1. A N O UTPATIENT P ROGRAM IN B EHAVIORAL M EDICINE FOR C HRONIC PAIN P ATIENTS B ASED ON THE P RACTICE OF M INDFULNESS MEDITATION : T HEORETICAL C ONSIDERATIONS AND P RELIMINARY R ESULTS By: John Kabat-Zinn, Ph.D.

2. S TRESS R EDUCTION & R ELAXATION P ROGRAM Training in mindfulness or awareness meditation Serves as major self-regulatory activity Used as an “net” for patients Based on development of internal resources of patients Alternative to traditional methods Self-regulation is promoted and learned via the directed attention characteristic of mindfulness meditation

3. C ONCENTRATION Transcendental Meditation - involves the restriction of attention to a single point or object, commonly a mantra, the experience of breathing, or a visual object and holding it in the mind for extended periods of time. Mantra- mental sound Based on Indian philosphy

4. M INDFULNESS MEDITATION Mindful Meditation- characterized by the specialized use of attention and careful self- observation Emphasizes the detached Concentration on one primary object until attention is stable Allows field of attention to expand to include all physical and mental events exactly as they occur in time No event is considered a distraction No mental event is allotted relative or absolute value

5. P AIN Pain is the result of the functioning of a normally adaptive neurological pathway. Chronic Pain - non-adaptive function Imposes severe emotional, physical, and economic stress Three interactions of pain experience Sensory-discriminative Motivational affective Cognitive- interpretative

6. G ATE C ONTROL THEORY Psychophysiologicial model for explaining the modulating effects that higher nervous system behaviors can have on perception and interpretation of pain.

7. P AIN & M EDITATION Meditation practice often accompanied by pain. Pain in meditation periods resemble chronic pain. Traditional meditation articles offer recommendations for achieving detachment Mindfulness requires focusing on unpleasant and painful sensations and discourages efforts to escape De-conditioning of alarm reaction

8. C URRENT S TUDY Used mindfulness meditation as the basis for a self-regulation strategy for chronic pain patients Uncoupling hypothesis - detaching the sensory component of pain from the affective and cognitive dimensions. Uncoupling is thought to be associated with higher brain centers Generate descending signals to close or narrow the spinal gate, resulting in primary sensory dimensions as well. “Refinement” of awareness

9. C URRENT STUDY Program was a 10 week course ( 3 cycles) Patients attended once per week for 2hrs 51 participants 18 male, 33 female 22 to 75 years old Classes of pain Lower back pain Upper back & shoulder pain Cervical pain Headaches Pre & post interviews were conducted

10. M INDFUL M EDITATION PRACTICES Sweeping- a gradual sweeping through the body from feet to head with the attentional faculty with periodic suggestions of breath awareness. Mindfulness of breath- practiced sitting in chair Hatha Yoga- introduced meditative exercise, developing mindfulness during movement Also taught mindfulness meditation using various activities

11. METHODS Hospital sessions taught mindfulness of breath and sensations Sweeping was practiced for 4weeks 45 minute homework cassette tape Once a day, 6 days a week Hatha yoga introduced next 4 weeks Alternate the sweeping with the yoga Practiced yoga 35-40 min per day Allowed to use any form last two weeks Given material on the physiology of stress and methods of coping Follow up questionnaires ( 2.5, 7, & 11 months )

12. M EASURES Pain Rating Index- scores which reflect quality and intensity of clinical pain experienced ( “right now”) Body Parts Problem Assessment (BPPA) – measures view of how problematic body parts are ( “this week) Three –color Dermatome Pain Map (DPM )- visual representation of the areas and intensities of pain Table of Levels interference (TLI)- frequency with which pain interferes with life activities Daily pain related drug uses was monitored MSCL – number of medical symptoms Profile of Mood States (POMS)- change in emotional affect and mood SCL -90R- change in psychological symptomatology Multidimensional Health Locus of Control – change in health related beliefs Outcome questionnaire Evaluated progress toward patient set goals Pain MeasuresNon- pain Measures

13. KEY ELEMENTS Group format Expectation of relief Non- goal orientation Self responsibility High demand characteristics Low cost Spectrum of meditation techniques Didactic material Finite duration Long-term perspective Advanced program

14. R ESULTS 65% showed reduction in pain (10 weeks) of ( ≥ 33% 50% showed reduction of pain (10 weeks of ( ≥ 50%). Large reduction in mood disturbance and psychiatric symptoms (26% -49%) Evidence suggest pain reductions are related to changes in attitudes and modes of perception of pain (TMD score ↓ 60% ) Some reductions maintained for up to 1.5 years follow up

15. A NDES SURVIVORS Pain and suffering similar to that of patients with chronic pain. Rosary for some period of mental relaxation or period of thought Survivors able to endure great physical and emotional pain