I went to PT school way back in the Dark Ages, when everything was extremely heavily pathoanatomically based and while we talked about the biopsychosocial model, no one was particularly clear on how to implement it. However, I think most of us are well aware of the advances we have seen in pain sciences and the impact of the –psycho- piece of that, and hopefully more of us are clearer on how to implement it, at least with our patients with chronic pain. Cognitive-behavioral therapy techniques have become a huge part of my practice (which is largely patients with chronic pain, many of whom have some pelvic floor component-though not all), far more than I would have ever thought back in PT school when I was busily memorizing information about upslips, downslips, and counternutations!
One of the very powerful tools that I have used with my patients is the concept of mindfulness. Now, I think many people have a picture of someone listening to an MP3 track of a person speaking in a soothing voice while harp music plays in the background when they think of mindfulness (and this was the extent of my own knowledge about mindfulness until fairly recently as well). While this is one option for introducing and incorporating mindfulness, it is certainly not the only one (and in some ways/for some people, may not be the most effective one either!).
The concept of mindfulness is both simple and hopelessly complex: awareness of feelings, thoughts, and sensations in that moment without judgment (that’s the hopelessly complex part!). This is an oversimplification (I couldn’t possibly fully describe mindfulness to you in a blog post! There are entire books and conferences on it!) but it is trying to make yourself an objective observer of your current reality without superimposing values on the observations. It has very powerful applications in therapeutic neuroscience/pain education, because it can really help patients drop the secondary suffering piece of pain and help lead them away from catastrophizing about what might happen.
Another very powerful tenet of mindfulness is: just because you have a thought, feeling, or sensation, you don’t have to engage with it! You can choose to just observe it, note its presence, and then move on to something else, or you can choose to engage with it (think through it, process it, allow it to dominate your thought patterns).
Clear as mud, right? Maybe some clinical applications will help. I tend to use mindfulness with my chronic pain patients, and often to help them with fear of touch or fear of activity (essentially, in combination with desensitization work). For the moment, let’s pretend we are working with a chronic low back pain patient named Mary, and one of her goals is to be able to cook a meal. Her current standing tolerance is 10 minutes. She is also very hypersensitive to touch and doesn’t tolerate manual therapy very well, but you feel that it would be beneficial to her (she also doesn’t tolerate pressure from clothing well). Some of the ways I might incorporate mindfulness with her include:
- In the clinic: while we work on desensitization for touch. As I touch her and she flinches, I ask her to just scan her body (without removing my hand) and let me know what exactly she is feeling. Hopefully, she can come up with a word such as “pressure” or “tickling sensation” (basically anything other than pain) on her own along with perhaps some anxiety or fear that she might feel pain. If so, that’s great and we work on renaming the sensation and calming her breathing to “let go” of the anxiety. If she calls it pain, then I do a similar touch on another part of her body that isn’t hypersensitive and explain that it is the same touch and ask her to name it there, then return to the hypersensitive region and ask her to name it as “light brushing sensation” instead of pain and try to think of it that way.
- I might have her do a recorded mindfulness meditation before I start working with her in the clinic (as a “warm up”) or at home. There are some great free ones here. In particular, body scanning can be very helpful for people with cortical smudging and central sensitization.
- When she is working on graded exposure at home (cooking/standing for 10 minutes at a time and then gradually working up to longer and longer amounts of time), I can ask her to just be aware of what her body is feeling, and to name it. Sometimes I will have patients jot notes to themselves, others might just keep track mentally. I explain it as “we are trying to pay attention to what your body is actually feeling, not what the alarm in your brain is trying to make you afraid you might feel.” Or “We are trying to give your brain a bigger vocabulary; instead of just naming everything ‘pain’ let’s try to appreciate the variety of sensations you are actually encountering.” Sometimes it can be helpful to give people a list of names for sensations as they may have the ability to recognize them, but not generate them, at first.
- I ask people to choose a point in the day, preferably a consistent time (teeth brushing or showering are common ones, or driving in the car) to just observe their bodies and environment. You want them to be an objective observer, not make judgments about the sensations, so I tell them to “Look at yourself and the sensations with curiosity. How does the toothbrush feel against your teeth? Do you notice any smells? Are there any sounds you are aware of? If your thoughts wander, that’s completely normal, just as you are aware of that, bring your attention back to the moment, to noticing what is happening around you right now.” This helps them get into the practice of just being aware of what is happening around them and what they notice about their body in that moment.
Like I said, I would be doing the concept of mindfulness a disservice if I attempted to summarize it in a single blog post. However, hopefully this at least gives an idea of some possible ways to use it with patients. Truthfully, at times I will use it even with patients who have acute injuries as a way to help them accept what is happening with their body along with positive education on how tissues heal and how they will get better. There is so much evidence out there on the positive benefits of mindfulness and other forms of cognitive behavioral therapy for re wiring those brain pathways, and I think it is a very helpful skill to add in with our patients.
What are your thoughts or questions about mindfulness (or CBT in general)? Do you think it’s a helpful tool for PTs to use, or should we be sending patients to counselors or other professionals for this piece of treatment if we think they need it?