6/20/2018. Mindfulness & Meditation

Transcription

1 Mindfulness & Meditation Rebecca Erwin Wells, MD, MPH Associate Professor, Neurology Founder & Director, Headache Program at Wake Forest Baptist Associate Director-Clinical Research, Center for Integrative Medicine Wake Forest Baptist No Financial Disclosures Disclosures Objectives Define mindfulness and mindfulness meditation Examine the evidence for mindfulness for headaches Describe the neuroscience of meditation Discuss how to apply this knowledge into the clinical practice of headache medicine 1

2 Objectives Define mindfulness and mindfulness meditation Examine the evidence for mindfulness for headaches Describe the neuroscience of meditation Discuss how to apply this knowledge into the clinical practice of headache medicine Meditation Self-regulation of attention and awareness Types Concentration Meditation Mindfulness Meditation Cultivate attention & awareness What is Mindfulness? The awareness that arises through Paying attention On purpose In the present moment Non-judgmentally -Jon Kabat Zinn Awareness Mindfulness Acceptance Present Moment 2

3 Historical Perspective Long historical roots (religious) Stress Reduction Clinic 1979 Research Media Mindfulness-Based Stress Reduction (MBSR) Standardized 8 weekly 2 hr classes + home Body scan, sitting meditation, yoga, mindfulness Teaches: Focus on present moment Practice without judgment 3

4 Number of Media Articles Relative to Meditation Published by Year Lauricella S, J Relig Health A Mindful Moment 4

5 Objectives Define mindfulness and mindfulness meditation Examine the evidence for mindfulness for headaches Describe the neuroscience of meditation Discuss how to apply this knowledge into the clinical practice of headache medicine Stress & Headaches Stress # 1 reported migraine trigger (60%) Meta-analysis of 7187 migraineurs HPA axis: hypothalamic-pituitary-adrenal Cortisol Autonomic Nervous Epinephrine, NE Peroutka SJ,

6 Behavioral & Mind/Body Treatments Headache 2012;52;S2: Behavioral Cognitive behavioral therapy (CBT) Stress management Coping skills Biofeedback Relaxation training Mind/Body Meditation, Yoga, Tai Chi Guided Imagery Biofeedback Hypnosis Qi gong Deep Breathing Exercises Progressive Relaxation Prevalence of Mind/Body Use among Adults with Severe HA Biofeedback <1% Guided Imagery Progressive relaxation Yoga Meditation 4% 6% 9% 17% Deep Breathing exercises 24% Percent Wells et al. Headache Non-Drug Treatment Options Needed Medicines Side effects Not 100% effective Not always ideal: Co-morbidities Pregnant Breastfeeding Mind-Body Congruent-beliefs Few side effects Concurrent- medicines Address other factors playing a role 6

7 18 yo with 4-14 Migraines/mo x 1yr (ICHD-II) Randomize to mindfulness meditation or control group Before and after, evaluated: HA frequency, severity QOL and well-being Assessed For Eligibility-Phone Screen (n=111) Excluded (n=82) Assessed For Eligibility-In-Person Screen (n=29) Maintained 28 day headache log Randomized (n=19) Excluded (n=10) Continued daily headache logs MBSR (n=10) (n=10) (n=10) Allocation Follow-up Analysis Wait-list usual care (n=9) (n=9) (n=9) Results Although underpowered, migraines were Less frequent by 1.4/mo Less severe (0-10) by 1.3 Shorter by 3 hrs* d=0.32 d=0.61 d=0.75 Qualitative Analyses: Emotional reactivity Pain catastrophizing Pain acceptance Lower Disability scores* MIDAS -13 d=1.37 HIT-6-5 d=0.91 Self efficacy & mindfulness improved* (d=0.8) *Statistically significant 7

8 Potential Mechanisms of Meditation on Migraine Pain Non-reactive approach to life stressors Decreases emotional reactivity Decreases affective response to stress Practice non-judgmental awareness of sensory events Detached observation of sensory experiences (pain) Reducing affective>sensory component of pain Headache Threshold } Raised Threshold Individual Baseline A } Lowered Baseline B Wells, RE Headache K Views In one week: 31K Views 129 Shares Help4Migraines@ wakehealth.edu Wakehealth.edu/BeInvolved/Migraine 24 8

9 Jacob, JAMA Objectives Define mindfulness and mindfulness meditation Examine the evidence for mindfulness for headaches Describe the neuroscience of meditation Discuss how to apply this knowledge into the clinical practice of headache medicine What happens physiologically with meditation? 9

10 Mindfulness Meditation-- Beyond Relaxation Attention regulation Body awareness Emotion regulation Non-reactivity Meta-cognition Kabat-Zinn 1982; Zeidan 2011; Goldin 2010; Farb 2012; Hoge 2013; Kerr 2013; Creswell The Psychological Effects of Meditation Improves well-being Decreases perceived stress Reduces recurrence of depression and levels of anxiety Grossman et al. 2004; Chiesa, Serretti. 2009; Teasdale et al. 2000; Kabat-Zinn et al Possible Mechanisms of Meditation Decrease depression and anxiety Improve coping skills Improve locus of control, self-efficacy Decrease stress hormones Increase parasympathetic tone Create changes in the brain 10

11 Neuroplasticity The brain is built to change in response to experience and training Structural Differences Ott, U., Hölzel, B.K., & Vaitl, D. Brain structure and meditation. How spiritual practice shapes the brain. Neuroscience, Consciousness and Spirituality: Proceedings of the Expert Meeting in Freiburg/Breisgau Lazar et al Pagnoni & Cekic Hölzel et al Vestergaard-Poulsen et al Luders et al Activation during Meditation Prefrontal Anterior Cingulate Insula Hippocampus Lou et al. Human Brain Mapping Lazar et al. NeuroReport Newberg et al Pscych Res Neuroimaging Brefczynski-Lewis et al. PNAS Thalamus Putamen Parietal Farb et al. SCAN Creswell et al. Psychosom Med Tang et al. PNAS Pagnoni et al. PLoS One Lutz et al. NeuroImage

12 The Impact of Meditation on the Brain 16 subjects learned to meditate MRIs before & after Increased concentration of gray matter in hippocampus Prefrontal Cortex Cingulate Cortex Attention Attention Concentration Executive function Emotional regulation Parietal Cortex Sensory/ spatial recognition Thalamus Cortical-subcortical Cognitive & affective response Amygdala Mediates stressrelated behavior Hippocampus Fear Learning & memory Emotional regulation Insula Body Awareness Empathy Awareness of consciousness 12

13 Pain Mechanisms: Psychophysical Pain Responses Using thermal heat to evoke pain, measuring: Pain intensity-sensory Pain unpleasantness-affective Journal of Neuroscience, April 6, 2011 Pain decreased after learning to meditate Pain unpleasantness (57%) & intensity (40%) Meditation related pain relief Directly related to brain regions Important for understanding pain The Journal of Neuroscience, March 16, Meditation Pain Intensity & Unpleasantness Naloxone failed to reverse these findings No differences in meditation + naloxone vs. meditation + saline Mindfulness meditation does NOT rely on endogenous opioid mechanisms to pain 13

14 Objectives Define mindfulness and mindfulness meditation Examine the evidence for mindfulness for headaches Describe the neuroscience of meditation Discuss how to apply this knowledge into the clinical practice of headache medicine When to Consider Medications not working Medication overuse Interested in non-drug approaches Build self-efficacy: empower, active Address other factors playing a role Stress, anxiety What are the Barriers & Risks? Barriers Time Energy Commitment Risks/Side Effects Generally safe Rare cases: psychosis -Psych history Teacher/training Paradoxical tension/anxiety Costs Musculoskeletal 14

15 Where do I go to get started? Local psychologist/therapist Local Classes Stress reduction Meditation, yoga, tai chi, etc. Retreats centers CDs, books, apps, websites Mindfulness in Medicine Being present: attention Non-judgment Acceptance Understanding of patients as people Awareness of patient s and own emotions JAMA. 2009;302(12):

16 Practicing Mindfulness with My Patients Room with patient: my presence Specific phrases of compassion I Honor Don t look ahead Work space environment Botox, occipital nerve block procedures Final Tips and Pearls Stress can be a potential trigger for migraines Mindfulness meditation may be helpful Potential for significant improvement With broad benefits, narrow harms Additional research pending Neuroscientific evidence suggests meditation may impact brain areas important for pain Practicing mindfulness may enhance providers well-being 16

17 Objectives Define mindfulness and mindfulness meditation Examine the evidence for mindfulness for headaches Describe the neuroscience of meditation Discuss how to apply this knowledge into the clinical practice of headache medicine Acknowledgements Research Support NIH National Center For Complementary & Integrative Health (NCCIH) K23AT American Pain Society Sharon S. Keller Chronic Pain Research Grant National Research Service Award T32AT from NCCAM at the NIH 2011 American Headache Society Fellowship Award National Institutes of Health (NIH) Loan Repayment Program 17

18 Any Appendix How to Learn More (Ideas, NOT endorsements) Training/Courses for Providers Websites 18

19 How to Learn More (Ideas, NOT endorsements) Retreats How to Learn More (Ideas, NOT endorsements) Apps Mindfulness Training App 57 How to Learn More-(Ideas, NOT Endorsements) Books 19

20 58 Results Improvements in: Mindfulness Burnout Empathy Physician Belief scale Total mood disturbance Personality factors (conscientiousness, emotional stability) Mindfulness correlated with: Total mood Physician empathy, perspective taking Decreased burnout Personal Factors JAMA. 2009;302(12): Positive Effects for Providers Enjoyment Sense of Control Personal Meaning Being present correlates more with meaning in work than diagnostic and therapeutic triumphs Horowitz 1995 West et al. JAMA Intern Med

21 61 Mindfulness Research Supports the Provider s Wellbeing Improves Positive Empathy Self-compassion Positive affect Life satisfaction Mood Reduces Negative Stress Ruminative thoughts & behaviors Burnout Anxiety Depression Emotional exhaustion Burton, et al. Stress Health Lamothe et al. Complement Ther Med Irving et al. Complementary Therapies in Clinical Practice,