Mindfulness versus Arthritis

Robert Hedaya MD

1. What is mindfulness in the context of arthritis pain as well as other forms of pain? What is its importance to patients with chronic conditions?

In the context of pain, mindfulness is a state of mind which enables one to step back and simply observe, without judgment, how one’s mind, and body are behaving at the moment. As a consequence, one can separate pain-a purely physiological response to a noxious stimulus, from the suffering, which is an emotional and cognitive response to that stimulus.
Suffering is a result of what the pain means to someone, a meaning which is linked to the pain immediately and often unconsciously by the deeper emotional parts of the brain, broadly called the limbic system. For example, pain in a hip might remind someone that they are getting old, fast approaching the age at which their grandmother had a hip replacement because of arthritis, and shortly thereafter died. Chronic pain can lead people to conclude that their life will never be the same; that they cannot enjoy, or be engaged in, their usual pursuits.
These types of automatic assumptions cause the pain to have an added dimension, which is what we call suffering–having trouble enduring the pain. In addition, there is a clear and consistent relationship between chronic pain and depression. Patients with a current and remitted depressive and/or anxiety disorder and those with more severe symptoms have more disabling pain than persons without a depressive or anxiety disorder.
One can say that they ‘travel together’.  In fact, depression and pain share many of the same pathways and molecules. And, when depression is worse, pain follows suit and visa versa.
Additionally many of the treatments for the two conditions overlap, with anti-depressants helping pain, and treatments for rheumatoid arthritis (as one example) actually have antidepressant effects.  The molecular link between many types of pain, including arthritis, are cytokines. Cytokines are the ‘hormones of the immune system’, which cause pain, inflammation, and we have recently discovered, depression.  This of course has implications for the treatment of depression, i.e., anything that reduces inflammation [mindfulness training] will reduce depression. Finally, mindfulness has recently been shown to reduce levels of some inflammatory molecules, which cause pain.
When one engages in mindfulness practices, one can step back and watch the thoughts around the pain, actually notice what the pain is (and is not), and begin to realize that they can choose how they hold the meaning of the pain, rather than allowing their run away mind automatically tagging the pain with a fear based meaning, and worse, begin to identify with their pain (e.g., “I am an arthritic”).  As a result, fear of the pain, and anticipation of the pain are reduced.        As the suffering is alleviated, and muscles relax and stress systems (e.g., the adrenal glands, the immune system) begin to heal, the pain itself can be reduced to some degree.

2. What scientific evidence do you know of that demonstrate how and why mindfulness is effective for pain?

The clinical use of mindfulness meditation for the self-regulation of chronic pain.
Kabat-Zinn J, Lipworth L, Burney R
J Behav Med. 1985 Jun; 8(2):163-90.
In the above study chronic pain patients who completed an eight-week Mindfulness-Based Stress Reduction program significantly improved their pain symptoms and overall quality of life, even up to four years after completion of this initial training.

Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study.
Morone NE, Greco CM, Weiner DK
Pain. 2008 Feb; 134(3):310-9.
Additional studies show it to be effective for fibromyalgia, irritable bowel, low back pain, etc.

Interestingly, mindfulness has been shown to help depression (mild to moderate), and some of the chemical mediators of depression (serotonin, cortisol, epinephrine, dopamine) are also mediators of pain. Their is evidence that mindfulness practice actually stabilizes/calms the emotional areas of the brain, and that practitioners of mindfulness meditation showed areas of the brain that were larger (thicker gray matter [mid-cingulate cortex]), and lower activity in parts of the (prefrontal cortex) brain that evaluate and judge pain situations.

Studies seem to indicate that the two different types of meditation —focused attention and open monitoring-are different: in the short term, focused attention meditation gives quick relief, but with practice over time, open monitoring gives significantly greater relief

3. What exercises would you recommend for those just beginning their mindfulness practice?’
Find a book that can guide you (The “8 Minute Mediation” is a good one, because it guides you thru different types of meditation practices to see which is most user friendly for you).
Exercise 1:
Dr. Hedaya’s three-step exercise (SNO) 1(Practice this for 5-10 minutes 2 times per day-or even for a minute here and there, when your pain increases):

  1. S=Make sure you are in a comfortable position, sitting as upright as you can comfortably sit, in a quiet place.

  3. N= Notice, when focusing on your breath, when, and where your mind wanders to—without judging-then bring it back to the focus point. You will notice that your mind has a mind of its own! You are not your mind, your mind operates independently from you and from your will.

  5. O=Out of your mind: After a few moments, you will notice that you are observing your mind from  place, you will -where the core you is.

Exercise 2
When the pain worsens, close your eyes (if you can) and even briefly ‘step back’ and observe the pain, notice its qualities, location, color, shape, movement, vibration, etc. Pick one attribute and imagine it is worse, then imagine the feeling of the pain lessening. With practice you will find that you can modulate the pain with your intention, because a great deal of pain is located and initiated in the brain; it is not completely emanating from the offending body part.
4. Do you of know someone who has personal experience in successful mindfulness practice? Is it possible for us to contact this person?
Sorry…no one I can disclose.

5. Is there any additional information you would like to share?
It is VERY important to know that there are many non-medicinal interventions to reduce the pain of arthritis, from exercise which strengthens muscles around joints, to correction of diet and gastrointestinal issues, and exercise, to non herbal and herbal supplements*.  These interventions can make a very significant difference in levels of pain.

*In the spirit of full disclosure, I, having had my own back pain, which did not respond to traditional medical interventions, researched and developed an herbal formula that alleviated my pain.  It was so effective that I went on to manufacture it.  It is herbal formula called Dr H Rejoint.

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