How to use Mindfulness for Pain Management in Speech Therapy

A growing body of evidence shows that mindfulness can significantly improve chronic pain.

How?

Pain has two components.

1. The sensory aspect of pain. This is the tissue damage, the herniated disk, the migraine, etc.
   
   
2. Our reaction to these sensations. These are the thoughts, emotions, and physical reactions that can bubble up and build over time.

The second components is where people have some control over their pain. And this is where mindfulness for pain management comes in.

* This article draws heavily from the work of physical therapist and mindfulness expert Carolyn McManus and from Mindfulness Northwest.

The Role of Speech Therapy in Pain Management

We often think of pain management as nursing or pharmacy’s domain. So what is speech therapy’s role?

We can help patients communicate their pain. We can turn pain management into a cognitive task to increase their independence.

When a patient has pain, you can help problem-solve strategies for pain management. And as an evidence-based practice, mindfulness can be one of these strategies.

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Evidence: Mindfulness and Pain

Research shows that mindfulness decreases pain across a wide range of populations.

1. People with Chronic Pain

MINDFULNESS & CHRONIC PAIN STUDY

• WHAT? A meta-analysis looked at 37 randomized control trials studying mindfulness and chronic pain
  
  
• RESULTS? People who practiced mindfulness experienced a significant improvement in depression and quality of life with a small improvement in pain (compared to control groups)

Hilton, L., Hempel, S., Ewing, B.A., et al. (2017 Apr). Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med, 51(2), 99-213.

AMERICAN COLLEGE OF PHYSICIANS LOW BACK PAIN STUDY

• WHAT? The American College of Physicians (ACP) did a systematic review of randomized control trials and systematic reviews on non-invasive treatment for low back pain
  
  
• RESULTS? Based on the evidence, they strongly recommended mindfulness-based stress reduction as a treatment for low back pain

Qaseem, A., Wilt, T.J., McLean, R.M., et al. (2017 Apr 4). Noninvasive treatments for acute, subacute and chronic Low Back Pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med, 166(7), 514-530

2. New Meditators and Pain

• WHO? New meditators
  
  
• WHAT? First, the participants were subjected to heat pain; their pain reactions were studied via fMRI. Next, they were given 4 days of mindfulness instruction and practice. Finally, they were subjected to the heat pain again. fMRI was used to compare their before and after-mindfulness pain reactions
  
  
• RESULTS? Meditating decreased pain unpleasantness by 57% and decreased pain intensity by 40% (compared to rest)

Zeidan, F., Martucci, K.T., Kraft, R.A., et al. (2011 April 6). Brain mechanisms supporting the modulation of pain by mindfulness meditation. J Neurosci, 31(14), 5540-8.

3. Long-term Meditators and Pain

• WHO? People who have meditated 1000+ hours were compared to age and gender-matched control participants
  
  
• WHAT? Both groups were subjected to moderately-painful stimuli
  
  
• RESULTS? The long-term meditators showed lower pain sensitivity plus analgesic effects while experiencing pain compared to the control group
  
  
• WHY? Researchers attribute the results to the long-term meditators’ greater cognitive and regulatory skills and slower respiratory rate

Grant, J.A., Rainville, P. (2009 Jan). Pain sensitivity and analgesic effects of mindful states in Zen meditators: a cross-sectional study. Psychosom Med, 71(1), 106-14.

4. Other Pain Conditions Helped by Mindfulness

Other studies have found that mindfulness practice improves pain and/or psychological distress in people with:

• fibromyalgia
• total joint replacements
• diabetic peripheral neuropathy
• rheumatoid arthritis
• migraine headaches
• pelvic pain
• postherpetic neuralgia
• cancer (reduces stress)

Andrasik, F., Grazzi, L., D’Amico, D., et al. (2016 Oct). Mindfulness and headache: A “new” old treatment, with new findings. Cephalgia. 36(12):1192-1205.

Dowsey, M., Castle, D., Knowles, S. (2019 Oct). The effect of mindfulness training prior to total joint arthroplasty on post-operative pain and physical function: A randomized controlled trial. Complementary Ther Med, 46, 191-201.

Fox, S.D., Flynn, E., Allen, R.H. (2011 Mar-Apr) Mindfulness meditation for women with chronic pelvic pain: a pilot study. J Reprod Med, 56(3-4), 158-62.

Mehta, R., Sharma, K., Potters, L., Wernicke, A. G., & Parashar, B. (2019). Evidence for the Role of Mindfulness in Cancer: Benefits and Techniques. Cureus, 11(5), e4629. https://doi.org/10.7759/cureus.4629

Nathan, H.J., Poulin, P., Wozny, D., et al. (2017 Dec). Randomized trial of the effect of mindfulness-based stress reduction on pain-related disability, pain intensity, health-related quality of life, and A1C in patients with painful diabetic peripheral neuropathy. Clin Diabetes, 35(5), 294-304.

Van Gordon W, Shonin E, Dunn TJ, et al. (2017 Feb). Meditation awareness training for the treatment of fibromyalgia syndrome: a randomized controlled trial. Br J Health Psychol, 22(1), 186-206.

Zhu, X., Hu, P., Fan, Z., et al. (2019 Jun). Effects of Mindfulness-Based Stress Reduction on depression, anxiety, and pain in patients with postherpetic neuralgia. J Nerv Ment Dis, 207(6), 482-486.

How to Introduce Mindfulness for Pain Management

Use the following sections as scripts to introduce mindfulness for pain management to your patients.

When introducing mindfulness for pain management in a speech therapy session (and for documentation purposes), think of it as patient education. Similar to how you would discuss swallowing anatomy and physiology post-stroke.

1. Introduce How Pain Works in the Body & Brain

Chronic pain is complex. But understanding the basics of how pain works in your brain and body can help you learn how to decrease the pain.

Our bodies have pain pathways. When we experience pain in a body part, a pain signal is sent from our nerve cells to our spinal cord and then to our brain.

The pain signal is sent to multiple parts of the brain to be interpreted. Our brains interpret the signals and then send responses back down the spinal cord and to the nerve cells.

These responses are signals to increase or decrease the amount of pain.

With chronic pain, this whole pain pathway can become extra-sensitive. This means that for people with chronic pain, some of the pain is coming not from the body parts but from how sensitive the pain pathways have become.

2. Teach How Thoughts Can Impact Pain

You have the power to influence how your brains react to pain signals. This means that you can learn how to desensitize pain by creating new brain pathways.

Studies show that changing beliefs about a painful experience can also change the amount of pain you feel.

When people were told that a painful experience was exercise, they could tolerate it much longer than the people who were told that the experience was painful. In the brains of those with a positive belief about the pain (it was a healthy exercise), pain-reducing chemicals were sent out. Their brains were sending signals to decrease the pain.

Benedetti F., Thoen, W., Blanchard, C., et al. ( 2013 Mar. Pain as a reward: Changing the meaning of pain from negative to positive co-activates opioid and cannabinoid systems. Pain, 154(3), 361-7.

3. Teach How Stress Inhibits Clear Thinking

When you’re stressed, the brain sends out an emergency signal to your muscles and organs to get ready for fight or flight. Stress hormones flood your body. Your heart rate increases, your immune system is suppressed, and emotions (like anger and fear) intensify.

With so much going on in your body, the parts of your brain that plan and think have less control. So instead of thinking clearly, you are more likely to react out of automatic habits and fear.

By decreasing your stress, you will be able to shift how you think. This can build new brain pathways; pathways with much less pain. You can learn how to have a healthier brain!

4. How Mindfulness Can Help

Pain has two components:

1. The sensation coming from your body
   
   
2. Your reactions to these sensations. These include stress. Plus your thoughts, emotions, and physical reactions to the sensations

MINDFULNESS CAN CHANGE HOW YOU REACT TO PAIN

• Becoming aware of your reactions to pain is the first step to decreasing your chronic pain
  
  
• The awareness that comes from attention to the present moment is called mindfulness
  
  
• Mindfulness can help you to calmly observe your present moment experiences
  
  
• Mindfulness can help you self-regulate
  
  
  • This means that you can learn to decrease your stress and think more clearly
    
    
  • And you can create new, non-pain brain pathways

Mindfulness for Pain Management Activities

These activities are key practices taught by the Mindfulness-Based Stress Reduction (MBSR) program and by Carolyn McManus, a physical therapist and mindfulness expert.

MBSR is an evidence-based, 8-week program developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center. It was designed to decrease stress, anxiety, depression, and pain.

When using these activities during a speech therapy session, you can:

• Provide verbal and written patient education
  
  
• Turn the mindfulness activity into a memory task. For example, ask the patient the memorize 5 yoga poses so that they can do them on their own later.
  
  
• Turn the mindfulness activity into a problem solving task. For example, review all the activities and ask the patient to sort them (e.g. identify 3 that are the most physically possible for them, arrange them by least to most interesting, etc).
  
  
• Follow-up every few sessions about how mindfulness for pain management is going

1. The Body Scan

The body scan is a systematic scanning of the body, from toe to head, with one’s mind. While scanning the body, a person becomes aware of sensations in their body. They notice all sensations, including those that are pleasant, neutral, or unpleasant.

During the body scan, one practices paying attention to anything that comes up, without judgment. This includes physical sensations, emotions, and thoughts.

Click for an audio library of Guided Body Scans by Mindfulness Northwest.

2. Mindful Movement

Mindful movements are a gentle sequence of movements such as Yoga or Tai Chi.

While moving, patients will practice non-judgemental awareness of their bodies, thoughts, and emotions.

Patients will also practice moving within their comfort zones and gradually expanding that comfort zone. All without overdoing it.

Click for an audio library of Guided Mindful Movement. Below are printable poses that go with the guided meditations (all from mindfulnessnorthwest.com). You’ll find both non-adapted Yoga poses and Chair Yoga poses.

Mindful Movement with Gentle Yoga

Chair Yoga

3. Awareness of Breathing

Evidence shows that deep breathing can improve pain and stress. It also shows that some people with chronic pain are shallow breathers.

Awareness of breathing involves observing one’s breath.

The practice is to feel the breath in the body. When the mind wanders, gently return the attention to the breath.

This gives one’s mind and body a break from worrying about the future or ruminating about the past.

Click for an audio library of Guided Breath Awareness meditations by Mindfulness Northwest.

Busch, V., Magerl, W., Kern, U., et al. (2012 Feb) The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing-an experimental study. Pain Med, 13(2), 215-228.

4. Walking Meditation

To do walking meditation, one chooses a comfortable walking path of 10 to 30 paces in length. The path can be indoors or outdoors.

The meditator first pays attention to the sensation of standing. This is to center themselves. Then they slowly walk the chosen path, paying attention to the sensations of walking. They walk mindfully for 10-20 minutes at a time, as appropriate.

With this practice, the meditator learns to self-regulate. Eventually, they can practice walking meditation to calm themselves and be more present while on errands and throughout their daily lives.

Click for the Walking Meditation PDF by Mindfulness Northwest.

5. Labeling & Noting Practice

Labeling & Noting is the practice of being aware of one’s thoughts and feelings. Then labeling these thoughts and feelings without the intention of changing them.

This allows the thoughts and feeling to move through the meditator. Instead of getting stuck in the mind and body by planning, analyzing, worrying, etc.

Here are 2 practical variations of the Labeling & Noting Practice for people with chronic pain:

1. Label Pain as “Sensation”
   
   
   • This can help patients realize that there are other sensations in their body that may be neutral or even pleasant
     
     
   • It can help them realize that pain is not constant. It is always changing
     
     
   • It can help them separate the 2 components of pain. “This is a sensation. And this is my story about the sensation. They’re separate”
     
     
2. Just Like Me
   
   
   • When uncomfortable sensations come up, such as pain, think, “Oh, this is what it’s like to be a human being and feel _____ (pain, fear, etc.)”
     
     
   • It can help patients feel connected to others as they realize that others have experienced this before. And others will come after them and experience it too.
     
     
   • It can help them have compassion for their own experience. And to extend that compassion out to others.

6. Savor Pleasant Experiences

As humans, we have a negativity bias. This is an evolutionary bias that helps us protect ourselves.

To better self-regulate and create new non-pain pathways, people can learn how to notice and savor the positive.

WAYS TO SAVOR PLEASANT EXPERIENCES

1. A pleasant experience must be personally meaningful to the patient
   
   
2. Seek out pleasant experiences
   
   
   • Examples are a gratitude journal, exercises that feel good, savoring a delicious treat or petting your cat, performing good deeds for others
     
     
3. During the pleasant experience, be fully aware of how it feels
   
   
   • Savor the physical sensations. Savor the positive emotions
     
     
4. Savor pleasant experiences throughout the day
   
   
   • The smell of food. A lovely view. Birds chirping

Helpful Mindfulness & Pain Management Resources

1. Pain Management Guide

Swedish Health Services offers an excellent and free downloadable Pain Management Guide.

The guide covers sleep and pain, ways to calm the nervous system, nutrition, the role of medication and surgery, and much more.

2. Insight Timer App

Insight Timer is a free app that offers thousands of guided meditations, calming music, and even courses.

Patients can explore different teachers and practices to find what feels best for them.

Keep in mind that although Insight Timer has guidelines for what content is allowed on the app, not all teachers offer the same level of quality or evidence-based practices.

3. Chronic Pain Support Group

Consider a mindfulness-based chronic pain support group.

Pain Connection offers online support groups.

Or search online for local options.

4. Mindfulness for Healthcare Professionals

If you’re interested in gaining the benefits of mindfulness for yourself, consider a mindfulness course.

Mindfulness Northwest offers a 5-week online course for healthcare providers.

For in-person or more local mindfulness classes, look up “Mindfulness-Based Stress Reduction” in your local communities.

Speech Therapy Handouts & Worksheets