Helping the Mind Heal the Body: Mind Body Approaches to Pain Medicine

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1 Helping the Mind Heal the Body: Mind Body Approaches to Pain Medicine Michelle Dossett, MD, PhD, MPH June 29, 2018

2 Disclosures I have no relevant financial conflicts of interest Funding: K23 AT (NCCIH/NIH) Osher Pilot Grant (HMS)

3 Why Mind Body Approaches to Pain Medicine? Effectiveness Safety Cost

4 Outline Mind body practices in the U.S. Neurobiology and physiology of meditation Clinical trials of mind body practices for pain Meditation Tai chi Yoga

5 Mind Body Medicine Practices that focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health. Includes: meditation, deep breathing exercises, guided imagery, progressive muscle relaxation, biofeedback, hypnosis, yoga, qi gong, and tai chi.

6 Mind Body Practices in America 12 month prevalence of use by adults in 2012: 10.9% deep breathing 9.5% yoga 8.0% meditation 2.1% progressive relaxation 1.7% guided imagery 1.1% tai chi 0.1% biofeedback Clarke, Natl Health Stat Report, 2015

7 Meditation Traditions in all of the world s cultures Conscious focusing of one s awareness on the breath, a word or phrase, a sound, an image, sensations Conscious disregard of every day thoughts

8 How stress affects the body and brain Central Nervous System Perception Narrowed Memory Coarse, Imprecise Learning Blocked Conditioning Defense Tendency Regress or Perseverate Expectancies Negative Tone Flee or Destroy Muscular System Tension Ready for Action Jaws Clench Body Braces for Action Autonomic Nervous System Heart rate Blood pressure Oxygen need Breathing rate Palms, face sweat Blood sugar Adrenalin flows Digestive tract shunts blood to muscles Blood vessels constrict in hands and face

9 Meditation reverses the physiologic stress response Dusek, Minn Med. 2009

10 Meditation changes brain structure Regions of the brain affected involve concentration & executive function emotion regulation neurotransmitter release Holzel BK, Psychiatry Res. 2011

11 Meditation slows brain aging At age 50, the brains of experienced meditators were estimated to be 7.5 years younger than matched controls. For every year over 50, meditators brains were estimated to be an additional 52 days younger. Luders E, Neuroimage. 2016

12 Meditation increases telomerase activity and may slow cellular aging Overall effect size (d) = 0.46 (p = 0.001, 95% CI 0.18, 0.78) Schutte NS, Psychoneuroendocrinology, 2014

13 Meditation changes gene expression > 1500 differentially regulated genes Decreases in inflammatory pathways Improved insulin utilization Increased ATP synthase/mitochondrial energy production Dusek JA, PLOS ONE, 2008 Bhasin MK, PLOS ONE, 2013

14 Meditation may reduce pain via multiple mechanisms Modulation of pain perception through self regulation of attention Decreased reactivity to negative stimuli Reduced depression & anxiety that may amplify suffering Enhanced body awareness/mechanics Increased parasympathetic activation Enhanced cognitive coping processes Rosenzweig, J Pychosomatic Res. 2010

Standalone interventions or in combination with medications, procedures or surgery Reduces need for opioids Reduces pain while also reducing anxiety and depression, nausea and vomiting, facilitating

15 Standalone interventions or in combination with medications, procedures or surgery Reduces need for opioids Reduces pain while also reducing anxiety and depression, nausea and vomiting, facilitating restful sleep, and increasing a patient s sense of well being and desire to participate in their own recovery Improves function with benefits lasting well beyond intervention periods Provides economic benefits Explore (NY), 2018, in press

Findings: Mindfulness meditation programs had moderate evidence of improved anxiety: 0.38, [0.12 0.64] at 8 weeks 0.22, [0.02 0.43] at 3 6 months depression: 0.30 [0.00 0.59] at 8 weeks 0.23 [0.

16 Findings: Mindfulness meditation programs had moderate evidence of improved anxiety: 0.38, [ ] at 8 weeks 0.22, [ ] at 3 6 months depression: 0.30 [ ] at 8 weeks 0.23 [ ] at 3 6 months pain: 0.33 [ ] For anxiety and depression, the effect size was similar to that of antidepressants, but without the associated toxicities. Goyal M, JAMA Internal Med. 2014

17 An evidence map of mindfulness Depression Pain Anxiety Hemple S, Department of Veterans Affairs, 2014

Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture,

18 Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness based stress reduction (moderatequality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low quality evidence). (Grade: strong recommendation) Qaseeem A, Ann Intern Med. 2017

342 participants Average length of back pain was 7.3 years 123 (53.7%) attended 6 or more of 8 sessions Clinically meaningful improvement in RDQ at 26 weeks: 60.

19 342 participants Average length of back pain was 7.3 years 123 (53.7%) attended 6 or more of 8 sessions Clinically meaningful improvement in RDQ at 26 weeks: 60.5% MBSR (RR vs. usual care = 1.31 [ ]) 57.7% CBT (RR vs. usual care = 1.31 [ ]) 44.1% usual care Findings persisted at 52 weeks Cherkin DC, JAMA. 2016

20 MBSR vs. UC CBT vs. UC Total societal costs $724 $125 Total payer costs $982 $495 Back related costs $127 $984 HRQoL Cost per participant over usual care (UC). MBSR was cost-saving and CBT was cost-effective (<$50,000/QALY). Herman PM, Spine. 2017

Total utilization (# of billable encounters) for the intervention group decreased by 43% (p<0.0001) - Clinical encounters decreased by 41.9% - Imaging decreased by 50.

21 Total utilization (# of billable encounters) for the intervention group decreased by 43% (p<0.0001) - Clinical encounters decreased by 41.9% - Imaging decreased by 50.3% - Lab encounters decreased by 43.5% - Procedures decreased by 21.4% Emergency department visits decreased from 3.6 to 1.7/yr (p<0.0001) Subgroup analyses matched for initial high utilization showed a 22.2% reduction in utilization in the intervention group compared to the control group. Stahl JE, PLOS ONE, 2015

22 Tai chi (Taiji) Martial art originating in China Consists of slow, gentle movements incorporating mindful awareness and the breath Sometimes referred to as moving meditation

23 Tai chi is a multicomponent intervention Wayne PM, Contemp Clin Trials, 2013

24 An evidence map of tai chi Osteoarthritis Depression Pain Solloway M, Systematic Reviews, 2016

25 Tai chi benefits multiple chronic pain conditions Osteoarthritis: 0.54 [ 0.77, 0.30] Low back pain: 0.81 [ 1.11, 0.52] Osteoporosis: 0.83 [ 1.37, 0.28] Fibromyalgia: 0.52 [ 1.09, 0.05] Kong LJ, Scientific Reports, 2016

26 Longer duration of tai chi practice is more effective < 5 weeks: 0.12 [ 0.49, 0.26] 6 10 weeks: 0.50 [ 0.83, 0.17] > 10 weeks: 0.57 [ 0.86, 0.27] Kong LJ, Scientific Reports, 2016

27 Tai chi improves pain, stiffness, and function in osteoarthritis Pain: 0.45 [ 0.70, 0.20] Stiffness: 0.31 [ 0.60, 0.02] Function: 0.61 [ 0.85, 0.37] Yan J, PLOS ONE, 2013

28 Patients: 204 participants with symptomatic knee osteoarthritis (mean age, 60 years; 70% women; 53% white). Intervention: Tai Chi (2 times per week for 12 weeks) or standard physical therapy (2 times per week for 6 weeks, followed by 6 weeks of monitored home exercise). Wang C, Ann Intern Med. 2016

29 Pain Function Global assessment SF-36, physical SF-36, mental Beck depression inventory Self-efficacy 6 minute walk 20 meter walk Wang C, Ann Intern Med. 2016

30 Yoga Origins in ancient India Combination of postures, breathing techniques, meditation, and philosophy Many styles of hatha yoga in the US: Ananda, Ashtanga, Bikram, Iyengar, Kripalu, Kundalini, Vini, others

31 Meta Analysis of Yoga for Pain Includes studies of headache, back pain, IBS, carpal tunnel, rheumatoid arthritis, labor pain, hemodialysis, & muscle soreness. Bussing, J Pain, 2012

32 Short term effects Pain: 0.48 [ 0.65, 0.31] Back specific disability: 0.59 [ 0.87, 0.30] Health related quality of life: 0.41 [ 0.11, 0.93] Cramer H, Clin J Pain, 2013

33 Long term effects Pain: 0.33 [ 0.59, 0.07] Back specific disability: 0.35 [ 0.55, 0.15] Health related quality of life: 0.18 [ 0.05, 0.41] Cramer H, Clin J Pain, 2013

34 Yoga noninferior to PT Yoga and PT groups were 20% less likely to use pain medication at 12 weeks No difference in frequency of adverse events Saper RB, Ann Intern Med. 2017

35 Summary Mind body therapies are associated with a variety of neurobiologic and physiologic changes and may reduce pain via multiple pathways. Meditation, tai chi, and yoga are effective in reducing pain in multiple conditions and may reduce the need for pain medication. Mind body therapies are often associated with improvements in mental health. Mind body therapies have an excellent safety profile. Mind body therapies may be cost saving.

The Resilient Woman: Through Mindfulness and Meditation

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