Managing Migraines without Medication

ResearchBlogging.orgAhhh, migraine – psychedelia without the high… nausea without the alcohol…

The diagnostic criteria: A) At least 5 attacks fulfilling B-D; B) lasting untreated 4-74 hours; C) two of the following: unilateral, pulsating, moderate or severe pain intensity, worsening with physical activity; D) one of the following: nausea and/or vomiting, photophobia or phonophobia; E) not attributed to another disorder. (International Classification of headache disorders, 2004) (go here for one of the most comprehensive sites on migraine)

The main treatment for migraine is to use medication – best evidence to date suggests:  “Only two pharmacological treatments have been shown to be effective in placebo-controlled randomized trials: topiramate and local injection of botulinum toxin. Both therapies are effective in patients with chronic migraine with and without medication overuse. “ (Diener, Holle, Dodick, 2011)

As one of the many people who have migraine to NOT find these two medications helpful, and someone who has slightly unusual migraine symptoms (my main symptom is nausea, with headache being secondary), it’s taken a long time for me to reach a clear-cut diagnosis for migraine.  In the meantime I’ve had to learn to “live with” my migraines without pharmacology.  No easy matter when even the best say “Most of the time migraines resolve with sleep. Occasionally, and especially in children, vomiting stops migraine.” (from Migraine Aura Foundation)

What helps migraine – apart from sleep and vomiting?

I’m going to start with the approaches that I commonly use in the Pain Management Centre for people with migraine.  Please note: these are NOT a panacea for all migraines, and they work most effectively in combination.  Please don’t use what I’m writing as a substitute for seeing a health care provider – you and your health care provider need to work together.

  1. Assessment: Step one for managing migraines is carrying out a good assessment to identify triggers (antecedents).  This is one occasion when diaries for recording headaches and activities over a month or so.  I’m generally not keen on pain diaries because they so often focus the person on their pain, but in the case of intermittent headaches the diary method is really useful.  It’s helpful to briefly record activities, “stress” level, aura, headache intensity, sleep and food/drink intake.  This might help identify triggers – but having identified them, avoiding them is not always the best approach!  Instead, it might be more preferable to consider ways of managing the overall vulnerability to migraine – more on this below.
  2. Self-regulation training: Self-regulation refers to a wide range of strategies to influence alertness and ability to achieve a given activity.  In the context of migraine management, it usually refers to using things like biofeedback modalities to help train the person to up and down-regulate their physiological activity.  I find this has to be conducted alongside cognitive therapy so the person remembers to use self-regulation, and to help manage the automatic thoughts that often occur both because of having a migraine and as a response to using different strategies.
  3. Cognitive therapy: This refers to recognising automatic thoughts, intermediate beliefs/attitudes, and core beliefs, and working with these to interpret events in a different way.  This approach helps people to reflect on why they feel the way they do about situations and establish whether these are “working” to help them achieve what is important and valued in their life.  Even if an interpretation of a situation is accurate, it may not be helpful.
  4. Effective communication: This might seem a strange one to put into migraine management, but something I have found is that emotional stress from interpersonal conflict is one of the “hidden” triggers for migraine.  Effective communication can be called “assertive” communication, but I find this to be a very value-laden term.  Being able to communicate effectively involves listening, hearing, interpreting then developing an honest and respectful response.
  5. Activity management: Yes, that old standby of timetables, planning, prioritising and putting off – oh, perhaps not that last one!  Seriously though, establishing a paced activity pattern that avoids “boom and bust” patterns, or “pain contingent” patterns really helps, especially on a day when a migraine has started.  Stopping everything isn’t an option for many people, so maintaining a “minimum” plan for those days can be useful.

Self-regulation training – some details

While learning self-regulation without biofeedback is perfectly fine, for some good reasons, various biofeedback modalities enhance the learning.

Biofeedback involves monitoring physiological processes usually considered involuntary or that are modulated outside of conscious awareness. The three most common forms of biofeedback for headache treatment are: thermal, electromyographic (EMG), and electrodermal.  I tend to use Galvanic Skin Response (GSR) rasther than electrodermal, simply because it’s available to me and also because it gives me (and the person I’m working with) a good “overall” assessment of alertness.

There are many things that you can do with biofeedback, but I usually begin by attaching the leads and showing the graphs on the computer monitor.  We talk for a while until the person’s graphs show they’re stabilising into a baseline state.

I then usually begin with a Stroop test to establish “working under stress”.  This is a test where people are asked to read words for colours, with the words printed in different colours from how they read.  For example GREEN RED BLUE.  This gives me some information on the parameters the person usually demonstrates “stress”.

I then progress to learning to breathe.  “Not so difficult”, you say – well, it’s surprising how few people demonstrate effective breathing and control of breathing.  I almost always begin with respiration – to firstly use diaphragmatic breathing, then to slow the breathing down, and finally, with a respiration monitor around the person’s chest, I might help them look at the S pattern they create on the monitor.  This helps them to create slow, regular and full breathing that smoothly inflates and deflates the lungs.

Then I often move onto some animated programmes – one of my favourites is the Wild Divine set called “Relaxing Rhythms”.  It monitors heart rate, heart rate variability and GSR, and has a number of really good animations that help people to develop control.

More on migraine management soon!

Grazzi, L., & Andrasik, F. (2010). Non-pharmacological approaches in migraine prophylaxis: behavioral medicine Neurological Sciences, 31 (S1), 133-135 DOI: 10.1007/s10072-010-0306-5
Paola Schiapparelli • Gianni Allais • Ilaria Castagnoli Gabellari •
Sara Rolando • Maria Grazia Terzi • Chiara Benedetto (2010). Non-pharmacological approaches in migraine prophylaxis: Part ii Neurological Sciences, 31 (S1), 137-139 DOI: 10.1007/s10072-010-0307-4

It’s really all about the brain
Neuroscience is such a geeky area to study. And I have to say I didn’t really study the brain all that well in my undergraduate training all those years ago – but oh, how the worm has turned! It’s so exciting to see how basic science directly influences treatments that we can use for people who don’t have many pharmacologic options for their pain.

While I don’t have really up-to-date papers today, I think the 2008 paper by Herta Flor presages some of the approaches we’re starting to use in clinical settings now, a scant three years later. Flor’s work has always been impressive – she has often looked at what happens when brains are deprived of their normal feedback because of trauma or amputation, and (really exciting!) she is coming to Australia for NOI’s Conference 2012.
I came across this 2008 paper while compiling some readings for students enrolling in the Postgraduate papers in Musculoskeletal Medicine through University of Otago (distance taught papers for health professionals interested in pain and pain management).

BTW it’s not too late to enrol for MSMX 704 (Pain) and MSMX 708 (Pain Management) – papers suitable for medics, nurses, occupational therapists, physiotherapists, psychologists, social workers – anyone working in the area of pain.

In this paper, Flor summarises some of the changes that occur along the neuraxis following amputation, and spends time expanding on the mechanisms of maladaptive neuroplasticity and from this, discusses therapies that might directly influence this plasticity.  She notes that the majority of current therapies (particularly pharmacological) don’t address this at all.  Sadly, most of these therapies have limited effect on people, and a large number of unpleasant side effects.

Let’s take a look at some of the mechanisms thought to play a role in phantom limb (and note the similarities between phantom limb, complex regional pain syndrome and post-spinal cord injury pain).  Also please note that I’ve simply abridged notes from Flor’s paper – no reinventing the wheel!

Peripheral mechanisms

  • Structural changes in neurons and axons – terminal swelling and regenerative sprouting of the injured axon end occurs and neuromas form, giving rise to abnormal afferent input to the spinal cord with upregulation, and altered trafficking, of voltage-sensitive sodium channels and decreased potassium channel expression, as well as altered transduction molecules for mechano-, heat and cold sensitivity in the neuromas.
  • Ectopic impulses – these occur in the DRG and can summate with ectopic activity from neuromas in the stump, which can lead to the depolarization and activation of neighbouring neurons, significantly amplifying the overall ectopic barrage.
  • Ephaptic transmission – this refers to transmission of nerve impulses without the need for a neurotransmitter, developing from non-functional connections between axons.
  • Sympathetic–afferent coupling – in some patients sympathetic dysregulation in the residual limb is apparent, and spontaneous as well as triggered sympathetic discharge can elicit and exacerbate ectopic neuronal activity from neuromas as well as at the level of the DRG
  • Down- and upregulation of transmitters – novel receptors in the neuroma that are sensitive to cytokines, amines and so on, may enhance nociceptive processing, while ‘setpoints’ at which the nerve may fire are lowered, requiring less input for the nerve to respond
  • Selective loss of unmyelinated fibres – following trauma, axotomized afferent neurons show retrograde degeneration and shrinking, primarily involving unmyelinated neurons

Central changes

  • Unmasking – Inhibitory GABA(γ-aminobutyric acid)-containing and glycinergic interneurons in the spinal cord could be destroyed by rapid ectopic discharge or other effects of axotomy, or might change from having an inhibitory to an excitatory effect under the influence of brain-derived neurotrophicfactor (BDNF) released from microglia at the spinal cord level, leading to a loss of the normal inhibitory responses.  Downregulation of opioid receptors, on both primary afferent endings and intrinsic spinal neurons can add to this disinhibition due to reducing the normal inhibitory GABA and glycine activity.
  • Sprouting – nerve growth factors can be released in part because of activation of previously quiescent pathways that become functionally strengthened.
  • General disinhibition – previously quiescent, or low-threshold afferents can become functionally connected to ascending spinal projection neurons that carry nociceptive information to supraspinal centres, leading to an increase in the amount of information flowing upwards to higher centres.
  • Map remodelling – reorganization of the spinal map of the limb,could be due to the unmasking of previously silent connections, is also reflected in brainstem and cortical remapping – this is experienced as increased sensitivity in areas adjacent to the original area of damage.
  • Loss of neurons and neuronal function
  • Denervation
  • Alterations in neuronal and glial activity
  • Sensory–motor and sensory–sensory incongruence – the effect of illusions, such as the perception of body ownership of a rubber hand originally demonstrate the speed at which the SI cortex and also frontal and parietal areas respond to visual and sensory incongruence.  It’s this aspect of brain function that is particularly targeted when we start to incorporate mirrorbox or other visual feedback into treatments for phantom limb pain.

I get all excited when I read about this kind of research.  It opens up a whole range of treatment strategies that, for some clinicians, has previously been thought of as ‘purely psychological’, as if there was no ‘real’ (ie ‘organic’, ‘we can image/detect it’) effect.  As we go further into how the neuromatrix works, it starts to provide us with both new ways for treating this kind of pain – but it also goes to explain why some of our treatments work the way they do.

Let’s take, for instance, hypnosis.  One of the effects of hypnosis in chronic pain management can be to provide a person with post-hypnotic analgesia.  An interesting factoid to consider is that hypnosis can also produce post-hypnotic pain, with the right kind of  suggestion.  How can that be?

We didn’t really know how hypnosis worked until fMRI started being used in research.  When someone is given a hypnotic suggestion of analgesia, the cerebellum, anterior midcingulate cortex, anterior and posterior insula and the inferior parietal cortex are all activated to a greater extent than when a suggestion of analgesia is given without hypnosis.

Another form of so-called psychological treatment, cognitive behavioural therapy including biofeedback (EMG and temperature modalities), also activates ‘higher centres’, providing people with structured feedback on what their bodies do in response to their own coping efforts.  When these approaches are monitored with fMRI, lo and behold, once again those same areas of the cerebellum, anterior midcingulate cortex, anterior and posterior insula and the inferior parietal cortex are affected.  This applies when people use ‘coping self statements’ like “I can manage”, “I’ll be OK”, and diaphragmatic breathing as well.

Where this leads me to is that over the next 5 – 10 years, I predict that there will be increasing recognition for pain management strategies that have been demonstrated to be effective for some people, in that the neurobiological basis for this treatment response will be imaged.  It’s a shame that “seeing is believing” rather than looking at longitudinal outcome results within RCT ‘s for treatments that are not biomedical to be accepted, but there you have it.

Tomorrow – some more approaches that have been found useful for phantom limb, post spinal cord injury pain, and CRPS pain.   Not just mirrorbox!

Flor, H. (2008). Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies Expert Review of Neurotherapeutics, 8 (5), 809-818 DOI: 10.1586/14737175.8.5.809

Flor, H., Nikolajsen, L., & Staehelin Jensen, T. (2006). Phantom limb pain: a case of maladaptive CNS plasticity? Nature Reviews Neuroscience, 7 (11), 873-881 DOI: 10.1038/nrn1991

Derbeyshire, S., Whalley, M., Oakley, D. (2009). Fibromyalgia pain and its modulation by hypnotic and non-hypnotic suggestion: An fMRI analysis. European Journal of Pain, 13(5), Pages 542-550 doi:10.1016/j.ejpain.2008.06.010

Why bother with happiness? Broaden and build theory & Chronic pain
Readers may be wondering why I’ve come over all happy clappy and jolly joy germ – well, I realised I’d been writing a lot about experimental and theoretical factors found to influence vulnerability to chronic pain, but I had been writing less about ways to help people cope more effectively with chronic pain.

I do have a soft spot for positive psychology because, as we can see in most of the major journals, psychological studies have primarily been interested in what goes wrong, why people may struggle to cope with their pain, and other aspects of vulnerability. Yet more people than not live well with their chronic pain, and rarely seek help for their pain – maybe we can learn something from how these people cope, and in doing so, help people who do need treatment develop some of those skills. This is the topic of my PhD – Living well with chronic pain.

Building on yesterday’s post about ways to increase positive emotions (I talked about savouring – recalling past positive experiences; being ‘in the moment’ in present positive experiences; anticipating future positive experiences) I want to briefly discuss why on earth positive experiences might be useful. Apart from just feeling good in the moment!

The ‘broaden and build’ theory provides a framework for understanding the utility of positive experiences – especially the value of having positive emotions during tough times.  In this theory, developed by Fredrickson (2001), both positive and negative emotions have useful functional effects.  From an evolutionary viewpoint, there has to be some sort of adaptive value in having emotions and in the broaden and build theory it is posited that negative emotions help with generating “action tendencies that focus and narrow thoughts and actions (to prepare the body for fight or flight)” (and I guess we’re all pretty familiar with this response, especially in Christchurch after the quake!), while positive emotions “broaden ones thoughts and actions, and by consequence build important personal resources.”

In other words, negative emotions help us reduce the number of action options so we can active and use them quickly, while positive emotions help us generate ‘out of the box’ options, those creative, flexible, innovative ideas that can solve a problem – you know those overnight ‘aha!’ moments when the solutions just fall into place.

The empirical support for these two opposing but complementary emotion-elicited strategies is pretty good – we are familiar with the idea that by relaxing and thinking of good times, peaceful moments and happy events, autonomic arousal generated by ‘stress’ is reduced.   When there is no pressure to perform, people are often able to experiment and make mistakes and by doing so, arrive at unusual and exciting new possibilities – put a time pressure on and the options are narrowed and people revert to ‘tried and true’ behavioural repertoires.

Psychological resilience, or ‘bounce-back’ is possibly more common than not, according to Tugade and Fredrickson.  They suggest that under short-term traumatic events (perhaps the death of a loved one, or, closer to home, an earthquake with disruption to homes, services and businesses) it’s normal to temporarily experience negative emotions – but the general life trajectory continues in similar directions as before the event.  And for the majority of people in Christchurch, for example, despite the disruption we’ve experienced, life goes on.  For a smaller number – life is disrupted much more seriously.  Yet – in a couple of years, while the events of the last few months will be remembered, for more people than not, life plans and direction will be going along reasonably smoothly.

Of course this situation is different when the event is not short term, as in chronic pain.

The point that Tugade and Fredrickson make is that if resilience is commonplace, maybe it is also something individuals can learn, at least to a greater or lesser extent.

Back to the theory and how it might apply in chronic pain.  Some people seem more able to bounce back than others – and one factor in this resilience, according to Tugade and Fredrickson, is that people who are high in general or trait resilience, might be more able to draw on positive emotions than people lower in this trait.  For example, some people find it easy to use humour to cope with stressful times; some use relaxation – allowing time to interpret and assess problems before acting; some use exploration – looking at possibilities and options before taking action; and others use gratitude or hope – looking for the ‘silver lining’ or being thankful for ‘small mercies’ as my Grandmother would have said.

There is a relationship between the ability to access positive emotions through these strategies and physiological responses.  Research cited in the paper by Tugade and Fredrickson found that “although both low and high resilient individuals experienced equal levels of cardiovascular arousal and subjective negative experience in response to a stressor, high trait resilient individuals exhibited faster cardiovascular recovery from negative emotional arousal. Additionally, ‘‘bouncing back’’ to cardiovascular baseline levels was partially mediated by resilient people’s experiences of positive emotion in the midst of distress (Tugade and Fredrickson, 2004).”

What does this mean for people with chronic pain?

Well it is well known that people with chronic pain can have difficulty down-regulating autonomic arousal.  Things like heart rate and respiration rate, skin conductance and EMG can be readily increased – but people with chronic pain, even when they’re only recalling a time when their pain was high, find it reasonably difficult to reduce these readings.  There are a range of programmes for biofeedback that can help people recognise their own body responses and just by giving visual feedback, can help people develop skills to down-regulate.  Clinicians could enhance this process by helping people to remember happy times, or plan future positive events, or even simply be mindful of what is happening right now, as strategies to help people become more able to reduce their level of arousal.

What might this mean?

Well, resilient people seem to be able to recognise their own levels of arousal quite quickly – and then recruit resources to manage these situations quickly.  Tugade and Fredrickson consider that one strategy resilient people use is ” effectively harnessing positive emotions to their advantage when coping, and they do so with a seeming intuitive sensibility.” They go on to suggest that by experiencing positive emotions, the short term effect is to broaden the range of behavioural options, making it more likely that they will find a solution to a difficult situation.  They suggest that over time, and with repeated experiences of positive emotions, this broadened mindset might become habitual. Success breeding success.

So, quite apart from the need to help people in distress from their pain to generate short-term, ‘do-able’ goals to increase self efficacy, it seems that by being able to succeed and feeling good about doing so, people can develop skills over time that support resilience.  Sort of like banking a range of coping resources based on creative and positive options that can be adapted to suit changing circumstances.

What can we do to help?

Step one is to recognise that resilience could be something we learn.  Yes, some people have more innate resilience than others, but they also use skills that, over time, become more and more flexible and responsive.  To help generate this resilience, helping people become more aware of good things that generate positive experiences seems an important step. 

This might include things like scheduling pleasant events, writing down three things that have been positive each day, sitting for some peaceful time to simply appreciate something from nature, setting small goals – and achieving them, noticing unhelpful thinking and letting go of these thoughts in order to focus on what is important and valuable in the here and now.

I can see an enormous potential in helping people with chronic pain use these positive strategies – and who knows, it might even help us as clinicians?!

Tugade, M., & Fredrickson, B. (2006). Regulation of Positive Emotions: Emotion Regulation Strategies that Promote Resilience Journal of Happiness Studies, 8 (3), 311-333 DOI: 10.1007/s10902-006-9015-4

Relaxation…how, why & the evidence
Over the weekend a discussion about relaxation and the how’s and why’s came up in a discussion group I belong to. Several members of the group, including me, contributed our ‘list of do’s and don’ts’, much of it based on years of clinical experience – until I thought (as I do!) what about the literature? What does research tell us about precautions and effectiveness of relaxation?

I have to say that my searches in the literature so far have failed to consider many of the practical tips that the group came up with, but I have found some really helpful reviews of relaxation that support its use in pain management.  One of those more recent references is the one I’m focusing on today.

At the same time as wanting to briefly look at the evidence base for relaxation, I’m still musing on the clinical and experiential information that this group of therapists came up with, mulling over a few things like:

  • how does this clinical information get passed on from clinician to clinician?
  • how ‘true’ are these nuggest of applied wisdom?
  • if I’m trying to identify the evidence for these gems, how do I go about it?
  • how much of this information is ‘common sense’ – and then again, how much holds up when examined under the light of systematic enquiry?

That last one is especially important to me because so many of the myths about, for example, low back pain are based on ‘common sense’ – like that it’s ‘common sense’ to change the way we lift and move things because ‘everyone knows that the biomechanical models show that it makes sense not to lift things that are too heavy’.  The problem is that while ‘common sense’ application of biomechanics to manual handling seems helpful, in practice the model doesn’t make a difference to whether low back pain develops, and can give people a misunderstanding about how ‘safe’ it is to actually move their backs.  Common sense – and theoretical models – need to be tested in clinical practice to see whether their predictions hold true.

The group came up with a few tips that I hadn’t considered, such as not driving for 30 minutes after a relaxation session, or avoiding relaxation for two hours after a meal – but by and large the tips and tricks were very similar.  Here’s a few that I came up with:

Rationale for introducing relaxation

  • Elevated scores on pain-related anxiety and measures such as the TSK and PASS can be indicators for the usefulness of relaxation training.
  • Reports of physiological arousal can be a rationale for introducing relaxation
  • It can be used as a strategy to delay escape or avoidance behaviour in the presence of an aversive stimuli such as increased anxiety around a particular movement, or during periods of negative affect
  • It’s useful to reduce physiological arousal when considering sleep management, and relaxation can form part of the ‘going to bed’ ritual to help with insomnia

Some researchers suggest relaxation is a cognitive strategy for coping with a situation – it provides the individual with a sense of self efficacy and control (ie ‘something to do’) when they’re in a situation they don’t feel comfortable with.  Others base the rationale on the inability to maintain both physiological arousal and the relaxation response at once (a behavioural rationale).
There is some evidence to suggest that diaphragmatic breathing increases descending inhibition in some pain disorders (but not fibromyalgia) (Zautra, A., Fasman, R., Davis, M., & Craig, A. (2010). The effects of slow breathing on affective responses to pain stimuli: An experimental study Pain DOI: 10.1016/j.pain.2009.10.001)

Guidelines and precautions

  • beware of getting up too fast – BP reduces during relaxation, and it’s important to stretch to restore a normal BP or you may end up with dizziness from postural hypotension
  • be aware of paradoxical arousal when carrying out relaxation with an individual who is very hypervigilant and anxious, as they may hyperventilate and/or become distressed due to sensations of ‘floating’, ‘tingling’ and/or being unable to feel the body
  • be wary of using imagery without discussing the content of that imagery first, with individuals who have experienced trauma (rape or accidents etc), as it can remind them of the situation they were in
  • always remind the person that at any stage they are in complete control, and that they can open their eyes at any time, they will respond to external cues such as telephone or fire alarm.   I often describe that relaxed state a person might be in when coming out of the movie theatre or reading a good book as comparable to a relaxation state
  • some individuals experience relaxation induced headache especially if they’re not used to diaphragmatic breathing, it’s useful to check this with the individual after relaxing, and encourage them to breathe a little less deeply the next time they carry out a relaxation

There are many different types of relaxation training – while the two that have most research attention are Jacobsen Progressive Muscle Relaxation and Mindfulness Meditation, there are many others.  In my clinical experience, it can often be a process of trial and error to identify the method that is most effective, practical and useful for an individual.

I have several strategies for going about relaxation training, depending on the clinical rationale for introducing it:
1.  Breathing is the most portable and discrete strategy, and forms the basis for almost all of the relaxation techniques we use (with the exception of mindfulness meditation)  I don’t progress beyond this much with a lot of individuals. I also focus mainly on the out breath because the in-breath will always happen (just try it and see what I mean!)  For many people this is the easiest strategy to use while working or engaged in activity.

I usually won’t introduce other techniques unless they’ve ‘got’ the breathing part first.  I often pair breathing out with a cue word and/or cue movement (eg finger to thumb).  This is usually a relaxation response I work with the person to develop once they’ve achieved a light hypnotic trance, and I often use hypnosis and posthypnotic suggestion to strengthen the conditioned response to the outbreath and cue word.
2.  Postural awareness and becoming aware of the contact of the body against the surface they’re resting on is often the next most important strategy, and I still use Laura Mitchell ‘Simple relaxation’ as one of the easiest to remember and integrate with normal activity as it can be carried out in most positions, and even while driving!
3.  I rarely use Jacobsen or the Progressive Muscle Relaxation because it involves tensing then relaxing, which is hard to do. Try it yourself: clench your fists, then relax them.  Then make your fingers long, then relax them – which one leads to a more relaxed experience?  Tense/release is useful for individuals who have little kinaesthetic awareness.
4.  I move quickly from a long and deep relaxation technique to briefer ones that can be integrated within a working situation. While I provide people with a CD of a long relaxation, this is best used prior to going to sleep, rather than one they can use at work, but it is useful when teaching someone the difference between being really relaxed and their usual state.
5.  I often use biofeedback (particularly skin conductance and BVP, or heart rate variability) as a monitor for myself to determine how deeply relaxed an individual is, but primarily use it to demonstrate to people with limited body awareness or difficulty ‘getting’ the idea that body and mind are linked to recognise that they have control over what is usually not something they’d be aware of.  The main difficulty with biofeedback is that people can’t take it home to practice with it.
6. I’m increasingly using mindfulness meditations now, because of their usefulness for attention management and the literature supporting its use in regulating emotions, physiological arousal, and maintaining engagement with negative experiences such as pain in a nonjudgemental way.

Persson, Veenhuizen, Zachrison & Gard (2008) reviewed 12 studies of relaxation techniques, in which at least 25 individuals were studied, the studies were RCT’s, relaxation techniques as single treatment, or combined with education, and participants were active in the treatment (ie not passive recipients of ‘relaxation’ by therapist).

It’s a good indication of the lack of systematic study of relaxation training in pain management that these authors found only 12 studies that met the inclusion criteria! Does this reflect the lack of ‘status’ of nonpharmacological pain management? Or simply that there is much less funding available for interventions that don’t involve pharmacology or surgery?

Positive effects were found regarding decreases in pain intensity, anxiety, depression, and fatigue (in fibromyalgia), and even reduced health care and medication costs.  Participants were more mobile and seemed to use more coping strategies when they’d learned relaxation.

The studies themselves were only of moderate quality – they didn’t always include a training protocol (so it’s not clear whether each participant actually received the same relaxation intervention); control groups weren’t matched for age, gender, or even control intervention; and follow-up periods were fairly short.

It looks like a rich field for further study, despite the long history of relaxation as an intervention for pain and for psychiatric conditions.  In the meantime, hopefully this post will introduce some of the ‘tips and tricks’ that could be useful.

Persson, A. L.,, Veenhuizen, H.,, Zachrison, L.,, & Gard, G (2008). Relaxation as treatment for chronic musculoskeletal pain a systematic review of randomised controlled studies Physical Therapy Reviews, 13 (5), 355-365

How does it work? Pick your theory

I’m working with a man who has neuropathic pain in his right (dominant) hand.  He developed his pain some 8 years ago after he caught it in a woodworking machine and basically mashed it, damaging most of the carpal tunnel area.  After numerous orthopaedic, and plastic surgical procedures, he’s now left with nasty scarring, and even nastier neuropathic pain with some central sensitisation elements.  While he has almost full range of movement in his wrist and fingers, he rarely uses his hand and instead, cradles it or leaves it sitting half-curled, palm up.

We’ve been working together for a month or so, along with physiotherapy and psychology, and my parts of this programme have been to help him develop a personalised model of the factors that contribute to his pain; help him develop some self regulatory skills particularly to downregulate his very sensitive sympathetic drive; and to start the process of him being mindful of his hand rather than ignoring it or focusing on it.

I’m using a combination of approaches – Socratic questioning and guided discovery to help him develop a better understanding of his pain – particularly focusing on helping him recognise that trying to control his pain through either avoiding the use of his hand, or using distraction is counter-productive.  When he avoids using his hand, he’s either limiting the activities he can get through during the day and gets bored, frustrated and is probably contributing to the pain because his neuromatrix isn’t receiving normal movement patterns.  When he uses distraction, he can almost completely ignore the pain while pushing himself to ‘do everything’ – but then he gets an overwhelming increase in pain when he stops, which is distressing.

We’ve spent quite a while discussing the nature of control – is it pain we’re trying to control? Is it his activities we’re controlling? Is it is thoughts and emotions that we’re controlling?  I’ve been using mindfulness and some of the concepts from ACT and suggesting that try as hard as we might, pain is not something to control, and neither are thoughts or emotions.  In fact it seems the harder we try to control any of these things, the more they dominate and control us!

As a result, much of what I’m working on is helping this guy to non-judgementally regard his body sensations as simply sensations, allowing his attention to go to his hand without trying to ignore it (you can’t!) or to over-attend to it, but simply to notice it.

Taking this a little further, we’ve been working on breathing and mindfully attending to breathing as one way of introducing self regulation. This involves gently guiding his attention to his breath, and just as gently, noticing when his attention drifts away and bringing it back to his breathing.  Not as easy as you’d think!

I’ve been using biofeedback as part of this process because this guy is a practical man.  He’s not one to just accept doing something without having some feedback about what is actually going on.  I’ve used skin conductance, surface EMG, heart rate, respiration rate and skin temperature to monitor his overall arousal level.  He’s aware now that he can influence usually unconscious processes just by breathing or even thinking differently!

Yesterday I took it a little further.  I asked him to look at his painful hand, and simply describe the sensations without judging them.  What this means is he told me about the tingly, burning sensation over his palm, the throbbing aching in his fingers, he noticed where the pain started and stopped on his hand and fingers, the sensation of heat where his fingers touched each other, the sensation of pressure on his forearm where it rested against the arm of the chair, the sensation where the fabric of his T-shirt touched his skin – and so on.

It was interesting for him to notice that the painful area isn’t as big as he’d imagined.  When he really started to notice the quality of his pain, it wasn’t nauseating or particularly intense, it varied in sensation.  What I noticed was that initially his readings on biofeedback jumped – but they gradually settled down as he looked at his hand and really noticed it.

We then did some deep relaxation, really a kind of hypnosis.  In this we used an imagery device I’d discussed with him before the session.  I guided him in to using his attention to become aware of his hand and in particular, its position in space and the sensations over his whole hand and forearm.  I then guided him through an imagery process where he imagined holding his hand in warm water, allowing his hand to ‘thaw’ and open.  We then spent some time imagining his hand feeling normal, moving normally and imagined opening and closing his hand to lift a cup, pour milk, and flex and extend his wrist.  Throughout I was monitoring his biofeedback readings, and using words like ‘relax’ and ‘warm’ and ‘comfortable’ whenever the readings suggested he was becoming ‘stressed’.

When we completed the session, he had achieved sustained attention to his hand for about 35 minutes, completed a guided imagery of his hand doing normal activities, and had remained calm throughout.  He reported some increased discomfort around his wrist particularly after imagining wrist extension and flexion, but what really excited me was that he’d been able to increase the skin temperature on the finger of his right hand.

So, lots of choices in terms of theory to explain what I’d been doing.

  1. Graded motor imagery and sustained attention gives the neuromatrix normalised input, while not activating what Lorimer Moseley and David Butler call ‘neurotags’ or emotionally-laden pathways in the brain.
  2. Graded exposure using visual imagery as described by Johan Vlaeyen and following the exposure paradigm used in phobia reduction.
  3. Using a behavioural model, biofeedback providing immediate feedback on progress and arousal levels, influencing both my behaviour (guided imagery) and the clients responses
  4. Hypnosis allowing the ‘judgemental’ aspects of the mind to be quietened, thus allowing the client to experience sensations without distress
  5. Mindfulness where sensations are experienced but judgements are stilled.

Take your pick!  I’m not entirely sure myself, but whatever the mechanism, I’ll be continuing with this approach to the point where this client can carry the same process out with eyes open, then when actually moving.  Oh, and at the same time, the rest of the team will be working (along with me) on helping him set and achieve goals, manage difficult emotions and maintain a regulated activity pattern, as well as work on his relationship, look to the future of work, and help him communicate effectively with his case manager.  This is why pain is often not the main focus in pain management!

Hypnosis for chronic pain management: How it works maybe?

This post was chosen as an Editor's Selection for ResearchBlogging.orgThere are plenty of people who look at me as if I’m stepping right into woowoo when I start to talk about hypnosis for managing chronic pain. I’m happy to say that science has provided some good evidence that not only does hypnosis have a neurophysiological basis, but it also has some good effect.

What exactly is hypnosis? Well, contrary to popular belief, it is NOT about a ‘hypnotist’ doing something to someone else – and most especially NOT about making people do things that they wouldn’t ordinarily consent to. This is the misconception that stage hypnotists perpetuate in an attempt to keep their mystique.

Hypnosis is ‘an induction followed by a suggestion (or set of suggestions)’ – now that has a lot of mystique, doesn’t it?! ‘The suggestions that follow the induction usually include ‘‘. . .suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought, or behavior” (Green JP, Barabasz AF, Barrett D, Montgomery GH. Forging ahead: the 2003 APA Division 30 definition of hypnosis. Int J Clin Exp Hypn 2005;53:259–64., cited in Jensen, in press).

I didn’t know it, but hypnosis has been used at least since the 1840’s (first documented evidence), but probably much, much earlier than this if we are to believe that trance and suggestion performed by various healers the world over are actually hypnosis.

Jensen’s paper suggests there are three reasons for the resurgence in popularity of hypnosis for pain management:

  1. confirmation that chronic pain is influenced by the activity of supraspinal neurophysiological processes
  2. similar evidence that neurophysiological processes associated with pain are influenced by hypnosis
  3. empirical confirmation that hypnotic analgesia is effective for chronic pain management

In the first part of this paper, he reviews the evidence for chronic pain being influenced by supraspinal neurophysiological processes. To translate, this means activity above the level of the spinal cord (both descending and ascending) is implicated.  As Jensen puts it ‘the experience of pain is directly associated with multiple integrative and interlocking neurophysiological mechanisms and sites, with supraspinal sites playing a key role.’

It’s not enough to look only at the peripheral nervous system to understand how humans perceive pain – we need to look above and beyond!  The specific areas thought to be involved are the thalamus, the insula, the primary (S1) and secondary (S2) sensory cortices, the anterior cingulate cortex (ACC), and the prefrontal cortex.  This means that treatments can be based on altering activity in many of these sites, including hypnosis which affects the cortex

Incidentally, that site is a very good one if you’re interested in the science behind hypnosis (Hypnosis and Suggestion)

Jensen then briefly looks at imaging evidence that hypnosis has a direct effect on activity in many of the CNS sites associated with pain perception.  Studies have shown that when people are taken through a hypnotic induction, and asked to ‘imagine pain’, the cortical activity is quite different from those who are asked to simply ‘imagine pain’ without an induction.  He goes on to say ‘Presumably, if hypnotic suggestions can produce pain and increases in pain-related cortical activity, they might also be able to produce pain relief and decreases in activity in these same brain areas.’ – and he goes on to cite a further study where exactly this effect was obtained.  In that study, participants with chronic pain were asked to imagine their pain ‘low’, ‘medium’ and ‘high’ – one group under hypnosis, and the other simply asked to imagine.  While both groups achieved changes in perceived pain, along with concurrent imaging results, those who had been using a hypnotic induction had a greater response.

What is interesting is that hypnotic suggestion was able to target different areas of the brain – in one study, participants were asked to ‘imagine themselves distant from the pain’, leading to a change in activity in the ACC (a part of the limbic system that is associated with emotional responding), without concurrent change to the S1 and S2 cortices, which process sensation but not necessarily the emotional response to sensation.  The reverse activity was achieved when participants were asked to ‘imagine changes in pain intensity‘.

Clinical trials have also been held to study the effect of hypnosis on clinical chronic pain. Four new studies have been carried out since 2006, giving a total of 17 RCT’s for hypnosis – these recent studies demonstrate that ‘hypnosis was either as effective or more effective than other active treatments, and more effective than no treatment or standard care.’

Jensen identifies an interesting finding from these studies – although over 2/3 of participants continued to use self-hypnosis, only around 22 – 40% of participants experienced ‘clinically meaningful pain reduction’ which is 30% reduction in pain. Now why would people carry on doing something that doesn’t reduce their pain? Maybe it is, as Jensen points out, that this is a skill that can be carried out to produce even a small reduction in pain for some people, and it’s available at any time, so it may simply increase a sense of control and reduce the feeling of being overwhelmed.

The final section of this paper looks at ways to enhance the hypnotic effect – perhaps through virtual reality (already used for some painful procedures), combining hypnosis with neuralbiofeedback, and perhaps teaching self hypnosis early in the ‘life’ of a chronic pain problem. Jensen remarks that ‘it is also possible that this treatment could buffer some of the negative long-term effects of pain on the CNS.’ when endorsing the idea of early commencement of hypnosis for chronic pain – he then describes how hypnosis is currently being used in the military, on the battlefield, to help with war injuries.

Caution now: hypnosis doesn’t work for everyone. Not everyone who can be hypnotised will feel effects of hypnotic analgesia, and many will only feel effects short-term. Despite this, it seems a promising area for people who have chronic pain. Some real benefits ensue: it’s something a person can do for him or herself, it’s free, it has no side effects once learned, and most importantly, it has no calories!

Jensen, M. (2009). Hypnosis for chronic pain management: A new hope Pain DOI: 10.1016/j.pain.2009.06.027

YouTube Mirror Box videos

I was just looking for a quick video on using mirror box for CRPS (Complex regional pain syndrome) – well I couldn’t find any on YouTube, but I did find a good few on use for stroke.

Take a look at these and let me know what you think!  BTW If you’ve made a video on mirror box therapy in CRPS, or phantom, let me know and I’ll link to it.

This link takes you to jeisea’s blog where she has posted an extensive range of articles and links on using mirror box therapy for CRPS. Thanks jeisea!

BTW you don’t always need the box – you can simply use a mirror…

Here’s another – this time from Australian physiotherapist David Butler

Another recent one from Jeisea.

This is a series of four videos of mirrorbox therapy including history – it’s by Dr Ilan Lieberman, and at a commercial website (note I don’t endorse any specific products)  but it is clear, and a great watch!

Biofeedback races: an activity to develop self regulation

I’ve written once or twice on biofeedback as I’ve used it, but I thought today I’d share an exciting idea that one of my colleagues (you know who you are!) came up with to help participants on our pain management programme get practice using their skills in a fun sort of way.

We’re a bit lucky in some ways, we have about 8 different portable biofeedback units – some monitoring EMG, and a couple of others monitoring heart rate and galvanic skin response. In the past we’ve taken our participants to the occupational therapy home unit to try out various household tasks while wearing the biofeedback units – but frankly, the men have switched off. Now I don’t know what this says about Kiwi males, but I do know it made the sessions really challenging. So as a team we were trying to think of ways to involve people in activities that they could be asked to start and stop, and periodically review their self regulation. (more…)

Dipping my toe into Wiihab…

Today was the first day I tried using the WiiFit balance board and the WiiFit programme with patients.  Their responses were interesting…two of the group of seven didn’t want to know about it ‘I hate computers and computer games’ they said.  Three of the group were really keen – and one especially (more about that shortly).

And the pain management team members? Couldn’t get two of them off it tonight!

At the moment, the WiiFit project is at the point where I want to see how people respond to the new technology – I’m using it within the three week interdisciplinary pain management programme, not as a ‘fitness’ or ‘rehabilitation’ tool, but as a fun and leisure activity (similar to the way we get the group members to play cricket, croquet, lawn bowls and table tennis). (more…)

Basic biofeedback in pain management

I’m no techno-whizz in biofeedback – you have to speak to one of my colleagues (she knows who she is!) to get the technical data on things like heart rate variability – but I do use several modalities reasonably often. So today I thought I’d discuss some of the ways I use biofeedback with the people I work with.

Biofeedback basically provides visual or auditory information about normally undetectable physiological processes. It ranges from temperature sensors through to skin conduction (galvanic skin response), and includes surface EMG, respiration, blood volume pulse and sometimes these are put together to provide feedback on heart rate variability. I’m not going into HRV yet, that’s for another day!

The most common sensors I use
everyday are GSR, which is a reasonably sensitive measure of general arousal level; respiration because it provides immediate feedback on the way the person is breathing and is helpful for developing diaphragmatic breathing; BVP because it responds quickly to respiration and can demonstrate to the person the effect of slowing their breathing down; and I often use surface EMG because it can provide immediate feedback on posture changes (more…)