“Nothing Up My Sleeve:” Encouraging Patients to Use Mindfulness Exercises

Nearly half of the American population is living with at least 1 chronic condition, including arthritis and other inflammatory conditions, and are among the highest risk for poor psychosocial outcomes. Patients with rheumatic disease have a very high risk of developing depression. In 1 study,¹ 30% of patients developed depression within 5 years of their rheumatic disease diagnosis and in another,² 60% of patients complained of mood and cognitive impairment. The presence of pain, in particular, is a significant predictor of poor psychosocial outcomes, including depression and deficits in working memory, inhibition, planning, and decision-making.

Maddy Pontius

One of the most powerful adjunctive interventions for these psychosocial complaints is a mindfulness routine which includes a suite of brief, self-directed exercises designed to reduce distress and pain. Mindfulness interventions teach and promote the use of psychological skills to improve quality of life among individuals with chronic conditions like rheumatic disease. The goal of mindfulness is to impart control of physical and mental experience to the patient. These interventions largely act by reducing pain-related activation in the sensory cortex and increasing activity in the cingulate cortex, the area of the brain responsible for learning, memory, and processing bodily sensations, like pain. Repeated activation causes a “decoupling”³ between brain circuits that interpret and analyze sensation. The overall aim of these interventions is to encourage patients to engage in active coping through awareness, acceptance, and acknowledgement of their thoughts, feelings, and sensations. The outcomes are nothing if not a little magical.

For newcomers to mindfulness, very brief exercises, such as guided meditation, can improve mood, processing speed, and working memory function. These interventions can also reduce the severity of pain, pain-related distress, and pain-related disruption to social function. One study⁴ of 28 rheumatoid arthritis (RA) patients found that mindfulness interventions improved illness perception and significantly reduced depression, stress, and anxiety ratings in actively symptomatic patients with RA. Another study⁵ of patients with chronic musculoskeletal pain found that exercises like breath awareness and body scan interventions, were related to improvements in mental health, engagement in pain self-management, and greater perceived control over pain. These interventions are also very well-tolerated, with 78% of participants finding mindfulness interventions moderately, very, or extremely useful.

One of the easiest mindfulness exercises to teach your patients is the Body Scan. In this exercise, your patients are asked to focus on sensations in different body parts and are “directed to focus attention on the present moment through observing the breath, and bodily sensations, while becoming aware of, and accepting without judgement, any thoughts and feelings which arise.”⁶

Body scans can be used anywhere, are free, require very little training, and yield nearly immediate benefit. In research⁷ settings, patients report reductions in pain after 10-minute body scans. Here is a set of directions, adapted from mindfulness-based stress-reduction expert, Dr. Jon Kabat-Zinn⁸, that you can share with your patients. You can encourage them to practice with you and on their own and then check back on their progress in future visits. You will likely be impressed with the results.

• Sit or lie down, however you are the most comfortable, and close your eyes.
• Start by being aware of your breath flowing in and out. Notice where your body touches the floor or chair and be aware of where your body is in the space. Take as much time as you need to get a good feeling of where you are and what you feel.
• When you are ready, breathe in deep and long. Pay attention to the air filling and exiting your lungs and the movement of your body as you inhale and exhale.
• After a few deep breaths, pay attention to your body 1 part at a time. Start by focusing on your toes and become aware of any sensations you feel there. Acknowledge those sensations with acceptance and without judgement, and then let the sensations go.
• Move on to your right foot, then your left foot, then to your ankles, calves, shins, and so on until you get to the top of your head. Keep focused on these specific parts of your body and acknowledge the different sensations, including pain, without trying to fight or change them.
• If you notice pain, acknowledge it, and any thoughts or feelings that accompany it, and gently breathe through it. Don’t expect the pain to disappear but observe the discomfort, notice any thoughts or feelings, and let them pass to help your body relax.
• It is normal if your mind wanders, and when it does, observe where your thoughts have gone and gently swing your attention back to your body parts without judgement.
• When you are done focusing on each individual body part, take a few moments to bring your attention back to your breathing.
• When you feel ready, slowly bring your awareness back to your body by wiggling your fingers or toes, doing a few neck rolls, or stretching (whatever feels the best for you) before slowly opening your eyes.

Maddy Pontius is a Master’s Student in Forensic Psychology at the University of Denver with interests in rehabilitation psychology, health psychology, and neuropsychology. She is hoping to work within the overlap of offender rehabilitation and healthcare in the future.

References:

1. Jacob, L., Rockel, T., & Kostev, K. (2017). Depression Risk in Patients with Rheumatoid Arthritis in the United Kingdom. Rheumatology and Therapy, 195-200. https://doi.org/10.1007/s40744-017-0058-2
2. Dick, B., Eccleston, C., & Crombez G. (2002). Attentional functioning in fibromyalgia, rheumatoid arthritis, and musculoskeletal pain patients. Arthritis Care & Research, 47(6), 639-644. https://doi.org/10.1002/art.10800
3. Zeidan, F. (2014). The Neurobiology of Mindfulness Meditation. https://www.achtsamkeitsinstitut-ruhr.de/wp-content/uploads/2018/12/Zeidan_NeurobiologyMindfulness_InPress.pdf
4. Dalili, Z. & Bayazi, M. (2019). The effectiveness of Mindfulness-Based Cognitive Therapy on the illness perception and Psychological Symptoms in patients with Rheumatoid Arthritis. Complementary Therapies in Clinical Practice, 34, 139-144. https://doi.org/10.1016/j.ctcp.2018.11.012
5. Brown, C. & Jones, A. (2013). Psychobiological Correlates of improved Mental Health in Patients With Musculoskeletal Pain After a Mindfulness-based Pain Management Program. The Clinical Journal of Pain, 29(3), 233-244. doi: 10.1097/AJP.0b013e31824c5d9f
6. Ussher, M., Spatz, A., Copland, C., Nicolaou, A., Cargill, A., Amini-Tabrizi, N., & McCracken, L. (2014). Immediate effects of a brief mindfulness-based body scan on patients with chronic pain. Journal of Behavioral Medicine, 127-134. https://doi.org/10.1007/s10865-012-9466-5
7. McClintock, A., McCarrick, S., Garland, E., Zeidan, F., & Zgierska, A. (2019). Brief Mindfulness-Based Interventions for Acute and Chronic Pain” A Systematic Review. The Journal of Alternative and Complementary Medicine, 25(3). https://doi.org/10.1089/acm.2018.0351
8. Harvard Health Publishing – Harvard Medical School. (2016). Body scan mindfulness exercise for pain. https://www.health.harvard.edu/pain/body-scan-for-pain