New Perspective on Managing Chronic Pain and Headaches

1. 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

2. 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

3. 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

4. Processing Pain Signals: The Gate Theory • Nociceptor (sensory neurons) transmit signal to • Spinal cord (Dorsal horn) which can inhibit, excite and modulate signal • Multiple inputs including perception, emotion, patterns of thinking affect signal • Hypothesize that tension is a common thread that weaves through inputs that increase pain perception

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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

17. The Role of Tension in Headaches • Cause (tension headache) • Trigger (cluster headaches and migraines) • Increases pain and dysfunction (all headaches)

18. 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

19. 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

20. Hypotheses Related to Effectively Managing Pain and Headaches • Resistance interferes with managing chronic pain and headaches. • Resistance involves physical, mental and emotional tension. • Physical tension is a natural protective response in response to acute pain. • Tension is a factor in many of the physical, emotional, and cognitive inputs that contribute to the perception of pain.

21. Hypotheses Related to Effectively Managing Pain and Headaches • Physical tension activates the SNS which diminishes the PNS capacity to clear pain triggers, irritates and inflames nerves and leads to muscle spasms. • Built-up tension results from continuous activation of muscle groups and creates a habitual imbalance between opposing muscle groups.

22. Hypotheses Related to Effectively Managing Pain and Headaches • 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 self-escalating pattern increasing both tension and pain. • Dwelling on or anticipating the severity of pain increases the perception of pain.

23. 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.

24. Hypotheses Related to Effectively Managing Pain and Headaches • 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. • Minimizing all sources of tension increases effectiveness of pain management.

25. Hypotheses Related to Effectively Managing Pain and Headaches • 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. • Developing awareness of small increases in tension provides an alert for exceeding limitations.

26. Hypotheses Related to Effectively Managing Pain and Headaches • Most headaches are either caused or triggered by or made more severe by increasing tension. • 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.