Hi Kate, can you tell us about the course you have designed Restorative Yoga for Physical Therapists?

My name is Kate Bailey and I am a pelvic floor physical therapist. I’ve been a pelvic floor PT going on4-5 years now.  Before that, I’ve been a pilates instructor for 20 years and taught yoga for over a decade. This course is a culmination of all of my experiences both with the yoga, pilates, and the pelvic floor population from kiddos through adulthood. It allows us to use the techniques from the yoga and pilates philosophies to support people in their healing process from pelvic pain and also just in their bodies.

What can participants expect to learn when they come to the course?

I wrote this course when the pandemic started. My whole intention was to make the didactic information self-paced and watch the videos as often as you want kind of course. This way, when we have dedicated time together it’s a lot more about discussion and me guiding people through the labs, and in turn, they can guide their colleagues or patients. It is designed so I’m not spending a lot of time lecturing to a screen and our time dedicated to each other is more about a conversation.  I want people to learn about the information in their own time, marinate in it a little bit, and then come with questions.

How do you feel that restorative yoga fits in with the care we provide to our patients with pelvic health conditions?

The restorative yoga component to me is really special because it’s one of the only times we prioritize rest, and not doing, and sitting with ourselves. Not necessarily trying to get strong, or trying to get more flexible. It’s really about allowing our bodies to be. Sometimes that is being in a little bit of discomfort. Sometimes that is just being with the exhaustion that I think we all have a little bit of. Just learning how to be with ourselves for 8, to 12, to 15 minutes and see that as a really productive part of our treatment plan.

How does trauma-informed care influence your course?

One of the things that I highlight in the course is how much trauma occurs in and around the home. So when we’re asking patients to do a home program one of the discussion points we have in the course is “what if the home is inherently triggering or unsafe?” How can we use concepts of graded exposure to get someone from needing a lot of sensory things, like lights on, windows locked, facing the window, eyes open to slowly getting people toward a little bit more safety. If that is not a possibility, finding another location and strategizing how we can prioritize our own safety and our own ability to relax rather than saying I must relax.

The other component of trauma in the course is the unveiling of how prevalent trauma is. In pelvic health, we talk a lot about sexual trauma because we are dealing a lot with the pelvic floor region and the genitals. One of the things I think we sometimes might be able to speak to more is the little subversive types of trauma. Whether it is emotional trauma, whether it is neglect, whether it is transgenerational trauma or intersectionality trauma…

There’s this other component in yoga that is coming out now that is the trauma that has been handed down through the yoga lineages. What I think is not understood is that a lot of people who practice yoga in a deep way have significant trauma from yoga. The question then is how do we reclaim a practice that is so lovely, done with care and kindness and non harming, for people who have maybe experienced it in a very harmful way – and introduce it as a non-harming, caring, compassionate method for people who haven’t experienced it. The whole idea is about how do you be in rest in your body and in empowerment.

Can you give an example of how a pelvic PT or OT would fit restorative yoga into their practice?

As PTs and Ots we are starting to bring mindfulness in, a lot, to our programming in terms of some of the work from Jon Kabat Zen on how great meditation is for so many things. There is still a question of “How do I put this in my plan of care?” The great thing about this class is that we can speak directly to this. Let's say that you are in a hospital-based scenario, you can give restorative yoga to someone n a hospital bed very easily. They’re not going anywhere and what a great thing to give them: a breathing practice, a concentration practice, and a rest practice.

For someone in private practice, such as orthopedics, this is the type of practice where maybe you’re not giving pelvic floor strengthening if someone has a large degree of overactivity in their pelvic floor. But they still need something to do at home, or they need something to do at the office. Maybe restorative yoga is a little bit too far out there for the patient. Maybe they don’t have a space they can lie down on the floor. That’s when we can say, ok how can we then transfer a pelvic floor restorative yoga posture to a desk situation? Can you cross your legs on your chair and lean forward, and modify it that way.

Then there is this component of the class that is all about breathing.  I think we know in pelvic health how wonderful and how great breath-work can be and so some of these techniques can be used as ‘secret exercises’ in your everyday life in addition to being a dedicated practice. We talk about all of that in class.

Watch the full interview with Kate Bailey at the Herman & Wallace YouTube Channel:

Join Kate to learn more about including restorative yoga into your practice with Restorative Yoga for Physical Therapists this year. Courses are scheduled for:

• May 21-22
• November 19-20

Rachna Mehta, PT, DPT, CIMT, OCS, PRPC is the author and instructor of the new Acupressure for Pelvic Health course. She is Board certified in Orthopedics, is a Certified Integrated Manual Therapist and is also a Herman and Wallace certified Pelvic Rehab Practitioner. An alumni of Columbia University, Rachna brings a wealth of experience to her physical therapy practice with a special interest in complex orthopedic patients with bowel, bladder and sexual health issues. Rachna has a personal interest in various eastern holistic healing traditions and she noticed that many of her chronic pain patients were using complementary health care approaches including Acupuncture and Yoga. Building on her orthopedic and pelvic health experience, Rachna trained with renowned teachers in Acupressure and Yin Yoga. Her course Acupressure for Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole focusing on the physical, emotional and energy body. Rachna is a member of the American Physical Therapy Association and a member of APTA’s Pelvic Health section.

According to the National Center for Complementary and Integrative Health (NCCIH), a branch of NIH, pain is the most common reason for seeking medical care¹. Over the last several decades there has been an increasing interest in safe and efficacious treatment options as our healthcare system faces a crisis of pills and opioid use. Among complementary medicine approaches, Acupressure has come forth as an effective non-pharmacologic therapeutic modality for symptom management.

Acupressure is widely considered to be a noninvasive, low cost, and efficient complementary alternative medical approach to alleviate pain. It is easy to do anywhere at any time and empowers the individual by putting their health in their hands. Acupressure involves the application of pressure to points located along the energy meridians of the body. These acupoints are thought to exert certain psychologic, neurologic, and immunologic effects to balance optimum physiologic and psychologic functions². Acupressure can be used for alleviating anxiety, stress and treating a variety of pelvic health conditions including Chronic Pelvic Pain, Dysmenorrhea, Constipation, digestive disturbances and urinary dysfunctions to name a few.

Acupressure uses the same points as Acupuncture; however, it is a very active practice in that we can teach our patients potent acupressure points as part of a wellness self-care regimen to manage their pain, anxiety and stress in addition to traditional physical therapy interventions. Traditional Chinese Medicine (TCM) believes in Meridian theory and energy channels which are connected to the function of the visceral organs. There is emerging scientific evidence of Acupoints transmitting energy through interstitial connective tissue with potentially powerful integrative applications through multiple systems.

Acupressure has also been used with various types of mindfulness and breathing practices including Qigong and Yoga. Yoga is an umbrella term for various physical, mental, and spiritual practices originating in ancient India, Hath Yoga being the most popular form of Yoga in western society. Yin Yoga, a derivative of Hath Yoga, is a much calmer meditative practice that uses seated and supine postures, held three to five minutes while maintaining deep breathing. Its focus on calmness and mindfulness makes Yin Yoga a tool for relaxation and stress coping, thereby improving psychological health³. Yin Yoga facilitates energy flow through the meridians and can be used for stimulating acupressure points along specific meridian and energy channels bringing the body to its physiological resting state.

As Pelvic health rehabilitation specialists, we are uniquely trained to combine our orthopedic skills with mindfulness based holistic interventions to improve the quality of life of our patients. We can empower our patients to recognize the mind-body-energy interconnections and how they affect multiple systems, giving them the tools and self-care regimens to live healthier pain free lives. Please join me on this evidence-based journey of holistic healing and empowerment as we explore Acupressure and Yin Yoga as powerful tools in the realm of energy medicine to complement our best evidence-based practices.

1. Pain: Considering Complementary Approaches published by National Center for Complementary and Integrative Health.2019.
2. Monson E, Arney D, Benham B, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-521.
3. Daukantaitė D, Tellhed U, Maddux RE, Svensson T, Melander O. Five-week yin yoga-based interventions decreased plasma adrenomedullin and increased psychological health in stressed adults: A randomized controlled trial. PLoS One. 2018;13(7).

Pauline H. Lucas, PT, DPT, WCS, NBC-HWC joins the Herman & Wallace faculty with her new course, Mindfulness for Rehabilitation Professionals. The course launches January 2021 and discusses the impact of chronic stress on health and wellbeing, and the latest research on the benefits of mindfulness training for both patients and healthcare providers. The following comes from Pauline, who hopes you will join her for her course.

As an integrative physical therapist treating people with pelvic pain, digestive issues, headaches, and various persistent pain conditions, I council my patients on strategies to reduce a chronically activated stress response (sympathetic dominance). Many of them are living stressful lives, and their medical condition can be an additional stressor. I share with them that by reducing their stress level and improving their overall awareness of what makes them feel better and worse, they may affect their condition in a positive way. When I ask if they have any experience with meditation, I often get the response: “Oh I tried that many years ago and I’m really bad at it; I just can’t meditate.” When I ask them to explain a bit more, they tell me that their mind is always super busy, they are always thinking, and when they try to stop the thoughts during meditation, it doesn’t work.

This is when I explain one of the essential concepts of meditation: It’s okay to have thoughts. In fact, it’s completely normal to become more aware of the busy thoughts when you first sit down to meditate. The trick is to allow the thoughts to be there, and at the same time keeping awareness with the focus of the meditation practice (i.e., the breath, a mantra, etc.). When we don’t resist the thoughts, the mind naturally gradually calms down, resulting in fewer and calmer thoughts. This is when I typically see relief on my patient’s face when they realize they may not be a bad meditator after all, and they are often willing to give the practice another try.

To learn more about using mindfulness and meditation in your personal life and in patient care, please join our 1 day virtual course Mindfulness for Rehabilitation Professionals.

Childbirth fear is associated with lower labor pain tolerance and worse postpartum adjustment.^1,2 In addition, psychological distress during pregnancy is associated with adverse consequences in offspring, including detrimental birth outcomes, long-term defects in cognitive development, behavioral problems during childhood and high levels of stress-related hormones.³ These negative consequences of fear and stress during pregnancy have inspired both interest and research into the role of mindfulness training during pregnancy to reduce fear and stress and improve outcomes.

In a randomized controlled trial, first-time mothers in the late 3rd trimester of pregnancy were randomized to attend either a 2.5-day mindfulness-based childbirth preparation course offered as a weekend workshop or a standard childbirth preparation course with no mind-body focus.⁴ Participants completed self-report assessments pre-intervention, post-intervention, and post-birth, and medical record data were collected. Compared to standard childbirth education, those in the mindfulness-based workshop showed greater childbirth self-efficacy and mindful body awareness, reduced pain catastrophizing and lower post-course depression symptoms that were maintained through postpartum follow-up. Participants in the mindfulness workshop also demonstrated a trend toward a lower rate of opioid analgesia use in labor.

In a qualitative study, researchers conducted in-depth interviews at four to six months postpartum with ten mothers at increased risk of perinatal stress, anxiety and depression and six fathers who had participated in a Mindfulness Based Childbirth and Parenting Program (MBCP).⁵ The MBCP program integrates mindfulness training into childbirth education. Participants meet for eight 2 hour and 15 minute weekly sessions and a reunion after babies are born. Specific mindfulness practices introduced include body scan, mindful movement, sitting meditation and walking meditation. Also, methods to integrate mindfulness into pain management, parenting and activities of daily living are introduced. Participants are asked to practice at home for 30 min per day in between sessions supported by audio guided instructions and informative texts.

Participants in the MBCP Program described gaining new skills for coping with stress, anxiety and pain, as well as developing insight and self-compassion and improving communication. Participants attributed these improvements to an increased ability to focus and gain a wider perspective as well as adopt attitudes of curiosity, non-judging and acceptance. In addition, they described mindfulness training to be helpful for coping with childbirth and parenting, including breastfeeding troubles, sleep deprivation and stressful moments with the baby.

These findings demonstrate potential therapeutic outcomes of integrating mindfulness training into childbirth preparation. Although this is a young field and more research is warranted, there is substantial research demonstrating mindfulness training improves stress management, pain management and decreases physiological markers of stress in a wide range of patient populations.^{6, 7} While the interventions in the above two studies introduce mindfulness in a group format, I have also found that patients can greatly benefit from being taught mindful principles and practices in one-on-one treatment sessions.

Carolyn will share her over-30 years of training and experience teaching mindfulness to patients both individually and in group settings in her course, Mindfulness-Based Pain Treatment, coming up on October 26 and 27 in Houston, TX. Participants will return to the clinic with skills to not only help patients, but to also help themselves be less stressed, more mindful providers!

1. Alehagen S, Wijma K, Wijma B. Fear during labor. Acta Obstet Gynecol Scand. 2001;80(4): 315–320.
2. Laursen M, Johansen C, Hedegaard M. Fear of childbirth and risk for birth complications in nulliparous women in the Danish national birth cohort. Br J Obstet Gynaecol. 2009:116(10): 1350–1355.
3. Isgut M, Smith AK, Reimann. The impact of psychological distress during pregnancy on the developing fetus: Biological mechanisms and potential benefits of mindfulness interventions. J Perinat Med. 2017 Dec 20;45(9):999-1011.
4. Duncan LG, Cohn MA, Chao MT. The benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with an active comparison. BMC Pregnancy Childbirth. 2017. May 12;17(1):140.
5. Lonnberg G, Nissen E, Niemi M. What is learned from Mindfulness-Based Childbirth and Parenting Education? – Participants’ experiences. BMC Pregnancy Childbirth. 2018; 18: 466.
6. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199-213.
7. Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis. J Psychiatr Res. 2017;95:156-78.

Most clinicians will agree that stress can amplify a patient’s pain and slow recovery. Mindfulness training provides patients with the ability to self-regulate their stress reaction and has been shown to reduce pain and depression and improve quality of life in patients with chronic pain conditions.¹ The growing popularity of meditation training to manage stress has led to an increased interest in the physiological mechanisms by which meditation influences the body’s stress reaction. A systematic review and meta-analysis examined the results of randomized controlled trials that compared the impact meditation interventions to active control groups on stress measures. ² Forty-five studies were included. Meditation practices examined were focused attention, open monitoring and mantra repetition. Outcome measures studied were cortisol, blood pressure, heart rate, lipid and peripheral cytokine expression. Studies had diverse participants including healthy adults, undergraduate students, army soldiers, veterans, cancer survivors, and individuals with chronic pain conditions, cardiovascular disease, depression and hypertension.

When all meditation forms were analyzed together, meditation reduced blood cortisol, C-reactive protein, resting and ambulatory blood pressure, heart rate, triglycerides and tumor necrosis factor-alpha. The effect of meditation on:

• Cortisol and resting heart rate was considered to be high level of evidence.
• C-reactive protein, blood pressure, triglycerides and tumor necrosis factor-alpha was considered to be moderate level of evidence.

Analyzed individually:

• Open monitoring meditation reduced ambulatory systolic blood pressure, systolic blood pressure following a stress test and resting heart rate. Effects assessed as providing moderate level of evidence.
• Focused awareness reduced blood cortisol and resting systolic blood pressure. Effects assessed as providing low level of evidence.
• Mantra repetition reduced systolic blood pressure. Effects assessed as providing low level of evidence.

Authors report the primary reason for downgrading the grade of evidence when analyzing meditation practices individually was the limited number of studies available and small sample sizes. They conclude overall, when compared to an active control (relaxation, exercise or education) meditation practice leads to decreased physiological markers of stress in a range of populations.

Carolyn will offer her popular course, Mindfulness-Based Pain Treatment, in Portland OR, July 27 and 28 and again in Houston TX, October 26 and 27. We recommend these unique opportunities to train with Carolyn, a nationally recognized leader trailblazing the successful applications of mindfulness into pain treatment and the field of physical therapy. Hope to see you there!

1. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199-213.
2. Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis. J Psychiatr Res. 2017;95:156-78.

We are thrilled to announce that Herman and Wallace instructor, Carolyn McManus, MPT, will co-present an educational session with internationally recognized pain researcher Etienne Vachon-Pressseau, PhD at APTA’s NEXT meeting in Chicago on June 13. Dr. Vachon-Presseau is an assistant professor at the Alan Edwards Centre for Research on Pain at McGill University and has led pioneering research into stress-associated brain changes in patients with persistent pain.

In a presentation entitled, When Stress Complicates Care for Your Patient in Pain: Evidence-Based Mechanisms and Treatment, Dr. Vachon-Presseau will discuss the latest research and theory illuminating the role of stress in the maladaptive neuroplastic brain changes observed in patients with chronic pain. Carolyn will discuss direct clinical applications of this marterial and highlight research on the role of mindfulness in the self-regulation of stress and pain. She will share a practical model for integrating mindfulness into physical therapy for the treatment of persistent pain conditions.

We are excited that Carolyn has been offered this honor to co-present at NEXT with a world renown researcher in the field of pain and contribute her insights from an over 30-year career specializing in mindfulness and pain. She will offer her popular course, Mindfulness-Based Pain Treatment, in Portland OR, July 27 and 28 and in Houston TX, October 26 and 27. We recommend these unique opportunities to train with Carolyn, a nationally recognized leader trailblazing the successful applications of mindfulness into the field of physical therapy. Hope to see you there!

Does cognitive self-regulation influence the pain experience by modulating representations of nociceptive stimuli in the brain or does it regulate reported pain via neural pathways distinct from the one that mediates nociceptive processing? Woo and colleagues devised an experiment to answer this question.¹ They invited thirty-three healthy participants to undergo fMRI while receiving thermal stimulation trial runs that involved 6 levels of temperatures. Trial runs included “passive experience” where participants passively received and rated heat stimuli, and “regulation” runs, where participants were asked to cognitively increase or decrease pain intensity.

Instructions for increasing pain intensity included statements such as “Try to focus on how unpleasant the pain is. Pay attention to the burning, stinging and shooting sensation.” Instructions for decreasing pain intensity included statements such as “Focus on the part of the sensation that is pleasantly warm. Imagine your skin is very cool and how good the stimulation feels as it warms you up.” The effects of both manipulations on two brain systems previously identified in the literature were examined. One brain system was the “neurological pain signature” (NPS), a distributed pattern of fMRI activity shown to specifically track pain intensity induced by noxious inputs. The second system was the pathway connecting the ventromedial prefrontal cortex (vmPFC) with the nucleus accumbens (NAc), shown to play a role in both reappraisal and modulation of pain. In humans, the vmPFC tracks spontaneous pain when it has become chronic and potentially dissociated from nociception.^2,3 In patients with sub-acute back pain, the vmPFC-NAc connectivity has been shown to predict subsequent transition to chronic back pain.⁴ In addition, the vmPCF is hypothesized to play a role in the construction of self-representations, assigning personal value to self-related contents and, ultimately, influencing choices and decisions.⁵

Woo and colleagues found that both heat intensity and self-regulation strongly influenced reported pain, however they did so by two differing pathways. The NPS mediated only the effects of nociceptive input. The self-regulation effects on pain were mediated by the NAc-vmPFC pathway, which was unresponsive to the intensity of nociceptive input. The NAc-vmPFC pathway responded to both “increase” and “decrease” self-regulation conditions. Based on these results, study authors suggest that pain is influenced by both noxious input and cognitive self-regulation, however they are modulated by two distinct brain mechanisms. While the NPS encodes brain activity closely tied to primary nociceptive processing, the NAc-vmPFC pathway encodes information about evaluative aspects of pain in context. This research is limited in that the distinction between pain intensity and pain unpleasantness was not included and the subjects were otherwise healthy. Further research is warranted on the effects of this cognitive self-regulation model on brain pathways in patients with chronic pain conditions.

Even with the noted limitations, this research invites the clinician to consider the role of both nociceptive mechanisms and cognitive self-regulatory influences on a patient’s pain experience and suggests treatment choices should take both factors into consideration. Mindful awareness training is a treatment that contributes to cognitive self-regulatory brain mechanisms.⁶ When mindful, pain is observed as and labeled a sensation. The term “sensation” carries a neutral valence compared to “pain” which may reflect greater alarm or threat to an individual. The mind is recognized to have a camera lens-like quality that can shift from zoom to wide angle. While pain can draw attention in a more narrow focus on the painful body area, when mindful, an individual can deliberately adopt a wide angle view, focusing on pain free areas and other neutral or positive states. In addition, when mindful, the unpleasant sensation rests in awareness not characterized by fear and distress, but by stability, compassion and curiosity. Patients may not have control over the onset of pain, but with mindfulness training, they can take control over their response to the pain. This deliberate adoption of mindful principles and practices can contribute to cognitive self-regulatory brain mechanisms that can ultimately impact pain perception.

I am excited to share additional research and practical clinical strategies that help patients self-regulate their reactions to pain and other symptoms in my 2019 courses, Mindfulness for Rehabilitation Professionals at University Hospitals in Cleveland OH, April 6 and 7 and Mindfulness-Based Pain Treatment in Houston TX, October 26 and 27 and Portland OR May 18 and 19. Hope to see you there!

1. Woo CW, Roy M, Buhle JT, Wager TD. Distinct brain systems mediate the effects of nociceptive input and self-regulation on pain. PLoS;2015;13(1):e1002036.
2. Baliki MN, Chialvo DR, Geha PY, Levy RM, et al. Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain.J Neurosci. 2006;26(47):12165-73.
3. Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(pt9):2751-68.
4. Baliki MN, Peter B B, Torbey S, Herman KM, et al. Corticostriatal functional connectivity predicts transition to chronic back pain. Nat Neurosci.2012;15(8):1117-9.
5. D’Argembeau. On the role of the ventromedial prefrontal cortex in self-processing: The Valuation Hypothesis. Front Human Neurosci. 2013;7:372.
6. Zeidan F, Vago DR. Mindfulness meditation-based pain relief: a mechanistic account. Ann N Y Acad Sci. 2016 Jun;1373(1):114-27.

Going to the Combined Sections Meeting of the American Physical Therapy Association (CSM2019)? Look for Herman & Wallace instructor Carolyn McManus, MPT, MA at the educational session titled “Pain Talks: Conversations with Pain Science Leaders on the Future of the Field”. Carolyn will be a panelist along with Kathleen Sluka, PT, PhD, Steve George, PT, PhD, Carol Courtney, PT, PhD and Adriaan Louw, PT, PhD. The panel will be moderated by Derrick Sueki, DPT, PhD and Mark Shepherd, DPT, OCS.

These influential leaders will share how they personally became interested in the field of pain and discuss innovative pain treatment, as well as leading edge pain research and its translation into clinical practice. Initiatives to standardize entry-level curriculum, develop pathways to pain specialization and create post-professional opportunities such as pain-specific residencies and fellowships will be explored. The session will conclude with the leaders discussing their views on the future of pain and the role of physical therapy in its management. The audience will be able to submit questions via text or email to the moderator for individual or panel discussion.

We are thrilled to have Carolyn on our faculty and excited that she has been offered this honor to contribute insights from her over 30-year career experience in the field of pain with her colleagues at CSM2019. Carolyn will offer her popular courses, Mindfulness for Rehabilitation Professionals at University Hospitals in Cleveland, OH on April 6 and 7, and Mindfulness-Based Pain Treatment in Portland, OR May 18 and 19, and Houston TX, October 26 and 27. We recommend these unique opportunities to train with a nationally recognized leader who pioneered the successful applications of mindfulness to the field of physical therapy. Hope to see you there!

As so many of our patients are shallow breathers, I found this research on the effects of mindful attention to the breath (MATB) on prefrontal cortical and amygdala activity especially informative and relevant to patient care. Twenty-six healthy volunteers with no prior meditation experience were introduced to MATB by an experienced meditation teacher and instructed to practice a 20-minute audio guided MATB meditation daily for 2 weeks.¹ At the end of the 2-week training period, subjects underwent fMRI scanning while viewing distressing emotional images with MATB and with passive viewing (PV). Participants were shown aversive pictures or no pictures and were instructed to “Please focus your attention on your breath as you were instructed in the training” or “Please watch the picture without changing anything about your feelings.” Subjects indicated their current affect on a 7 point scale ranging from -3 (very negative) to +3 (very positive).

Breathing frequency significantly decreased during MATB compared to PV. Researchers controlled for this by including breathing frequency as a covariate in further behavioral and brain data analysis.

Analysis of affective ratings showed that participants felt significantly less negative affect when viewing distressing visual stimuli during MATB than PV. During negative visual stimuli, MATB significantly decreased bilateral amygdala activation compared to PV. Also, right amygdala activation decrease specifically correlated with successful emotional regulation. That is, those participants with greater reductions in right amygdala activation reported greater reductions in aversive emotions during the MATB. In addition, emotion-related functional connectivity increased between the prefrontal cortex and amygdala during the viewing of negative images and MATB.

It’s exciting to have some initial science behind the benefits of MATB. I teach all of my patients MATB and have found it rewarding to get feedback from participants in my courses about their integration of MATB into their own patient care. Patients with complex pain conditions can be challenging to treat, however sometimes a simple practice of taking 2 to 3 minutes prior to and/or at the end of a treatment to have a patient calmly focus on their breath with the mindful attitudes of acceptance, kindness and curiosity can help a person shift from tension and distress to calm and confidence. I look forward to presenting this and additional research on the impact of mindful meditation on brain structure and function in my upcoming course, Mindfulness-Based Pain Treatment, in Seattle, November 4 and 5. Hope to see you there!

1. Doll A, Holzel BK, Bratec SM, et al. Mindful attention to breath regulates emotions via increased amygdala-prefrontal cortex connectivity. Neuroimage. 2016;134:305-313.

For many of our patients, chronic pain is a chronic stress. Unfortunately, the resulting ongoing physiological stress reaction can have neurotoxic influences in key brain regions, including the prefrontal cortex, amygdala and hippocampus, and drive maladaptive neuroplastic changes that may further fuel a chronic pain condition.¹ For example, chronic stress generates extensive dendritic spine loss in the prefrontal cortex, hyperactivity in the amygdala, and neurogenesis suppression in the hippocampus.^2,3,4 In parallel, patients with chronic pain have been shown to exhibit reduced gray matter in the prefrontal cortex, increased neuronal excitability in the amygdala and reduced hippocampal neurogenesis.^5,6,7

These three brain areas have been identified to play an important role in fear learning and memory.⁸ Modulated by stress hormones and stress-induced neuroplastic changes, stress may:
(a) enhance the memory of the initial pain experience at pain onset
(b) promote the later persistence of the pain memory
(c) impair the memory extinction process and the ability to establish a new memory trace.⁹

In other words, an ongoing stress reaction, triggered by distressing cognitions and emotions in response to pain or other life circumstances, could reinforce and strengthen the memory of pain. The experience of pain could be generated not by nociceptive activity, but by a well-established memory of pain and inability of the brain to create new associations. Leading researchers in the cortical dynamics of pain at Northwestern University suggest this learning process and persistence of pain memory could be a major influencing mechanism driving chronic pain.^9,10

In addition, neurogenesis suppression in the hippocampus is associated with depression, while increased amygdala excitability is associated with anxiety, two mood disorders that frequently accompany and complicate chronic pain conditions.^11,12

Why is this important? Appreciating the complex factors that contribute to chronic pain conditions can point to treatment strategies that address these factors.¹³ For example, strategies that help reduce a patient’s stress reaction, mitigate the experience of fear and anxiety, and/or promote relaxation, positive mood and self-efficacy could conceivably reduce the stress reaction and reverse maladaptive neuroplasticity. While chronic pain is a multifaceted and highly complex condition with no simple answers or one-size-fits-all successful treatment strategy, initial research suggests promise for this approach to modulate cortical structure. In a study of cognitive-behavioral therapy (CBT) in the treatment of chronic pain, an 11-week CBT treatment course increased gray matter in the prefrontal cortex and hippocampus.¹⁴

In addition, a systematic review of brain changes in adults who participated in Mindfulness-Based Stress Reduction identified increased activity, connectivity and volume in the prefrontal cortex and hippocampus in stressed, anxious and healthy adults.¹⁵ Also, the amygdala demonstrated decreased activity and improved functional connectivity with the prefrontal cortex. Although yet to be studied in patients with chronic pain, these neuroplastic changes could potentially promote improved cortical dynamics in our patients.

I am excited to share this model of chronic stress and chronic pain and evidence-based applications of mindfulness to pain treatment in my upcoming course Mindfulness-Based Pain Treatment in Arlington, VA August 4 and 5, 2018 and in Seattle, WA November 3 and 4, 2018. Course participants will learn about mindfulness and pain research, practice mindful breathing, body scan and movement and expand their pain treatment tool box with practical strategies to improve pain treatment outcomes. Research examining the application of mindfulness in the treatment of patients at risk of opioid misuse will be included. I hope you will join me!

Vachon-Presseau E. Effects of stress on the corticolimbic system: implications for chronic pain. Prog Neuropsychopharmacol Biol Psychiatry. 2017; Oct 25. pii: S0278-5846(17)30598-5.
Arnsten AF. Stress signaling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci 2009:10(6):410-422.
Zhang X, Tong G, Guanghao Y, et al. Stress-induced functional alterations in amygdala: implications for neuropsychiatric diseases. Front Neurosci. 2018 May 29;12:367.
Kim EJ, Pellman B, Kim JJ. Stress effects on the hippocampus: a critical review. Learn Mem. 2015;22(9):411-6.
Fritz HC, McAuley JH, Whittfeld K, et al. Chronic back pain is associated with decreased prefrontal and anterior insular gray matter: results from a population-based cohort study. J Pain. 2016;17(1):111-8.
Veinante P, Yalcin I, Barrot M. The amygdala between sensation and affect: a role in pain. J Mol Psychiatry. 2013;1(1):9.
Vachon-Presseau E. Roy M, Martel MO, et al. The stress model of chronic pain: evidence from basal cortisol and hippocampal structure and function. Brain. 2013;136(Pt 3):815-27.
Greco JA, Liberzon I. Neuroimaging of fear-associated learning. Neuropsychopharmacology. 2016;41(1):320-334.
Mansour AR, Farmer MA, Baliki. Chronic pain: role of learning and brain plasticity. Restor Neurol Neurosci. 2014;32(1):129.
Baliki MN, Apkarian AV. Nociception, pain, negative moods and behavior. Neuron. 2015;87(3):474-491.
Schmaal L, Veltman DJ, van Erp TG, et al. Subcortical brain alterations in major depressive disorder: findings from ENIGMA major depressive disorder working group. Mol Psychiatry. 2016;21(6):806-12.
Shin LM, Liberzon I. The neurocircuitry of fear, stress and anxiety disorders. Neuropsychopharmacology. 2010;35(1):169-91.
Greenwald J, Shafritz KM. An integrative neuroscience framework for the treatment of chronic pain: from cellular alterations to behavior. Front Int Neurosci. 2018 May 23;12:18.
Seminowicz DA, Shpaner M, Keaser ML, et al. Cognitive-behavioral therapy increases prefrontal cortex gray matter in patients with chronic pain. J Pain. 2013;14(2):1573-84.
Gotink RA, Meijboom R, Vernooij, et al. 8-week Mindfulness Based Stress Reduction induces brain changes similar to traditional long-term meditation practice – A systematic review. Brain Cogn. 2016;108:32-41.