Transcript A New Perspective on Managing Chronic Pain and Headaches

New Perspective on Managing
Chronic Pain and Headaches
NASW MI 2010 Annual Conference
Bob Van Oosterhout, MA, LMSW, LLP
An updated version of this handout along with
other information and video links are available at
www.bobvanoosterhout.com
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Principles of Effective Pain
Management
• Accept
– Do not fight or resist pain
– Avoid blame and dwelling on loss or intensity
• Balance
– Resolve physical, mental, and emotional tension
– Stay within limitations
– Insure proper, appropriate rest, nutrition, and activity
• Clarify
– Focus away from pain
– Identify and clarify options, limitations, opportunities
– What works
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Cultural Assumption that Pain
is “Bad”
• Creates tendency to resist pain
• Resisting pain creates physical, mental and
emotional tension
– Increases pain
– Narrows focus
– Restricts and intensifies emotion
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Processing Pain Signals:
The Gate Theory
1. Nociceptor (sensory neurons) transmit
signal to
2. Spinal cord (Dorsal horn) which can
inhibit, excite and modulate signal
3. Multiple inputs including perception,
emotion, patterns of thinking affect signal
4. Hypothesize that tension is a common
thread that weaves through inputs that
increase pain perception
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Evidence for the Role of
Tension in Chronic Pain
• Tension is a protective reflex in response to pain
• Pain intensifies during high stress
• There is evidence that nociceptors (free nerve
endings found on small blood and lymphatic
vessels, within connective tissue and on nerves)
become hypersensitive in response to tension
• Evidence that stress hormones increase the
perception of pain
• Experience that resolving tension and resistance
reduces pain by 2-4 points on 10pt scale
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The Nature of Tension
Tension involves resistance
• Physical – groups of muscles working
against each other
• Mental – narrowing and fixing of
perceptions and patterns of negative
thinking that create physical tension
• Emotional – resisting the full experience of
emotions through breath-holding and
patterns of physical tension
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Physical Tension
• Muscles working without movement
• Develops into habitual patterns of posture and
protective reaction which builds additional tension
• Evidence that tension increases activity of neurons
that transmit pain signals (nociceptors)
• Suppression of parasympathetic nervous system
diminishes body’s ability to respond effectively to
conditions that may be contributing to the pain
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Physical Tension (cont.)
Regulated by Autonomic Nervous System (ANS)
• Sympathetic Nervous System (SNS -required for
activity) becomes over stimulated while the
Parasympathetic (PNS - required for health
maintenance) is suppressed (Fight or Flight)
• High levels or intensity of tension stimulates release of
stress hormones which boosts SNS and suppresses PNS
• Creates a self-escalating process when more stress
hormones are released as tension builds, thus
stimulating the release of more stress hormones.
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Mental Tension
• The build up of physical tension is perceived as
an indication of a threat, which
– Narrows focus and perception
– Leads the mind to ask “what’s wrong”
• Evidence that anticipating and dwelling on
severity of pain increases pain
• Creates a self-escalating process
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Emotional Tension
Specific muscle movements are associated
with various emotions
• Facial expressions are obvious but other muscle
groups move in response to specific emotions
• Resisting emotions involves restricting muscle
movement which creates physical tension
which leads to mental tension and emotional
tension and increased pain
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Principles of Effective Pain
Management
• Accept
– Do not fight or resist pain
– Avoid blame and dwelling on loss or severity
• Balance
– Resolve physical, mental, and emotional tension
– Stay within limitations
– Insure proper, appropriate rest, nutrition, and activity
• Clarify
– Focus away from pain
– Identify and clarify options, limitations, opportunities
– Keep track of what works
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Resolving and Preventing
Physical Tension
• Requires more than relaxation. Balance must be
restored to the ANS
• Rhythmic diaphragmatic breathing stimulates the PNS
and suppresses the SNS
– Precise rhythmic movement of the diaphragm stimulates the
right vagus nerve activating the PNS (proper rhythm is
critical)
– Regular PNS activation over time allows liver to remove
stress hormones from bloodstream restoring balance to ANS
• Grounding reverses patterns of tension while
developing awareness of tension habits.
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Teaching Diaphragmatic Breathing
• Explain how and why it works
– Opposing parts of ANS prepare the body for activity or
maintenance
– Movement of diaphragm stimulates right vagus nerve which
activates internal organs and stops build up of tension
• Demonstrate slow, rhythmic, effortless movement of
diaphragm with hand on abdomen
– Fingers move out
• Watch for obstacles to diaphragmatic rhythm
– No diaphragmatic movement – use positioning, metaphors
– Inability to bring air to bottom of lungs –deep exhale
– Trying too hard – pair with rhythm phrase
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Teaching Grounding
• Describe need for balance between opposing muscle
groups and how to achieve “neutral”
• Feet width of hips apart, pointing straight
• Pelvis over feet (weight over ball of feet)
• Knees bent (explain “tensing up”)
• Observe from side, check that weight is supported by
skeleton
• Observe and correct for deviations from neutral in
head and shoulder positioning
• Sitting – make sure pelvis is back in chair and forms a
base to support the spine – feet flat on floor pointing
straight ahead, head supported by spine
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Resolving and Preventing
Mental Tension
• Clarify direction of thoughts and limitations
on perceptions
• Use Labeling and Rhythm Phrases to block
and redirect negative mental habits
• Expand perceptions to include reason for
hope and life satisfaction
• Regular meditation develops mental
discipline and perceptual flexibility
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Resolving and Preventing
Emotional Tension
• Accept and experience emotion without resistance
• Identify and reverse patterns of tension which
restrict emotions
• Separate thought from emotion
• Understand that emotion results from perception
• Don’t dwell on intensity of pain or loss resulting
from pain
• Decide if, when, and how expression of emotion is
helpful and appropriate
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The Role of Tension in
Headaches
• Cause (tension headache)
• Trigger (cluster headaches and
migraines)
• Increases pain and dysfunction
(all headaches)
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Identifying Patterns of Tension
that Contribute to Headaches
• Observe in neutral muscular position (grounding)
• Identify deviations – areas where tension is being
used habitually or as means of support
• Identify areas where pain is experienced and
discern contributing patterns of tension
• Observe routine movement in daily activities
• Identify movements and postures that build
tension
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Resolving Patterns of Tension
that Contribute to Headaches
• Identify postural changes and movements
that restore balance
• Identify and address obstacles to
maintaining neutral muscular position
• Develop reminders to correct habitual
patterns of tension
– Regularly practicing grounding
– Physical or mechanical reminders
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Hypotheses Related to Effectively
Managing Pain and Headaches
1. Resistance interferes with managing
chronic pain and headaches.
2. Resistance involves physical, mental and
emotional tension.
3. Physical tension is a natural protective
response in response to acute pain.
4. Tension is a factor in many of the
physical, emotional, and cognitive inputs
that contribute to the perception of pain.
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Hypotheses Related to Effectively
Managing Pain and Headaches
5. Physical tension activates the SNS which
diminishes the PNS capacity to clear pain
triggers, irritates and inflames nerves and
leads to muscle spasms.
6. Built-up tension results from continuous
activation of muscle groups and creates a
habitual imbalance between opposing
muscle groups.
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Hypotheses Related to Effectively
Managing Pain and Headaches
7. Tension narrows focus and leads the mind
to ask “what’s wrong?” This pattern of
thinking intensifies attention on pain and
increases tension, creating a selfescalating pattern increasing both tension
and pain.
8. Dwelling on or anticipating the severity of
pain increases the perception of pain.
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Hypotheses Related to Effectively
Managing Pain and Headaches
9.
Experiencing emotion involves
proprioception (muscle movement) in
various places in the body. Tension limits
this movement and the capacity to
experience emotion (referred to as
emotional tension) Emotional tension
increases the perception of pain.
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Hypotheses Related to Effectively
Managing Pain and Headaches
10. Reported levels of pain can often be
reduced two to four points on a ten point
scale by resolving physical, mental and
emotional patters of resistance and
tension.
11. Minimizing all sources of tension
increases effectiveness of pain
management.
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Hypotheses Related to Effectively
Managing Pain and Headaches
12. Exceeding physical limitations increases
tension and pain. Increasing awareness of
limitations creates the freedom to function
optimally within them and limits
frustration by establishing realistic
expectations.
13. Developing awareness of small increases
in tension provides an alert for exceeding
limitations.
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Hypotheses Related to Effectively
Managing Pain and Headaches
14. Most headaches are either caused or
triggered by or made more severe by
increasing tension.
15. Balance is restored and maintained by
keeping the body “in neutral” so patterns
of tension resolve and there is increased
awareness as they begin to develop.
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