The word ‘mindfulness’ means compassionate and lucid awareness, a sense of knowing what is happening in the external and internal world as it is happening.  In its more common usage in recent clinical literature, it has come to mean intentionally paying attention to moment by moment events as they unfold, noticing habitual reactions to such events, often characterized by aversion or attachment, and cultivating the ability to respond to events with an attitude of open curiosity and compassion.

Mindfulness is traditionally cultivated by the practice of meditation in which people learn to pay attention to each moment with full intentionality and with friendly interest.

There are a number of mindfulness techniques that are utilized as part of MBCT including meditation, body scan exercises, mindfulness practices and yoga.  People might also be taught the ‘three minute breathing space technique’ which focuses on three steps, each one minute in duration.  Firstly, observing your experience (how are you doing right now?).  Secondly, focusing on your breath and thirdly, attending to your body and other physical sensations.

BENEFITS OF MBCT

A primary assumption of cognitive therapy is that thoughts precede moods and false self-beliefs lead to negative emotions such as depression.  MBCT utilizes elements of cognitive therapy to help you recognize and reassess your patterns of stress inducing thoughts and replace them with calming thoughts.  This approach helps people review their thoughts without getting caught up in them.  The combination of mindfulness and cognitive therapy is what makes MBCT so effective.  Mindfulness helps you observe and identify your feelings while cognitive therapy teaches you to interrupt automatic thought processes and work through feelings in a healthy way.

MBCT is also helpful in managing pain, particularly with helping the body to relax and to use calming thoughts as opposed to ones that may increase the subjective experience of pain.

Research has shown that Mindfulness-Based Cognitive Therapy can be effective for helping individuals who have experienced multiple episodes of depression and has also proved to be helpful with a wide range of mental health concerns such as anxiety disorders, low mood, bipolar disorder and depression associated with medical illnesses or trauma.  However, because it is a relatively new treatment modality, the long term benefits of this approach may not yet be fully determinable and further research may provide greater support for its effectiveness when treating bipolar, eating disorders, psychosis and other conditions.

KEEPING ACTIVE AND WELL

It is important for the patient to stay both physically and mentally healthy while they wait for their surgery as this will help them get the best results from their treatment in the long term.  There are many online tools and resources available to help them keep active and to support their mental health.  Some specific treatments that might help patients include:

Pain Medication and anti-inflammatories          Painkillers and anti-inflammatories can help significantly in terms of allowing people to cope with their daily activities, remain mobile and getting a good night’s sleep. Use of any pain relief medication should be carefully controlled.  Steroid injections can help to ease the pain of osteoarthritis but the likelihood of a steroid injection working can be highly variable depending on the damage to the knee or hip.  Steroids also mask a patient’s symptoms but without addressing the actual underlying cause of the symptoms, thus fooling the patient  into thinking that their knee or hip is better, when it is not resulting in further damage occurring to the joint.

Physiotherapy and Chiropractic            Physiotherapy or chiropractic are recommended by NICE as part of the treatment pathway for knee and hip arthritis.  Appropriate treatment prior to surgery can improve a patient’s mobility and build strength and fitness levels and increasing the likelihood of a successful outcome from the replacement joint surgery.

Non-impact cardio fitness exercise       Exercise programmes can be helpful providing the patient with specific exercises and hands-on supervised guidance.  Cardio fitness exercise is something the patient can do for themselves.  The best exercises for patients with arthritis are those that are light and gentle on the joints such as walking, cycling and swimming.  Performing regular cardio exercise causes the body to produce endorphins helping to raise the patient’s natural pain threshold.

IN SUMMARY

With NHS waiting lists for knee and hip replacement surgery getting longer,  there will be a greater need for patients to consider alternative treatment options in order to delay the need for surgery,  to help them cope while waiting for surgery and to ensure that they are in the best possible shape when they undergo their operation.

USEFUL LINKS

whileyouwait.org       Provides additional information, support and resources to help patients while they are waiting for hospital care.

escape-pain.org  Provides a group rehabilitation programme for people with chronic joint pain that integrates educational self-management and coping strategies with an individualized exercise regimen.

Learning deep breathing techniques is one of the most effective strategies for coping with the symptoms of stress and anxiety.  By breathing slower and more deeply from your stomach, you signal your parasympathetic nervous system to produce a state of calmness.  Diaphragmatic breathing enables more air to flow into your body, calming your nerves, improving your attention span and lowering pain levels.

WHAT IS DEEP BREATHING?

The use and benefits of deep breathing can be traced back to ancient traditions including yoga, tai chi, qi gong and meditation disciplines. In yoga, for instance, breath is a key element of the practice.  Pranayama, or breath regulation, refers to the extension of the vital energy through the breath and can be understood as an umbrella term for different breathing techniques, including deep breathing.   More recently, science has delved into this topic, accumulating a considerable body of research supporting the effectiveness of these techniques.

Also known as yogic breathing, deep breathing is the voluntary regulation of breath by consciously and actively using the diaphragm to increase the depth and slow down the inflow and outflow of air.  The diaphragm is the muscle separating the abdomen and chest cavity.  Attached to the base of the lungs, the diaphragm is rarely activated when breathing unconsciously.  This translates into a shallow breathing pattern leading to poor ventilation.  On the other hand, when breathing deeply, you engage this muscle by allowing your belly to rise and drop freely, facilitating a greater.  This allows an array of positive physiological and psychological processes to take place.

BENEFITS OF DEEP BREATHING

Scientific reviews have shown that deep breathing techniques can improve symptoms in sick patients, and they are also beneficial in enhancing wellbeing in healthy people.  Different emotions have been associated with varying patterns of breathing, heart activity and activation of either the sympathetic or parasympathetic nervous system.  Evidence suggests that it can also inhibit sympathetic (anxiety) activity and increases a parasympathetic (happiness) response which translates to experiencing less distressing and more positive emotions.

Abdominal breathing for 20-30 minutes each day will produce a state of relaxation, reduce stress and anxiety and will help you to feel more connected to your body bringing your awareness away from the worries in your head and helping to quiet the mind.

There are about twenty different types of endorphin, the best known being beta-endorphin associated with ‘runner’s high’.  They are also es involved in pain management and have the ability to block nerve cells from releasing pain signals to the brain .  In the peripheral nervous system, they produce analgesia by binding to opioid receptors.

How to Release Natural Endorphins

There are many ways to release natural endorphins including exercise, laughter, acupuncture, being in nature and meditation.

Exercise:     Since 2008, with the use of PET scans, researchers have been able to measure the release of endorphins in an athlete’s brain before and after exercise.  After exercise, they found a significant increase.  As exercise has been proven to boost mood, some medical professionals prescribe regular exercise as a treatment for mild to moderate depression and anxiety.

Meditation:   When you are stressed, your body triggers the release of stress hormones causing inflammation and increasing pain.  Meditation helps to shift your focus to something quiet and calming, helping your brain to release endorphins.  One study showed that mindfulness based stress reduction which combines meditation and yoga, was more effective than drugs and surgery for alleviating chronic low back pain.  With practice, meditation can increase your pain tolerance, lower hypertension and deepen respiration.

Acupuncture:   Placing fine needles into the skin at specific points around the body (acupoints) helps trigger the release of pain relieving endorphins.

Laughter:    Laughter is the best medicine as it also releases other ‘feel good’ hormones such as dopamine and serotonin and suppresses stress hormones to improve mood, reduce pain and support a stronger immune system.

Chiropractic: Research has shown that chiropractic manipulation stimulates the release of endorphins in the brain. This may explain the feeling of well-being patients claim to experience immediately after treatment.

The science of human endorphin levels is still evolving as researchers continue to study this chemical and how it affects our overall health.  In addition to decreased feelings of pain, their secretion leads to feelings of euphoria, modulation in appetite, release of sex hormones and enhancement of the immune response.  With high levels, we feel less pain and fewer negative effects of stress.

Biotensegrity offers a unique way of examining the human body in the light of new understanding about functional anatomy. It is an overriding concept that describes a relationship between every part of the organism and the mechanics that integrate them into a complete functional unit.
This concept can be attributed to the work of Orthopaedic surgeon, Dr. Stephen Levin MD who says that the body is made up of many bones and structures and that, if one applies an external force, the entire shape “adapts” or changes according to the applied force, up until a breaking point is reached. The level of force applied to individual joint structures will affect the function of the joint or how it moves. Too much force may a restrict a particular movement or cause pain and too little force can make a joint unstable or prone to injury.  As the body adapts to poor movement at individual joints, pain can manifest in locations distant from the source of dysfunction

Individual Joints

The tensile structures surrounding each joint hold the joint surfaces apart, so that in a well-functioning joint there is no pressure on the bones as they move. This has significant implications for joints such as the hip and knee which are well known to wear out and need replacement. It is also important in spinal care; traditionally the discs in between vertebrae are thought of as shock absorbers, but in the Biotensegrity model, when the spine is well aligned with correct tension in the surrounding muscles and ligaments, there is no pressure on the discs. As you can see in the picture, the red and blue cords, which represent spinal ligaments, are tensioned so that the vertebral box are held apart from each other.

Biotensegrity and Pregnancy

A particularly good example of Biotensegrity at work is during pregnancy due to the change in the centre of gravity. During pregnancy, the hormone relaxin is released which results in a loosening of ligaments and joint structures throughout the body. These changes are gradual and occur over the entire nine months of pregnancy. Structure and function are inextricably linked as the skeletal frame has a direct impact on joint function. Differences in tensile and compressive forces throughout pregnancy can often lead to aches and pains as the body adapts. However, after the baby is delivered, there is an instantaneous change in forces affecting both structure and function. Relaxin stops being secreted  causing ligaments to start tightening up again. This is a good time to assess the functioning of the musculoskeletal system to avoid misalignments.

Biotensegrity recognizes that interactions between different components of the body follow basic principles of self-organisation and it recognizes the wholeness of the human body.

The spine is designed to move. Each vertebra is connected to the next by a disc and 2 facet joints. It is similar to a snake, which is not surprising as we evolved from the same source. For optimum health our backs should be mobile at every joint. Our spines should be as fluid and flexible as a snake. However, they are not. This may, in part, be due to our upright posture which puts more stress on the spinal muscles and joints.

You may have noticed that young people are flexible while older people are more stiff. The older we get the more our backs stiffen up. This is because the fibres that cover our spinal joints get thicker and more brittle over time. These fibres are a kind of scar tissue and those parts of the spine that get more stress on them due to our habitual postures or repetitive work activity, tend to develop more scar tissue. This is called “wear and tear” by some people and may be the first stage of arthritis.

Chiropractic treatment releases the adhesions that form on people’s spines giving them more mobility. When you have a more mobile spine you suffer less pain. Many people think that a chiropractor’s job is about relieving back pain. It is not. It is about restoring mobility.  Reduced pain is a by-product of chiropractic treatment

The first stage in restoring health to your back is to improve mobility. When your back is more mobile it is important to work on your core strength. Core stability exercises, such as taught in a Pilates class, help to strengthen the muscles that support the spine. They also help to develop neurological control over these muscles so that they contract to protect the back at the right time. (It doesn’t matter how strong a muscle is, if it contracts at the wrong time it is useless!)

A mobile spine and strong core are the two essential components of a healthy back. One without the other is insufficient. If you spinal joints are inflexible  your spine is like a solid broom handle. The muscles around it, that move the vertebrae, are ineffective if the joints cannot move. On the other hand a flexible back without a strong core is unstable.

When your back is flexible, strong and stable then all you have to do is to use your back the way it is meant to be used. That is to be active in your daily life; Keep your whole body moving as much as possible. The beauty of being pain-free is that you don’t have to think about your back, you can just get on with the things you want to.

How Mindfulness Can Help

Mindfulness is a powerful tool to help address many of the causes of back pain because it puts your mind back in touch with your body. Our modern world tends to make us goal focused, looking out there, while we are unaware of the subtle tensions that arise in our bodies through everyday activity. These tensions can build up to such a degree that the body finally starts to break down, leading to pain. When you are more in touch with your body you will not like the effect of eating unhealthy food, you will feel restless with a sedentary lifestyle, you will be aware of the hormonal changes in your blood chemistry caused by stressful situations. Your habitual postures will start to feel uncomfortable, you will notice the strain that repetitive activities are placing on your body.

When you are more aware of these negative effects, you will feel compelled to make changes. Mindfulness will make you eat a better diet, exercise more, maintain better posture and, most important of all, find creative ways to deal with stress in your life.

History of Mindfulness

Mindfulness is a Buddhist practice that started to filter to the west in the sixties. As more and more people found the practice beneficial, meditation centres sprang up in Europe and the USA. Mindfulness is one aspect of the Buddhist spiritual path known as the Eightfold Noble Path. Many people found the practice hard to stomach, either because it challenged their Christian beliefs. Others found it difficult because people were becoming averse to anything that smacked of religion.

Jon Kabat Zinn, an American writer and ex-Buddhist monk, is recognised as a major proponent in the secularisation of mindfulness. Since the 70’s universities around the world have been studying the effects of mindfulness, based on his work. Researchers have published hundreds of  papers that show remarkable benefits for this practice. Bangor, Exeter and Oxford are the main universities where mindfulness is studied. You can get masters degrees and other post graduate qualifications in mindfulness from these universities.

The universities developed an eight week, one evening a week, course based on thirty years of research into mindfulness practice; Mindfulness Based Stress Reduction.  I include simple mindfulness practices as part of my treatments for people suffering from back pain and stress at my chiropractic clinics in Chester and North Wales, but to really get a taste for mindfulness I would recommend the 8 week MBSR training as a starting point.

One of the most important parts of yoga therapy is proper breathing. The effectiveness of yoga therapy on back pain has been researched and published recently in Spine and according to the study, there has been a significant improvement in terms of the intensity of the symptom, depression, and amount of medication use in patients after therapy (Spine (Phila Pa 1976). 2009 Sep 1;34(19):2066-76).

There has also been a study by Mehling et al.,  published in 2005 that emphasises the potential benefits of proper breathing exercises in relieving backache. In this study, they used a group of chronic low back pain patients. These patients were grouped in two; one group received a six- to eight-week breath therapy exercise lessons, and the other received traditional physical therapy (Altern Ther Health Med. 2005 Jul-Aug;(4):44-52). It was found that both groups have reported improvement in their condition.

. Andrew Weil, an integrative medicine expert, believes that breathing exercises can indeed benefit backaches. According to him:

“I’m impressed by the power of breath and its ability to correct specific health problems and promote our general wellness. Proper breathing is a master key to good health.”

Below is a step-by-step guide on how to do basic breathing exercises properly.

ABDOMINAL BREATHING TECHNIQUE:*

Breathing exercises such as this one should be done twice a day or whenever you find your mind dwelling on upsetting thoughts or when you are experiencing pain.

• Place one hand on your chest and the other on your abdomen. When you take a deep breath in, the hand on the abdomen should rise higher than the one on the chest. This helps to reinforce that goal of having the diaphragm is pulling air into the bases of the lungs.
• After exhaling through the mouth, take a slow deep breath in through your nose imagining that you are sucking in all the air in the room and hold it for a count of 7 (or as long as you are able, not exceeding 7)
• Slowly exhale through your mouth for a count of 8. As all the air is released with relaxation, gently contract your abdominal muscles to completely evacuate the remaining air from the lungs.  It is important to remember that we deepen respiration not by inhaling more air but through completely exhaling it.

Repeat the cycle four more times for a total of 5 deep breaths and try to breathe at a rate of one breath every 10 seconds (or 6 breaths per minute). At this rate our heart rate variability increases which has a positive effect on cardiac health.

Improper breathing is one of the first things that chiropractors notice in patients with chronic back pain. At the Back Doctor Chiropractic Clinic in Chester, we teach patients the proper way to breathe, and make you understand the connection between poor breathing and chronic back pain. We guide the patients to use the diaphragm and not just the chest when breathing.

For many years, it has been a belief that pain is a just sensation that the body experiences when exposed to injury, illness, or surgery. It is believed that when the body is exposed to this sensation, signals (or information) are sent to the brain via the nerve pathways. We think of  it as a signal that travels from the periphery to our brain, such as when skin gets in contact with a hot surface. However, chronic back pain is also affected by psychological factors. It can be either relieved or worsened depending on how the patient perceives it. A person goes through different degrees of psychological distress every time he or she experiences pain. It will be more noticeable, even intolerable, if the brain perceives it as important. If the brain sees the discomfort as harmless, it will be less noticeable and less bothersome.

Negative Thinking Makes Chronic Back Pain Worse

Exaggerated orientation to the symptoms or catastrophic thinking is not helpful for many reasons. One is because this only promotes dysfunction and worsening of the symptom. It creates anxiety, stress, and even depression, which worsens the symptom and impairs function. We are likely to become less functional if we keep thinking of pain as a threat to our overall health. Those who consider it as “just a trivial annoyance” are more likely to enjoy their day-to-day activities as they are more confident, have lesser worries, and no pain-related fear. Simply put, if you are injured, you will experience some discomfort. If it is confronted without negative appraisals, it is likely that you will achieve faster recovery.

On the other hand, if you focus on the possible threat that movement might cause, you will hesitate from any kind of muscle activity due to fear of re-injury, which will result to disuse and depression, and possibly a worsening of the condition.

Having chronic back pain or any kind of pain can affect one’s mood and emotions; likewise, mood and emotions can also affect the symptoms profoundly. The more a person focuses on it, the more it will bother him/her, and the more it can ruin his/her mood. Physical discomfort can make one irritable, even anxious. However, a simple diversion, such as watching a feel-good TV show or reading a book, can improve tolerance.

Aside from stress, anxiety, fear, and depression, there are a lot of other things that could affect chronic back pain, including one’s way of understanding of their own health and capacity. If you believe that doing activities can exacerbate or worsen your condition, you may become invalid. A person with more confidence, even with the same medical condition, may be doing their daily activities without any problem.

Positive Thinking Can Help To Relieve Chronic Back Pain

Confidence is one of the most important factors for a patient to be able to function normally and comfortably. It is difficult for patients to remove their attention away from their symptoms completely, but focusing on fear and anxiety may cause disability. Frustration and anger caused by pain can also worsen it. It is important to note, however, that even though psychological factors affect your condition, it does not necessarily mean that the it does not exist.

Pain is complex; it is a combination of psychological, emotional, and physical factors, and chiropractic care is one of the best options for patients to get relief. We, at the Back Doctor Chiropractic Clinic in Chester, take into consideration how pain impacts each patient . This way, we are able to choose the best approach for each patient in order to heal them. While chiropractic care is effective, it is even better when you believe that chiropractic therapy can help reduce your symptoms and when you avoid catastrophic thinking.

The BioPsychoSocial Model addresses the problem of back pain (or any kind of health issues) in three ways: Bio (biological) refers to biological, physical, or medical aspects of the pain such as injury; Psycho (psychological) refers to the way you react to it and how it affects your emotions and behaviours; and Social refers to how social pressures affect your symptoms. In this model, Pain is surrounded by Attitudes and Beliefs, Psychological Distress, Illness Behaviour, and Social Environment. These are the things that have to be addressed in order to identify the best approach to treatment as all these aspects have an effect on pain and recovery.

The BioPsychoSocial Model has six basic elements:

1. Sensory – This basically refers to the physical sensation of the pain in four dimensions:

• Location – Which part of the body is the symptom being experienced.
• Intensity -How severe the symptom is, ranging from 1 to 10, or from mild to excruciating.
• Quality – The type of pain, whether it is a dull, achy, stabbing, burning, or sharp kind.
• Time – How long the pain has been present

2. Emotional – This refers to how you respond to the symptom emotionally; whether or not it makes you feel anxious, depressed, worried, discouraged, irritable, angry, or scared.

3. Mental – This refers to how aware you are of the sensation, your expectations regarding the condition, and how you think you can cope with it. This also includes your thoughts about it, your decision-making process, and your attitude towards it.

4. Behavioural – This refers to the things you do in response to your condition. For some, pain affects their physical activities, routine activities, and habits. It sometimes affects social interactions, which can have a great effect, both mentally and emotionally.

5. Environment – This refers to your surroundings or physical environment, which has an effect on your awareness and ability to cope with the symptoms. This includes the weather, house, furniture, and availability of material resources.

6. Social Environment – This refers to your family, friends, physicians, and other people who can affect or be affected by your symptoms.

Interactions:

These elements interact with one another and can directly affect each other in two ways; in positive or negative cycles.

Positive Cycle –  Pain can have an effect on your emotions and physical sensations but you can control its effect through shifting your thoughts and your attitudes towards the pain and your body.

Negative Cycle – These elements can interact in a negative way. For instance, Sensory (or pain sensation) can decrease physical activity (behaviour). With decreased physical activity, depression (emotional) may occur, which can result to decreased self-worth and motivation (mental). This cycle could go in many different ways and can greatly affect your condition.

Chiropractors, physiotherapists and osteopaths are beginning to take into account the biopsychosocial model in their practices, and those that do are more effective.