When Does it Stop Being Hocus Pocus?

The prevalence of co-morbid psychological symptoms in individuals with FM has led many health practitioners to look for guidance on the use of psycho-therapeutic treatment options.  Cognitive behavioural therapy (CBT) has been known to have benefit but it can be time intensive and costly, prohibiting its use in many individuals.

In addition to this more traditional therapy (remember when this was considered hocus-pocus!), current research suggests that hypnosis and guided imagery may have a role in treating FM.  This interesting treatment option was discussed in a recent review of the literature investigating the effectiveness of psychotherapeutic treatments in FM.

The review focused on two randomized controlled trials evaluating the use of hypnotherapy and three studies evaluating the use of guided imagery.  These five randomized controlled trials, the gold standard experimental design in clinical research, found consistent positive results in the treated patients as compared to the control patients.

Hypnotherapy

In one study, 40 patients were treated with eight hypnotherapy sessions over the course of 3 months.  These hypnosis sessions focused on sensory and affective (emotion-based) approaches to FM pain control.  The results show that pain intensity was reduced, there was less fatigue on awakening, and the participants sleep patterns were improved.

A second study evaluated the effect of up to five hypnosis sessions on 53 patients.  This study also found that hypnotherapy improved sleep quality and resulted in less morning stiffness.

For many, hypnosis brings to mind a parlour game or nightclub act, where a man with a swinging watch gets volunteers to walk like a chicken or bark like a dog. But clinical or medical hypnosis is more than fun and games. It is an altered state of awareness used by licensed therapists to treat psychological or physical problems.

During hypnosis, the conscious part of the brain is temporarily tuned out as the person focuses on relaxation and lets go of distracting thoughts. The American Society of Clinical Hypnotists likens hypnosis to using a magnifying glass to focus the rays of the sun and make them more powerful. When our minds are concentrated and focused, we are able to use them more powerfully. When hypnotized, a person may experience physiologic changes, such as a slowing of the pulse and respiration, and an increase in alpha brain waves. The person may also become more open to specific suggestions and goals (such as reducing pain!) In the post-suggestion phase, the therapist reinforces continued use of the new behaviour.

Benefits of Hypnosis

Research has shown medical hypnosis to be helpful for acute and chronic pain. In 1996, a panel of the National Institutes of Health found hypnosis to be effective in easing cancer pain. More recent studies have demonstrated its effectiveness for pain related to other conditions. An analysis of 18 studies by researchers at Mount Sinai School of Medicine in New York revealed moderate to large pain-relieving effects from hypnosis, supporting the effectiveness of hypnotic techniques for pain management.

If you want to try hypnosis, you can expect to see a practitioner by yourself for a course of 1-hour or half-hour treatments, although some practitioners may start with a longer initial consultation and follow-up with 10- to 15-minute appointments. Your therapist can give you a post-hypnotic suggestion that will enable you to induce self-hypnosis after the treatment course is completed.

To find a hypnotherapist, speak to your doctor.

More reading on Hypnosis:

Find a licensed Hypnotherapist:

Guided Imagery

The three studies which evaluated the effectiveness of guided imagery found that pain was reduced in intensity and anxiety was lessened.  In particular, one study compared guided imagery that used pleasant imagery with guided imagery focused upon the “active workings of the internal pain control systems”.  The pleasant guided imagery was significantly more effective in reducing FM pain.

This technique uses visual imagery and body awareness to achieve relaxation. The person imagines being in a peaceful place and then focuses on different physical sensations, such as heaviness of the limbs or a calm heartbeat. People may practice on their own, creating their own images, or be guided by a therapist. Patients may also be encouraged to see themselves coping more effectively with stressors in their lives.

We have very few effective treatment options.  Fortunately, research is beginning to discover the effectiveness of certain psychotherapeutic treatment options.  Hypnosis and guided imagery may be one effective option to improve the mental, emotional, and physical symptoms of FM.

Stress = Pain = Stress

Stress and pain are intimately related.

In our case, often, being stressed causes pain AND/OR pain causes stress. Psychological therapies – including hypnosis, meditation, and relaxation – may help break the cycle.

For pain therapists, these treatments, which focus on the relationship between the mind and body, are considered mainstream.

For other health professionals, they may be considered alternative or complementary therapies.

And for the layman, they may be considered hocus pocus!

Regardless of how they are labelled, there is evidence that for many people they work.

Hypnosis

fate2For many, hypnosis brings to mind a parlour game or nightclub act, where a man with a swinging watch gets volunteers to walk like a chicken or bark like a dog. But clinical or medical hypnosis is more than fun and games. It is an altered state of awareness used by licensed therapists to treat psychological or physical problems.

During hypnosis, the conscious part of the brain is temporarily tuned out as the person focuses on relaxation and lets go of distracting thoughts. The American Society of Clinical Hypnotists likens hypnosis to using a magnifying glass to focus the rays of the sun and make them more powerful. When our minds are concentrated and focused, we are able to use them more powerfully. When hypnotized, a person may experience physiologic changes, such as a slowing of the pulse and respiration, and an increase in alpha brain waves. The person may also become more open to specific suggestions and goals (such as reducing pain!) In the post-suggestion phase, the therapist reinforces continued use of the new behaviour.

Benefits of Hypnosis

Research has shown medical hypnosis to be helpful for acute and chronic pain. In 1996, a panel of the National Institutes of Health found hypnosis to be effective in easing cancer pain. More recent studies have demonstrated its effectiveness for pain related to other conditions. An analysis of 18 studies by researchers at Mount Sinai School of Medicine in New York revealed moderate to large pain-relieving effects from hypnosis, supporting the effectiveness of hypnotic techniques for pain management.

If you want to try hypnosis, you can expect to see a practitioner by yourself for a course of 1-hour or half-hour treatments, although some practitioners may start with a longer initial consultation and follow-up with 10- to 15-minute appointments. Your therapist can give you a post-hypnotic suggestion that will enable you to induce self-hypnosis after the treatment course is completed

To find a hypnotherapist, speak to your doctor.

More reading on Hypnosis: Look into my Eyes

Find a licensed Hypnotherapist:

The American Society of Clinical Hypnosis

American Psychotherapy and Medical Hypnosis Association

Mind Motivations – For US, UK and Australia

Therapy Tribe – for US, UK, Canada and Australia

Meditation

Meditation involves using a number of awareness techniques to help quiet the mind and relax the body. The two most common techniques are:

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  • Transcendental meditation. The patient repeats a single word or phrase, called a mantra, and is taught to allow other thoughts and feelings to pass.
  • Mindfulness Meditation. The person focuses all of his or her attention on thoughts and sensations. This form of meditation is often taught in stress-reduction programs. Want to give this a try?

meditationBenefits of Meditation

Studies suggest that meditating can increase pain tolerance, activity levels, and self-esteem and decrease anxiety, stress, depression, and use of pain medications.

Mindfulness meditation has been used successfully in programs to reduce pain and improve mood in patients with chronic pain from a variety of conditions, including headache, low back pain, chest pain, and gastrointestinal pain.

Because there are varied forms of meditation and opinions about requirements for training, there is no formal certification or licensing process for instructors. Training requirements differ widely by institution. If you would like to find a meditation instructor, speak to your doctor or a friend, who may be able to recommend one.

To practice meditation, repeated meetings with the instructor may not be necessary. A recent study examining the perception of pain and various mental training techniques has found that relatively short and simple mindfulness meditation training can have a significant positive effect on pain management.

Relaxation Therapies

Relaxation therapies include a range of techniques with the goal of reducing stress. In addition to meditation, the major types of relaxation techniques are:

  • Progressive muscle relaxation: Also known as systematic muscle relaxation and Jacobson relaxation, this technique involves slowly tensing, briefly holding, and then releasing each muscle group in a systematic fashion, starting with the muscles in the toes and moving upward. During this exercise, the person should notice the differences between tension and relaxation.

MINI-RELAXATION PROCEDURE (for those on a tight schedule!)

For relaxation to be of the most benefit, you need to learn how to relax and calm yourself instantly upon your awareness of tension or irritability. While a 20-30 minute relaxation period is great, and very pleasant, you cannot escape and listen to your tape or do your long practice when you are tense in traffic or irritated with your family or co-workers.

A mini-relaxation is done as follows:

  1. Take a deep breath and raise your shoulders slightly (until you can feel increased muscle tension).
  2. Starting at the top of your head, focus on letting go of muscle tension (beginning with the muscles across your forehead). Allow sensations of relaxation, release, and heaviness to flow downward from your forehead, downward through your face, shoulders, arms, torso, and legs and imagine all the muscle tightness and tension draining right out your feet. Exhale as you allow the tension to drain away, and use your “key word” as you do so (this may be Relax, Peace, Calm, Serene, Ocean or any other word or phrase that denotes deep relaxation to you). Be certain that your deep breath was a deep diaphragmatic breath.
  3. This whole procedure should take no more than about 30 seconds (and can be done in as little as 10 seconds if that’s all the time you have). At the end of this period, go about your business regardless of how relaxed you feel.
  4. Repeat this process many times during the day, at least 20. Use the coloured dot procedure to remind yourself to do a mini-relaxation, preferably several times an hour. Place coloured dots in places you will see them often: your telephone, kitchen faucet, refrigerator, bathroom mirror, the door frame of doors you walk through frequently, your notebook or appointment book that you consult frequently, and even cut a small part of the coloured dot to place on your watchband. Whenever you see the coloured dot that is your reminder to do a mini-relaxation: deep breath, raise shoulders, let go of muscle tension as you breathe out and drop your shoulders, while repeating your ‘key word.’ You will notice that you become better and better at producing sensations of relaxation in a very short period of time, as you practice this over days and weeks. Do not extend your mini-relaxation more than one minute. If you are still tense, continue with what you are doing, and do another mini-relaxation the next time you see a dot, or the next time you are aware of feeling annoyed.

NB: A note of caution regarding relaxation if you are driving your car: Never practice long periods of deep relaxation while driving. Never listen to a deep relaxation tape while driving. Frequency is the key! The more you practice relaxation, or mini-relaxation, the better you will become at releasing stress and tension quickly and effectively.

Autogenic training: This technique uses visual imagery and body awareness to achieve relaxation. The person imagines being in a peaceful place and then focuses on different physical sensations, such as heaviness of the limbs or a calm heartbeat. People may practice on their own, creating their own images, or be guided by a therapist. Patients may also be encouraged to see themselves coping more effectively with stressors in their lives.

Breathing: Breathing techniques teach people to breathe effectively to relieve stress. While placing one hand on the chest and another on the belly, the person is instructed to take a slow, deep breath, taking in as much air as possible. During this, the belly should press against the hand. After holding their breath for a few seconds, patients are instructed to slowly exhale.

Benefits of Relaxing

According to a 1996 National Institutes of Health report, there is strong evidence to support the effectiveness of relaxation techniques for reducing chronic pain related to a variety of medical conditions. Other benefits may include reduced muscle tension and insomnia and increased activity level.

chronic comic 167The best way to learn relaxation techniques is with the help of a trained practitioner (although you can find many guided meditations, etc. on the Net). Usually these techniques are taught in a group class and then practiced regularly at home.

There is no widely accepted license for practicing relaxation therapy. However, it is often practiced by therapists and psychologists. Ask your doctor for a recommendation.

More reading on Relaxation: Relax

Risks of Mind-Body Therapies

Although mind/body therapies don’t have the risks of medical or surgical therapies, there have been rare reports of adverse reactions from them.

  • If you have poorly controlled cardiovascular disease, experts recommend avoiding progressive muscle relaxation, because abdominal tensing can cause increased pressure in the chest cavity, slowing of the pulse, decreased return of blood to the heart, and increased venous pressure.
  • If you have a history of psychosis or epilepsy, you may wish to speak with your doctor before trying meditation. There have been reports of some people having further acute episodes following deep and prolonged meditation.
  • Hypnosis or deep relaxation can sometimes worsen psychological problems in people with post-traumatic stress disorders or a susceptibility to false memories. Its use should be avoided in patients with borderline personality disorder, dissociative disorders, or with patients who have histories of profound abuse. Because competent hypnotherapists are skilled in recognizing and referring patients with these conditions, only appropriately trained and experienced practitioners should undertake hypnosis.

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Anyone in/near Rochester or Seattle?

As most of us know, current therapies leave most fibromyalgia patients still living with considerable pain. So it is reassuring to know that there is new and continuing research into our condition, and into ways that may reduce our daily pain.

In a media release from the University of Rochester (NY) Medical centre and the University of Washington School of Medicine (Seattle) have received a $5.5 million grant from the National Institutes of Health, to evaluate the ability of behaviour-change therapy added to the pain drug tramadol to ease fibromyalgia’s chronic, widespread pain.

The trial will enrol approximately 250 patients in Rochester and Seattle over the next four years, with enrolment likely to begin this (Northern hemisphere) summer. (So, anyone we know in this area?)

“Overall, current treatments for fibromyalgia are only partially effective: No more than half of patients get relief, and the other half stop therapy because they don’t get relief or they don’t like the side effects,” says Robert H. Dworkin, PhD, a professor in the University of Rochester’s Centre for Human Experimental Therapeutics. “Of those patients who do get relief, their pain doesn’t decrease dramatically; it goes down by a third, a half at most, so they are still living with considerable pain.”

And no other studies have looked at the combination of medication and behavioral treatment in any chronic pain condition, he suggests.

This will be a combined effort between Dr. Dworkin and lead investigator Dennis C. Turk, PhD, a professor in the department of anesthesiology and pain research at the University of Washington, who specialises in the study of fibromyalgia.

Drs Turk and Dworkin will study the effects of tramadol  combined with either cognitive-behavioral therapy or health education treatment – both of which work to change the way people think about their condition to ultimately improve the way they act and feel. Their objective? To determine if a drug plus one of the behavioural health treatments could be better than either one alone.

Quality of Life

Past research, and Drs Dworkin and Turks’ own experience studying fibromyalgia, suggest that increasing activity is critical in helping patients get better. Researchers are not only interested in the combo’s influence on pain, but on patients’ ability to carry out the activities of daily life, as well.

“When you are more active and can do the things you want to do – go to the movies with your family, walk around the mall, do housework – it takes your mind off the pain and makes you feel better about your life overall,” says Dr Dworkin.

Major goals will be to measure both physical activity and enhanced sleep quality. “I liken it to a virtuous circle or a positive loop, says Dr Dworkin, “When you are more physically active you sleep better, and when you sleep better you have less pain, and when you have less pain you can do more of the things you love to do.”

Specially Designed Behavioural Treatments

The behavioural health treatments that will be used in the study were designed specifically for fibromyalgia patients, says the University of Rochester’s Prof Ellen Poleshuck, PhD, who will help run the trial. Participants will learn about fibromyalgia and various strategies for improved coping.

The researchers will measure pain reduction using daily pain diaries completed just prior to and at the end of each treatment.

Independent Measurements

Patients will be provided with an ActiGraph, a wrist watch-like device that includes an accelerometer to provide an objective measure of changes in activity level. The device also determines sleep patterns and circadian rhythms so will be used to measure the quality of participants’ sleep as well.

Bring on more research and a cure!