not yet known, Ms Hunnable says the pilot produced a lot of good feedback and positive changes in staff attitudes.  She is optimistic there will be more programmes like the one at Torbay. 'The more people know about it, the greater the ripple effect will be,' she says. Ms Burch is equally hopeful that mindfulness will have a firm place in the future of UK healthcare. Breathworks is building up a bank of clinical evidence on mindfulness, and next year the centre will begin research in collaboration with Hope Hospital, Salford, using brain scans to assess whether mindfulness can reduce pain.'It's all very new and it's quite remarkable that mindfulness is being talked about as the next big thing to cognitive behavioural therapy. The next 5 to 10 years are going to be really exciting,' she says. FURTHER INFO Bangor University:    Breathworks: Kabat-Zinn et al. 'The clinical use of mindfulness meditation for self-regulation of chronic pain', Journal of Behavioural Medicine (1985), 8:163McCracken et al. 'The role of mindfulness in a contextual cognitive-behavioural analysis of chronic pain-related suffering and disability', Pain (2007) in press

The patient's perspective

Mandy Millichamp suffers from chronic pain and undertook the three-week residential programme at Bath pain management unit. 'The programme taught me how to concentrate on body and sensation and what we block out in our daily lives. We did some sessions walking around in Bath and we realised when we are in pain we often block out our surroundings. It made us aware of how our bodies adjust to walking on cobble stones and what the impact of compensating might be, such as gripping your toes when you're in pain. 'It was about finding your current ability and at what point negative sensations kick in. The point was not to have a boom and bust situation, but to listen to your body and keep activity on an even keel and an acceptable pain level. 'The programme has helped me to do things I couldn't before, such as horse riding with my daughter. I hadn't ridden for 21 years... I found mindfulness very empowering.'

Mindfulness and medicine

Jon Kabat-Zinn, professor of medicine emeritus at the University of Massachusetts medical school, pioneered the movement of mindfulness into mainstream western medicine in the late 1970s. He founded the stress reduction clinic and the center for mindfulness in medicine, healthcare and society at the University of Massachusetts medical school, where he developed mindfulness-based stress reduction. This combines meditation and yoga to help patients cope with stress, pain and illness. Over the decades his work has been widely researched and peer reviewed. He has published a number of number of books on the technique, including the widely read Full Catastrophe Living (1990).
Louise Hunt

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