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Mind Body Medicine for Musculoskeletal Pain

Course Authors

Hilary Tindle, M.D., M.P.H.

Dr. Tindle is Assistant Professor of Medicine, University of Pittsburgh School of Medicine. Within the past 12 months, Dr. Tindle reports no commercial conflicts of interest.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 
Learning Objectives

Upon completion of this Cyberounds®, you should be able to:

  • Describe standard mind body therapies that may be applicable to the treatment of musculoskeletal pain

  • Discuss the evidence supporting the use of mind-body therapies for pain and their potential neural mechanisms

  • Educate patients with musculoskeletal pain as to when a mind body therapy may be appropriate as part of a comprehensive treatment plan.

 

Introduction

Persistent and chronic pain affects approximately 30% of the United States population,(1),(2) yet remains a frustrating condition to treat. Melzack and Wall's gate control model of pain (in which peripheral sensory input is regulated at the level of the dorsal horn before ascending the spinothalamic tract) provided an initial context for understanding how psychological factors may influence pain perception.(3) In accordance with the biopsychosocial model of disease,(4),(5) increasing attention is now placed on the patient as a multidimensional individual who has not only physiologic, but also psychological and social components contributing to pain. This broader understanding of the complex experience of pain has resulted in the adoption of a multifaceted approach to treatment.(6),(7),(8),(9)

Common mind body therapies include relaxation techniques, guided imagery, biofeedback, hypnosis, cognitive behavioral therapy and meditation...

Rationale for Use of Mind Body Medicine to Treat Pain

In 1996, an NIH Consensus Panel on the Integration of Behavioral and Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia recommended the use of mind body therapies as adjunctive therapy for chronic pain.(10) Since that time, there has been increasing evidence to support the efficacy of mind body therapies in the treatment of select chronic pain syndromes.(11),(12),(13),(14),(15) In addition, many mind body therapies are relatively inexpensive(16),(17) and in certain clinical settings, have been shown to be cost effective even when used in addition to the standard of care.(18) When used appropriately, mind body therapies are considered safe for most populations.(12),(13),(14),(15),(16),(17),(18),(19) Finally, to the extent that mind body therapies emphasize self-care, they may result in decreased utilization of the health care system.

Definitions

Mind Body Medicine

Mind body medicine, as defined by the National Center for Complementary and Alternative Medicine (NCCAM) "focuses on the interactions among the brain, mind, body, and behavior, and the powerful ways in which emotional, mental, social, spiritual, and behavioral factors can directly affect health."(20) Mind body medicine is one of the five major domains of complementary and alternative medicine (medicine that has not been incorporated into the standard of care),(21) and mind body therapies are some of the most commonly used CAM therapies among US adults.(22)

Mind Body Therapies

Mind body therapies, which are the components of mind body medicine, are characterized by NCCAM as "techniques designed to enhance the mind's capacity to affect bodily function and symptoms."(23) Common mind body therapies include relaxation techniques (such as deep breathing, progressive muscle relaxation and the relaxation response),(24) guided imagery, biofeedback, hypnosis, cognitive behavioral therapy and meditation (Table 1). Meditation is further divided into several sub-types, with the two most commonly studied being transcendental meditation(25) and mindfulness meditation(26) (mindfulness meditation has also been referred to as attentional training or metacognitive awareness).(27),(28) There is substantial overlap between mind body therapies, making their taxonomy challenging. For example, many guided imagery exercises begin with progressive muscle relaxation and involve deep breathing and meditation, while various forms of meditation incorporate breathing exercises and imagery. Table 1 does not provide an exhaustive list but rather is intended to provide basic information for clinicians who are unfamiliar with mind body therapies.

People with musculoskeletal pain were almost twice as likely as those without pain to use mind body medicine...

Table 1. Description of Common Mind Body Therapies.

Mind Body Therapy Brief Description
Relaxation techniques Relaxation techniques are a variety of practices intended to effect a state of relaxation or reduced sympathetic arousal. The goal of these therapies is to allow patients to perform self-relaxation at will.
Guided Imagery Guided imagery involves the process of image generation for the purpose of improving health. There are active styles of guided imagery, where the patient mentally creates the image(s), as well as more passive styles in which the guide describes the images through a script, while the patient listens intently.
Biofeedback Biofeedback utilizes a device to amplify normal physiological processes (e.g., muscle tension) to make them more easily perceptible. Patients then receive feedback regarding their physiologic state (e.g., tension in a given muscle group) and learn to manipulate their own physiology (e.g., decreasing muscle tension) guided by cues.
Hypnosis Similar to passive style guided imagery, described by expert David Spiegel as "a natural state of aroused, attentive focal concentration coupled with a relative suspension of peripheral awareness."(67) The hypnotic state includes three main components:
  1. absorption (in an object of concentration),
  2. dissociation (from ordinary conscious perception) and
  3. suggestibility.
In functional imaging studies, the hypnotic state appears to be characterized by activation of a cortical network that is distinct from mental imagery and normal alertness.(68),(69)
Cognitive Behavioral Therapy Cognitive behavioral therapy is composed of both cognitive and behavioral techniques that address the role of maladaptive cognitions and behaviors in disease. Cognitive therapy emphasizes the process of correcting negative thinking patterns through a process called cognitive restructuring, while behavioral therapy rewards behaviors that are beneficial in order to effect positive behavior change.(70)
Meditation When used in clinical settings, meditation is the practice of consciously bringing one's attention to inner experience. It may also be described as the self-regulation of attention. Two main forms of meditation interventions that have been extensively studied for health conditions are transcendental meditation, in which practitioners silently repeat a word or phrase (mantra), and mindfulness meditation, which involves non-judgmental attention to internal events such as thoughts, emotions, and physical sensations on a moment-to-moment basis. Meditation, like other mind body therapies, often effects a hypometabolic state.(71)

For additional descriptions of these and other mind body therapies, see Barrows and Jacobs, Med Clin North Am, 2002[66], and a recent review by Dr. John Astin.(12)

While most mind body therapies are considered to be part of complementary and alternative medicine, cognitive behavioral therapy is a mind body therapy that has become main stream. Cognitive behavioral therapy is used to treat chronic pain because it, like other mind body therapies, addresses the associated cognitive and emotional issues that may accompany or enhance pain symptoms.(30)

Some complementary and alternative therapies such as Qi Gong, Tai Chi and yoga share features of more traditional mind body therapies (such as the use of imagery and breathing techniques) but are not always classified as such. For the purposes of this Cyberounds®, we will focus on the more classically defined mind body therapies in Table 1. Similarly, prayer also meets criteria for a mind body therapy and is widely used by U.S. adults for health reasons.(22) However, in research studies of mind body therapies and health, prayer is often considered separately because the characteristics of respondents who pray and the reasons for use of prayer may differ from that of other mind body therapies.(31),(32)

Prayer for one's own health was used by 43% of U.S. adults.

Mode of Delivery of Mind Body Therapies

Mind body therapies are delivered in a variety of ways. Clinical settings may involve group or one-on-one therapy. For most populations, mind body therapies also lend themselves well to self-care. For example, many forms of relaxation techniques combine practitioner-based instruction with a home-study program. There are no hard and fast "exclusion criteria" for use of mind body therapies, since their safety profile is well-established.(12) Certain therapies such as guided imagery or meditation may not be appropriate for patients with untreated psychiatric conditions (such as uncontrolled depression or active hallucinations), though one recent study safely used a mindfulness-based therapy for patients with active depression and anxiety.(29)

Epidemiology of Mind Body Therapies for Pain

According to three large, nationally- representative surveys, use of mind body medicine by U.S. adults is widespread. In 1997, Eisenberg and colleagues surveyed 2055 individuals and found that 16.3% of U.S. adults used relaxation techniques (such as meditation or the relaxation response.(33),(34) Chronic pain was the third-most common reason (19.5%) to use mind body therapies and was reported to be "very useful" for that condition by 55% of users.(32)

The 1999 and 2002 National Health Interview Surveys (NHIS) were conducted by the Census Bureau for the National Center for Health Statistics. In 1999, 30,801 U.S. adults were asked if they had persistent joint pain during the past year and also if they had used a mind body therapy (including relaxation techniques, guided imagery, hypnosis and biofeedback) during the past year. People with musculoskeletal pain were almost twice as likely as those without pain to use mind body medicine (9% vs. 5%, respectively) and prayer (20% vs. 12%, respectively).(35) The 9% who used mind body medicine represent about 3.5 million U.S. adults. These individuals were more likely to be female, younger, White, more highly educated and have a history of depression as compared to adults with pain who did not use mind body medicine. These factors were similar to those seen in a prior analysis of mind body medicine.(32)

Of the mind body therapies asked about in the survey, relaxation techniques were the most commonly used (8.0%), followed by imagery (2.7%), biofeedback (1.2%) and hypnosis (0.9%).(35) In the 2002 NHIS, 31,044 adults age 18 and older were surveyed about use of mind body therapies. Prayer for one's own health was used by 43% of U.S. adults. After prayer, deep breathing exercises were the most commonly used mind body therapy, with 12% of adults reporting use of this relaxation technique in the past year.(22)

Efficacy of Mind Body Therapies for Musculoskeletal Pain

Back Pain

A recent Cochrane Review examined the efficacy of behavioral therapy for non-specific chronic low back pain to determine if behavioral therapies were effective and, if so, which ones were most effective. (36) Subjects were between 18 and 65 years old. The authors calculated a pooled effect size for post-treatment and long-term results for a variety of outcomes including behavioral outcomes, overall improvement, back pain specific and generic functional status, return to work and pain intensity. Effect sizes were classified as small (between 0.2 and 0.5), medium (between 0.5 and 0.8) or large (0.8+). The behavioral interventions were divided into three categories: operant, cognitive and respondent. Operant therapies (e.g., behavioral therapies, based on the operant conditioning principles of Skinner(37) and applied to pain by Fordyce),(38) use reinforcement to modify behavior. Respondent therapies (e.g., relaxation techniques or guided imagery) aim to modify patients' physiologic responses, while cognitive therapies (such as cognitive restructuring techniques) aim to modify patients' thoughts about their pain.

...for treatment of chronic low back pain...breath therapy was comparable to physical therapy in the short- and long-term.

The authors examined several comparisons, including behavioral treatments vs. waiting list controls, a comparison among different types of behavioral treatment and behavioral treatment vs. other types of treatment. Only 7 of the 21 randomized controlled trials identified were considered high quality and none had blinded participants. The authors concluded that there was strong evidence (4 trials, 134 people) to support respondent therapy (relative to a wait list control) for a medium effect size on pain. There was moderate evidence (2 trials, 39 people) to support progressive relaxation (relative to a wait list control) for a large effect size on both pain and behavioral outcomes but only in the short term. Interestingly, there was no evidence that one behavioral therapy was more efficacious than another for pain-related outcomes, and there were no differences seen in efficacy when behavioral components were used in addition to usual care. This is in contrast to an earlier meta-analysis of 65 studies that demonstrated multifaceted treatments for pain that included cognitive or behavioral therapies were more efficacious than single modality treatments such as usual medical care.(39)

A more recent trial of breath therapy (a mind body therapy integrating body awareness, breathing, meditation and movement) for treatment of chronic low back pain in 36 adult patients found that breath therapy was comparable to physical therapy in the short- and long-term.(40) A randomized trial of mindfulness meditation for 37 older adults with chronic low back pain found significant improvements in pain acceptance (effect size=.83, p=.008) and physical function (effect size=.46, p=.03) relative to wait-listed controls.(41)

Other Musculoskeletal Pain Syndromes

Mind body therapies appear to be effective for some types of headache. Holroyd and colleagues examined the use of mind body interventions for recurrent tension type headaches. Relaxation training, EMG biofeedback and a combination of the two therapies reduced symptom severity by half.(42),(43) An earlier meta-analysis found that relaxation and biofeedback were equivalent to propranolol for the treatment of migraine.(44)

Hadhazy and colleagues examined 13 controlled trials of mind body therapies for fibromyalgia.(45) While mind body therapies have been shown to improve self-efficacy in this patient population, evidence that mind body therapies were more effective than a waiting list control was limited.

Several mind body therapies have also been studied for arthritis (including rheumatoid and osteoarthritis) but the most commonly studied intervention is the Arthritis Self Management Program, which has components of education, cognitive therapy and relaxation techniques. Patients adhering to this self-management program have reported reduced pain and disability relative to baseline. Astin and colleagues performed a meta-analysis of over 20 randomized trials of mind body therapies for rheumatoid arthritis.(46) Significant effect sizes were seen in the short-term (post-intervention): pain (effect size=.22), functional disability (effect size=0.27), psychological status (effect size=0.15), coping with pain (effect size=0.46) and self-efficacy (effect size=0.35). At long-term follow up, effect sizes were moderate for psychological status (0.30) and coping with pain (0.52).

...there is emerging evidence that mind body therapies facilitate patient empowerment and other patient-centered outcomes.

Proposed Mechanisms of Mind Body Therapies for Treatment of Pain

The mechanism by which mind body therapies may alleviate pain is not well established but may result from their effect of increasing patients' sense of self-control and/or self-efficacy,(45) both of which can influence the experience of pain.(45),(47),(48) Similarly, there is emerging evidence that mind body therapies facilitate patient empowerment and other patient-centered outcomes.(10),(49) Mind body therapies may also modify the cognitive and emotional components of pain perception known as pain unpleasantness and pain affect.(50),(51) Pain unpleasantness and pain affect are distinct from pain sensation(52),(53) and also contribute to suffering.(54) Clinically, the emotional components of pain often have the effect of magnifying pain severity and a variety of other pain-related outcomes.(55)

Pain as a Complex Sensory Experience

Effectively integrating mind body therapies into the management of musculoskeletal pain requires an understanding of pain as a multidimensional experience. In a recent commentary on the complexity of pain, entitled "Pain: From Molecules to Suffering," author Troels Staehelin Jensen asks, "What is pain: a sensation, an experience, a symptom, or even a disease?"(56) In this statement he refers not only to the sensory components of pain but also to pain unpleasantness and secondary pain affect. His description of the experience of pain as "the activation of specialized high-threshold receptors to warn the organism of potential tissue damage" followed by "a less-well-definied but strong emotional experience" in which a person is "irresistably driven to stop the pain or escape from the stimulus that causes it" offers a concise summary of the "complex combination of sensory-discriminative and affective-motivational elements in pain, and the role of cognitive processes in evaluating this information."(56)

Figure 1 displays a schematic of the interactions between emotional and sensory components of pain. Nociceptive input from the periphery results in activation of primary and secondary somatosensory cortex and a number of other areas involved in autonomic activation including the amygdala and the hypothalamus. The pain signal ascends to higher centers, including the anterior cingulate cortex and the prefrontal cortex, where it is processed further.

Figure 1. Interactions Between Pain Sensation, Pain Unpleasantness, and Secondary Pain-Effect.

Figure 1

Interactions are illustrated by arrows. Neural structures likely to have a role in these dimensions are shown. Dashed arrows indicate nociceptive or endogenous physiological factors that influence pain sensation and unpleasantness. ACC, anterior cingulate cortext; PCC, posterior cingulate cortex; IC, insular cortex; HYP, hypothalamus; S1 and S2, first and second somatosensory cortical areas; PPC, posterior parietal complex; SMA, supplementary motor area; AMYG, amygdala; PFC, prefrontal cortex; RF, reticular formation.

Reprinted with permission from DD Price, Molecular Interventions, 2002.

There are two key points to be made regarding this model. First, the anterior cingulate cortex (ACC) appears to be an important site for the phenomenon of pain unpleasantness. This is supported by several brain imaging studies.(57),(58),(59) In addition, subregions of the cingulate cortex may be the site of interactions between acute pain and emotion(60) Second, secondary pain affect is a process resulting from activity at higher centers (prefrontal cortex). Theoretically, mind body therapies have the ability to interrupt the generation of either immediate pain unpleasantness (at the level of the anterior cingulate cortex) or secondary pain affect (at the level of the prefrontal cortex).

A recent review of the neural pathways underlying sensory and affective components of pain outlines the serial and parallel connections between the ascending pathways, subcortical structures and cerebral cortical structures involved in processing the various dimensions of pain (see Figure 2). This figure provides an anatomic context for understanding the complex processing of pain, and shows the multiple ascending pathways (in serial and parallel) for pain. For a more detailed description, please see Price DD, Molecular Interventions, 2002, pp. 394-399.)

Figure 2. Ascending Pathways, Subcortical Structures and Cerebral Cortical Structures Involved in Processing Pain.

Figure 2

PAG, periaqueductal grey; PB, parabrachial nucleus of the dorsolateral pons; Vmpo, ventromedial part of the posterior nuclear complex; MDvc, ventrocaudal part of the medial dorsal nucleus; VPL, ventroposterior lateral nucleus; ACC, anterior cingulate cortex; PCC, posterior cingulate cortex; HY, hypothalamus; S1 and S2, first and second somatosensory cortical areas; PPC, posterior parietal complex; SMA, supplementary motor area; AMYG, amygdala; PF, prefrontal cortex.

Reprinted with permission from DD Price, Molecular Interventions, 2002.

...placebo analgesia is not attributable only to reporting bias, but in fact reflects the inhibition of afferent input to the brain.

Given that mind body therapies aim to alter cognitive and emotional processes, it is expected that they may modulate the experience of pain by altering neural activity in a variety of structures involved in pain processing. However, evidence on their exact site(s) of action of is limited. Figure 3 provides a visual aid demonstrating the pathways responsible for transmission of pain signals (spinal cord → brain; left side) and the pathways responsible for "top-down" modulation of those signals (brain → spinal cord; right side).

Figure 3. Afferent Pathways for Pain and Descending Brain-to-Spinal Cord Modulatory Pathways.

Figure 3

Left: ascending pathways for pain, including receptors and primary afferent neurons, ascending spinothalamic tract, and thalamocortical pathways to somatosensory cortex. Right: descending pain modulatory pathways. This system originates in cerebral cortical areas, including amygdala, and projects to central grey. The latter, in turn projects to cells of the rostroventral medulla, which in turn project to the dorsal horn. Both inhibitory and facilitatory effects are exerted at the level of the dorsal horn. Thus, there is bi-directional control of nociceptive transmission at this level.

Reprinted with permission from DD Price, Molecular Interventions, 2002.

Brain imaging studies have begun to provide evidence for the mechanism of some mind body therapies for pain. For example, hypnotic suggestions for experiencing either high or low pain unpleasantness produced corresponding changes in activity in the anterior cingulate cortex (but not primary somoatosensory cortex).(58) Brain imaging studies of the placebo effect (considered a non-specific component central to many mind-body therapies) have contributed to the partial elucidation of cortical areas involved in pain modulation.(61) For example, placebo and opioid analgesia appear to share a common network that involves activation of the rostral anterior cingulate cortex.(62) In one study of patients with irritable bowel syndrome, placebo analgesia was accompanied by reductions in pain-related brain areas (including somatosensory cortices, anterior cingulate cortex, insula, and thalamus) during painful stimulation. This is an important finding supporting the theory that placebo analgesia is not attributable only to reporting bias, but in fact reflects the inhibition of afferent input to the brain.(63)

Providing Informed Consent for Mind Body Therapies

Some mind body therapies, such as relaxation techniques, are used as part of an existing comprehensive program for pain management. However, there may be times when a clinician wishes to prescribe one or more mind body therapies for a patient with pain symptoms. In this case, it is important to have a discussion with the patient about informed consent. A discussion of informed consent should focus on the safety and efficacy of the therapy in question (see Figure 4).

Figure 4. Safety and Efficacy of Complementary and Alternative Therapies.

Figure 4

Reprinted with permission from Cohen and Eisenberg, Annals of Internal Medicine 2002.

In this schema, there are four possibilities for any given mind body therapy: the medical literature supports A) safety and efficacy (top right panel), B) supports safety but evidence for efficacy is inconclusive (top left panel), C) supports efficacy but evidence regarding safety is inconclusive (bottom right panel) and D) evidence indicates potential harm or inefficacy (bottom left panel). As noted in the text of panel A, mind body techniques for chronic pain have been shown to be efficacious and safe (within the limitations noted above in the section on efficacy). Close monitoring of progress, as is necessary with any therapeutic intervention, is essential.

Conclusions

...when a clinician wishes to prescribe one or more mind body therapies for a patient with pain symptoms...the clinician must discuss informed consent with the patient.

Mind body therapies constitute a wide variety of techniques that are generally safe, inexpensive and used widely by the U.S. public. Despite this, much of the existing literature on the efficacy of mind body therapies for pain suffers from methodological flaws. While their efficacy for musculoskeletal pain appears limited to moderate, mind body therapies may be particularly useful when applied in combination with more standard therapies.

Further study is needed to identify the sites of action of hypnosis and other mind body therapies for pain, and to delineate the relative importance of both specific (e.g., skills training) and non-specific components (e.g., placebo effect) of each mind body therapy. This latter point is important since many experts in the field have argued that "non-specific" components of mind body therapies may have a relative contribution to their efficacy and that removing them may reduce the observed effect sizes.(11)

Finally, mind body therapies may be particularly applicable to certain populations, such as the elderly, where there is a higher risk of medication interactions,(64) or in populations who prefer to use CAM therapies. The latter population is substantial considering that the 14% of U.S. adults who used relaxation techniques in 2002 represents about 29 million people.(65)

Resources

For patients seeking more information about mindfulness meditation and guided imagery.

For professional development in mindfulness meditation and guided imagery:
Footnotes

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