Jessica Valentine December 6, 2011

Be comfortable implementing brief mind- body interventions in an office visit

Brief review of mind-body methods Physiology Mind-body medicine in medical conditions Practice! Resources

With a few tools, its easy to offer patients an effective method to manage their symptoms Its a great bridge to therapy and/or medication There is a lot of research to support Only good side effects You can do it.

As you inhale through your nose, let your belly expand As you exhale through your mouth, consciously draw your belly inward as flat as possible, exhaling as much as possible Repeat

What is meant by mind-body connection? What are some examples of mind-body techniques/therapies?

What is the mind-body connection? The mind and body are essentially inseparable – via the brain, peripheral nervous system, hormones, and immune system the mind influences the physical body Our thoughts, feelings, beliefs, and attitudes can positively or negatively affect our biological functioning. From: body-therapies

What are mind-body techniques/therapies? Techniques designed to enhance the minds positive impact on the body. U.S. National Center for Complementary and Alternative Medicine (NCCAM) classification that covers a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms U.S. National Center for Complementary and Alternative Medicine

Relaxation training methods used to reduce sympathetic muscle arousal and muscle tone Ex: Progressive muscle relaxation Meditation Intentional self-regulation of attention to inner and outer experiences Ex: Mindfulness meditation Guided Imagery Use of inner images and symbols with therapies to induce a specific state (such as calmness)

Cognitive Behavioral Therapy A method of replacing inner thoughts and dialogue that may be irrational or that contribute to distress (e.g., depression, anxiety, pain) with a revised, healthier script and frame of reference Biofeedback A system of externally generated signals that measure some aspect of physiology (e.g., thermal biofeedback, muscle tension biofeedback, galvanic skin response to sweating) Hypnosis The use of aroused, attentive, focused concentration and relative suspension of peripheral awareness to create opportunities for suggestion Psychoeducational (we do already!) Combined with other biobehavioral strategies, these methods help patients become more informed about their disease and how to manage it with improved self-efficacy

Movement Qi Gong Tai Chi Yoga

Dr. Herbert Benson s Found to reverse stress response Written for patients to easily do on their own

Increases parasympathetic nervous system/reduces sympathetic nervous system Wallace & Benson: Reduced O2 consumption, CO2 elimination, rate and volume of respiration Decreased blood lactate level Slowed heartbeat Increased skin resistance EEG with slow alpha waves with occasional theta waves

5 days mindfulness x 20min Mindfulness group with: Increased skin conduction Increased heart rate variability All markers of increased parasympathetic activity Tang et al. Central and autonomic nervous system interaction is altered by short-term meditation. Proc Natl Acad Sci U S A Jun 2;106(22): Epub 2009 May 18.Proc Natl Acad Sci U S A.

Over a period of months: Decreased cortisol and catecholamine levels Different gene expression

Progressive Muscle Relaxation

Relaxation techniques and depression Cochrane MetaAnalysis Relaxation treatment showed improved self- reported depression scores compared to wait list (but non-significant difference in clinician rated depression) Scores improved more with CBT (but again no difference in clinician scores

Mind Body Group training, Education, Diet/Exercise Training Improved Becks Depression Score that was sustained Baseline: 24.8 At 12 weeks (end of intervention): 11.5 Four week follow-up: 16.5 Three month follow-up: 14.5 Manicavsgar et al. Mindfulness-based cognitive therapy vs cognitive behaviour therapy as a treatment for non-melancholic depression. J Affect Disord Apr;130(1-2): Epub 2010 Nov 20.J Affect Disord.

Good evidence that relaxation training and meditation improve anxiety Works as both a long term and short term Helps with a variety of types of anxiety Manzoni et al. Relaxation training for anxiety: a ten-years systematic review with meta-analysis.BMC Psychiatry Jun 2;8:41.BMC Psychiatry.

For use at onset of anxiety/panic attacks

PET scans show increased glucose metabolism in the brain in insomnia Glucose metabolism decreased with relaxation techniques.

Migraine Headache AHRQ meta-anaylsis: Behavioral techniques reduced migraine symptoms by 32-49% vs no treatment Relaxation, biofeedback, CBT, stress management training Meta-analysis: Similar decrease in number of headaches with B-blockers, CCB, and relaxation training Kids: relaxation and biofeedback the best

Level A Evidence(consistent good quality patient oriented evidence) CBT Combined progressive relaxation and biofeedback Biofeedback Relaxation training Level B (inconsistent or limited quality patient oriented evidence) Behavioral therapy with prophylactic drug therapy

Tension Headaches Meta-analysis Behavioral treatments (biofeedback, relaxation training, CBT, stress management training) showed 37-50% reduction of symptoms vs 2-9% in control groups. Level A Evidence: Relaxation training in children and adolescents CBT in children and adolescents Level B Evidence: Stress management training Progressive Muscle relaxation Biofeedback CBT

Effectiveness of an Online Mind-Body Intervention for Older Adults with Chronic pain Six weeks, six online modules: abdominal breathing, relaxation, writing about positive experiences, writing about difficult experiences, creative visual expression, positive thinking Improved pain scores, depression, anxiety

Subjects had 4 meditation sessions (20min each) Pain intensity ratings before and after meditation training compared to controls.

Pain in kids? C-section prevention? Greater volume of breastmilk expression? Increased pregnancy rates in IVF

Qi-gong mind-body therapy and diabetes control a randomized controlled trial. 12w Qi-Gong vs. standard medical treatment. Qi-Gong group had improved A1c, other glucose parameters, decreased wt, decreased waist circumference Complementary use of tai chi chi augments escitalopram treatment of geriatric depression: a randomized controlled trial. 4 weeks of ecitalopram Partial responders randomized to 2 hours Tai Chi vs 2 hours health education per week Tai Chi group had significant improvement in depression, cognitive functioning, and CRP levels

Vacation spot

Gratitude Practice

Mindfulness Scripted Meditation

Loving Kindness Meditation

Swedish Physical Therapy Department Mindfulness Based Stress Reduction Biofeedback Headache Management Back on Track Class

The Pain Puzzle Swedish Outpatient Therapy 2 session class Teaches patients about types of pain, how stress modulates perception of pain Similar classes shown to decrease perception of pain

Swedish Family Medicine Cherry Hill Mind/Body group led by Dr. Sethi Monday afternoons Call for cost/availability info

Biofeedback Headaches Abdominal Pain Vomiting Raynauds

Yoga Classes Samalya Center YMCA Most studios occasionally have free classes Online, Goodwill Videos, etc Tai Chi Classes Qi Gong

Online Gratitude Meditation atitude-meditation/ atitude-meditation/ 6 min Progressive Muscle Relaxation: Anxiety and Stress Reduction Center of Seattle Nice to use during a clinic visit while you step out 18 minutes

Online: Many 3-8 minute guided meditations Quick Getaway Stress Reduction Free PodCasts Meditation Oasis: min Guided Meditations. Other: Many free podcasts, itunes downloads, CDs at the library and at used bookstores

Brief review of mind-body methods Physiology Mind-body medicine in medical conditions Practice! Resources you can give your patients

With a few tools, its easy to offer patients an effective method to manage their symptoms Its a great bridge to therapy and/or medication There is a lot of research to support Only good side effects You can do it.