Hypnosis and pain management

Hypnosis has been dimonstrated being a powerful and succesfull tool in the treatment of pain (acute and chronic). However the success of hypnosis in the relief of pain is not empiric but supported by hundreds of papers in literature (Lee at al, 2012). Hypnotic analgesia has been shown as a quick and safe technique that can be used in any environment (Patterson DR et al, 2003), in any situation with anyone and it is extremely flexible and completely tailored on patients’ symptoms and necessities.

 

The fields of application include:

  • Musculoskeletal pain (acute and chronic): low back pain, neck pain, shoulder pain, temporomandibular pain . (Simon EP et al, 2000)  (Elkins et al, 2007)
  • Headaches and migraines (Hammond DC, 2007)
  • Reflex sympathetic dystrophy (Complex Regional Pain Syndrome)(Siddiqui et al. 2000) (Lebon J et al, 2017)
  • Fybromialgia (Haanen HC et al, 1991) (Bernardy et al, 2011) (Picard P et al, 2013)
  • Burning pain and hypersensitivity of the skin
  • Post-Herpetic neuralgia
  • Irritable Bowel Syndrome (IBS) and general abdominal pain (Tan G et al, 2005) (Chiarioni et al, 2008) (Palsson OS et al, 2015)
  • Pelvic Pain
  • Cancer related pain (Montgomery GH et al, 2010)
  • Uncomfortable or painful medical and minor surgical procedures(Montgomery GH et al, 2002) (Elkins G et al, 2006) (Schnur JB et al, 2008) (Accardi MC et al, 2009)

 

However hypnosis doesn’t work exclusively directly on pain but it can be used to change all the factors we know are involved with pain. Negative beliefs and expectations, negative limitations, catastrophization, pain anticipation, central sensitization, kinesiophobia, fear avoidance etc.. Hypnosis offers great and several techniques to work these aspects out having a indirect impact on pain experience

“Hypnosis not only affects pain intensity, but it also affects the emotional responses to pain. In the brain, ACC is responsible for processing emotion. During hypnosis, when an unpleasantness due to pain is suggested to increase or decrease, the unpleasantness changed in accordance to the suggestions, and the ACC activity also changed accordingly.” Lee et al, 2012

There are hundreds of techniques that can be used to help the patient to manage pain. However the session has to be tailored completely on patient’s necessities and symptoms. Some patient would react better to direct suggestions and others to indirect ones and metaphors, some patients would work better with “time distortion suggestions” and others with dissociative techniques. The beauty of hypnosis is that is extremely flexible and follows no protocols.

The most famous techniques used in pain management are:

  • Distraction
  • Time distortion
  • Suggestions of numbness and insensitivity (usually in the hand and then spread on the painful spot)
  • Paradoxical injuction (to be used with caution)
  • Metaphors
  • Dissociation (out of body experience)
  • Displacement (the therapist ask the patient to imagine the painful spot moving towards another area in which pain can be managed better)
  • Reinterpretation
  • Relaxation

Hartland’s, Medical and Dental Hypnosis, fourth edition

Some authors suggest it is necessary a deep state of trance to have a successful outcome, however excellent results can be achieved even with a light state of trance. At the end of the session the patient will be taught to do self-hypnosis in order to improve and maintain the results.

Hypnosis goes together with medical interventions like drugs and physiotherapy and it can only be done after the patient is examined by a medical doctor to exclude any red flag.

In conclusion we can say that hypnosis is an effective and successful tool that can be used in pain management as literature says. It can be done anywhere, in any moment, without side effects and it takes few minutes only (from 5 minutes to 30 minutes depending on the patient). Regrettably, there are not so many health professionals who integrates hypnosis in their daily practice, therefore would be marvellous to see an increase in the use of this beautiful technique.

Thanks for reading

Davide Lanfranco

“I could be bounded in a nutshell and count  myself a King of infinite space”  Shakspeare, Hamlet

 

 

REFERENCES:

1) Jing Seong Lee, Young Don Pyun (2012). Use of Hypnosis in the treatment of pain

2) Patterson, D. R., & Jensen, M. P. (2003). Hypnosis and clinical pain. Psychological Bulletin, Vol. 129, pp. 495-521.

3) Simon EP, Lewis DM. Medical hypnosis for temporomandibular disorders: Treatment efficacy and medical utilization outcome. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 2000;90:54–63.

4) Gary Elkins, Mark P. Jensen, and David R. Patterson “Hypnotherapy for the Management of Chronic Pain” The internation journal of clinical and experimental hypnosis  2007 Jul; 55(3): 275–287

5) Hammond DC (2007).  Review of the efficacy of clinical hypnosis with headaches and migraines. The internation journal of clinical and experimental hypnosis 2007 Apr;55(2):207-19.

6) M Siddiqui, S Siddiqui, J Ranasinghe, F Furgang. Complex Regional Pain Syndrome: A Clinical Review. The Internet Journal of Pain, Symptom Control and Palliative Care. 2000 Volume 2 Number 1.

7) Lebon J et al, 2017. Physical therapy under hypnosis for the treatment of patients with type 1 complex regional pain syndrome of the hand and wrist: Retrospective study of 20 cases. Hand surgery & rehabilitation 2017 Jun;36(3):215-221

8) Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC, Mallee C, Terwiel JP, et al. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. Journal of Rheumatology. 1991;18:72–75.

9)   Bernardy et al. 2011. Efficacy of hypnosis/guided imagery in fibromyalgia syndrome – a systematic     review and meta-analysis of controlled trials. BMC Musculoskeletal Disorders 201112:133

10)    Picard P et al. 2013 Hypnosis for management of fibromyalgia. The internation journal of clinical and experimental hypnosis  2013;61(1):111-23.

11)  Tan G, Hammond DC, Joseph G. Hypnosis and irritable bowel syndrome: a review of efficacy and mechanism of action. Am J Clin Hypn. 2005;47:161–178.

12) Chiarioni et al. 2008, Hypnosis and upper digestive function and disease. World Journal of Gastroenterology 2008  Nov 7; 14(41): 6276–6284.

13) Palsson OS et al, 2015 Hypnosis Treatment of Gastrointestinal Disorders: A Comprehensive Review of the Empirical Evidence. The American Journal of Clinical Hypnosis. 2015 Oct;58(2):134-58.

14) Montgomery GH, Hallquist MN, Schnur JB, David D, Silverstein JH, Bovbjerg DH. Mediators of a brief hypnosis intervention to control side effects in breast surgery patients: Response expectancies and emotional distress. J Consult Clin Psychol. 2010;78(1):80–88

15) Montgomery GH, David D, Winkel G, Silverstein JH, Bovbjerg DH. The effectiveness of adjunctive hypnosis with surgical patients: A meta-analysis. Anesth Analg. 2002;94(6):1639–1645.

16) Elkins G, White J, Patel P, Marcus J, Perfect MM, Montgomery GH. Hypnosis to manage anxiety and pain associated with colonoscopy for colorectal cancer screening: Case studies and possible benefits. Int J Clin Exp Hypn. 2006;54(4):416–431.

17)Schnur JB, Kafer I, Marcus C, Montgomery GH. Hypnosis to manage distress related to medical procedures: A meta-analysis. Contemp Hypn. 2008;25:114–128.

18) Accardi MC, Milling LS. The effectiveness of hypnosis for reducing procedure-related pain in children and adolescents: a comprehensive methodological review. J Behav Med. 2009;32(4):328–339.

It is (almost!) all about body awareness

Most of the clients I treat visits the clinic because they are in pain. Obviously…

Neck pain, low back pain, pain in the shoulder etc…

Most of them come with minor problems (no neurological signs, no red flags etc…) and tons of yellow flags.

One of the most common phrases to describe their situation  is  “I feel tension here….”

They wants me to stretch that area, to massage it, to rub it, to pull it, to click it etc…

They consider their body like a machine: when a part of it is not working anymore you fix it or you replace it in order to restore the functionality.

Regrettably, how I said in the previous posts it doesn’t work in this way. If you want to reduce the risk to have these problems , one of the things you have to improve is  the awareness of your body.

Lot of people spend 8 hours in the office every day and 1h in the car or in the underground commuting to work. They come back home in the evening and the only physical activity they do is to lift up the fork to take food to the mouth sitting on the couch.

Day after day they lose  awareness of their body. With body-awareness I mean especially the capacity to understand if you are using more muscles of what that specific activity you are doing requires. The sense of the physiological condition of the entire body (interoception, Craig 2002,2003)

The ability to feel if you have unnecessary tensions in your body.

Diers et al. (2016) wrote a nice article “Watching your pain site reduces pain intensity in chronic back pain patients”

in which he shows that ” real time video visual feed-back from the painful site reduces habitual pain intensity”.

The author continues saying that: ” the awareness of one’s own body seems to be essential in pain reduction through visual input. This could be due to a shift from affective-cognitive-evaluative aspects to a sensory-perceptual processing mode.”

“The effective link between pain reduction and visual feedback from the site of chronic pain reported here is evidence in favour of an important role of visual-somatosensory integration in pain perception. The present results suggest that repeated simple realtime video feedback, without any additional manipulation, may turn out to be helpful in alleviating chronic pain.”

Thanks to my friend Tiziano for the article

https://www.ncbi.nlm.nih.gov/pubmed/26282334

Daffada et al. (2015) in: ” The impact of cortical remapping interventions on pain and disability in chronic low back pain: a systematic review.” shows that: “visualisation of lumbar movement may significantly improve movement-related pain severity and duration. A combined sensorimotor retraining approach has been shown to produce short-term improvements in both pain and disability outcomes in chronic low back pain”

https://www.ncbi.nlm.nih.gov/pubmed/25442672

Stretching or pulling a muscle without teaching your client how to feel it could be useless .

How can you decrease the tension on the upper back of your patients if they are not aware of it? if they are not aware of the fact that they are lifting up the shoulders tensing up all the muscles…

The first thing you have to work on, especially with people suffering of chronic pain, is body awareness.

How can they do an exercise properly if they are not able to feel their body? how can that exercise improve anything if they are not able to feel the movement?

It takes times and effort. People usually come for 4-5 sessions of 30 minutes each and you don’t have the time to work successfully on all of these aspects

How can you do to improve body awareness?

During the session I make them feel what having relaxed shoulders and arms means. Then I ask them to try to reproduce that sensation during the day. They have to focus often during the day on their body trying to feel if they are tensing up their muscles. I told them that I don’t want it to become an obsession but has to be done frequently at the beginning.

It is difficult to relax your body when you are experiencing pain; the first reaction is to tense it up even more.

The goal is basically to make your client feeling the body relaxed and deprived of unnecessary tension. Once he/she becomes aware of that sensation you ask him/her to reproduce it.

There are cases in which it is very hard and almost impossible to do it. These are the cases in which you need to “force the door” instead of knocking at it asking the permission to enter.

This is a perfect example of how hypnosis would be beneficial.

Look at this video of my colleague and friend Giancarlo Russo (a physiotherapist who teaches hypnosis to medical professionals in all over the world). Look at the effect that the hypnotic induction has on her muscles tone…Don’t focus on anything else but on the tone of her muscles.

 

Hypnosis is a powerful “technique” to improve the perception your clients have of their body.

You basically hypnotize the person and once you get the relaxation and/or the awareness you need you create an “anchoring” to that state. You can use a word, a gesture or even a picture that you link, in hypnosis, to the state of relaxation your client has  achieved. The patient can reproduce that state during the day: whenever and wherever he/she wants.

All the procedure takes 10 minutes. Sometimes, like you can see in the video, even less..

Thanks for reading

Davide

 

p.s. pic taken from http://fonthillcare.co.uk/activities/new-class-tai-chi/

As above, so below

AS ABOVE, SO BELOW is a quote that appears for the first time in the EMERALD TABLE.

The Emerald Table gives its author as Hermes Trismegistus and it rapresents a piece of “The Hermetica” (the text forms the base of Hermeticism discussing about nature, mind, divine and cosmos).

The text of the EMERALD TABLE, translated into latin by Isaac Newton is composed by 14 statements.

Here you can find the statement we are going to discuss about

“What is above is like what is below, and what is below is like what is above. To make the miracle of the one thing.”

ABOVE and BELOW. The Macrocosm and the Microcosm that refer to a vision of cosmo.

It is not referred to a vision of Cosmos only but it is even referred to a vision of Life.

I am going to explain it better.

As above so below means that you are the one who you think you are.

Above means mind, below means body…

But I am going to tell you even more: “above” means your own reality, THE ONE YOU ARE LIVING IN YOUR MIND, while “below” means the reality of the facts. The one in which you are EFFECTIVELY living.

I will make an example: a girl suffering from anorexia is worried and concern about her bodyweight. She sees herself in the mirror fat and awful.

She can even have a palpatory illusion touching herself: she will feel a soft and chubby body rather than a skinny one. The reality of the facts is that her weight is 30kg.

Trust me: no way to convince her of the fact that she is not fat. You can use all your logic and rational tricks but she will never trust you. The reality that she is living inside herself is much stronger of the “real one”. This is an extreme example but not far away from what happens to people that have not been diagnosed with mental diseases.

Considering that we can discuss about it for hours, without finding a certain and objective explanation, the meaning I like to give to this quote is that our mind is the creator of our own reality.

It has been already proved that we cannot separate our mind from our body. They are not two separate entities, they don’t influence each other: THEY ARE THE SAME THING.

If you are a medical professional you CANNOT treat the body without taking care of the mind. Working as a physiotherapist I often see during the day cases of people having excruciating pain even if all the exams and all the test I do are negative. There is not massive tension in the soft tissues and the mobility of the spine is good.

Despite of all these things they are in a lot of pain. Their own reality is  pain, sufferance and tears that take over the “real reality” in which their body is and in which almost everything is ok.

It is certainly true to say that a life of pain enhanced our belief that life is pain and sufferance. This process works in both  the directions, even if the STARTING POINT, the primum movens, is our mind that filters and processes the reality.

At this stage we can consider two different realities: the real one (the reality of the facts in which we are living) and our own one (the reality created by our own mind).

The first reality is apparently the most important one: the place in which we live, the people who love us, the people who surround us, our job, our car, phone etc…. We can call it the “objective reality” deprived of any filters. The reality of the facts is 1+1=2

The second reality is our own one and it is the result of the real reality filtered by our own mind according to our experiences (it is becoming a delirium!). It is apparently a “subjective reality” because it is our own one and it is not shared by anyone else. The subjective reality is 1+1=3. But it is also 1+1=4 or 5 etc..

Now you may think that there is a border between these two realities and that the most important one is the reality of the facts.

However, the purpose of this delirium is to show that the “main reality” is our own one: the reality processed and created by our mind.

Think about this: it is not what happen to you (real reality) that make you miserable, desperate or joyful but IT IS HOW YOU PROCESS (your own reality) THE EVENTS THAT HAPPEN IN YOUR LIFE. It is the meaning and the importance that you give to people, objects, events that determines the amount of pain and joy in your life.

In “Letters to Lucilius” Seneca wrote:

“We are tormented either by things present, or by things to come, or by both.”

“There are more thing, Lucilius,that frighten us rather than injure us, and we suffer more in imagination than in reality”

It is our own reality that reflects on the “real one” conditioning the quality of our life. IF we think we are miserable we will be miserable. If we think that we are sick we will be sick.

If we think that our condition is unchangeable it will be almost impossible to change it.

If we think that our chronic pain will never disappear, because we are doomed to sufferance, we will always be in pain.

And so on..

Our own reality becomes the most important one. It becomes objective and irrefutable.

That is why: AS ABOVE, SO BELOW

Thanks for reading

Davide

How to build a rapport with clients

The difference between a mechanic and, a health professional is that the first one fix cars and the second one, a physiotherapist for example, “fixes” people (we don’t really fix anyone).

Captain obvious! Great point!

Yes apparently it seems obvious but IT IS NOT.

Many therapists are still not aware of it.  

 

Some therapists complete a 2-day-course, where the teacher gives them the key to solve any low back pain. On that following Monday they begin to deliver techniques and to fix people following the incredibly innovative protocol they have received: press here, pull there, stretch this and click that…then put everything in the oven at 180 degrees for 20 minutes…

…Et voilà! Pain is disappeared..

COOOOL!

There is no difference between a mechanic and a therapist who uses those tools.

The only reason why we are here and we keep succeeding and progressing is because of our incredible mind.

YOU CANNOT BE A SUCCESSFUL THERAPIST IF YOU DON’T CONSIDER IT.

So, how can we do?

 

Personally, I focus most of my energy in building a strong relationship with my client. Sometimes we see them for just a couple of sessions, sometimes even less. The treatment is very important but comes always after the construction of a successful relationship. Without a proper therapeutic relationship there can be no effective or meaningful therapy.

 

First of all you have to be CONFIDENT. Extremely confident. The patient doesn’t have to suspect that you are not in control of the situation. You have to exude confidence: the way you move, the way you walk, the way you speak: THE CLIENT IMMEDIATELY UNDERSTAND IF YOU ARE RELIABLE OR NOT.

 

A person who studies non-verbal communication knows these aspects very well.

 

I personally use a lot of non-verbal communication techniques to build this aspect: PROXEMICS, GESTICULATION, TONE OF THE VOICE AND THE WAY YOU TOUCH YOUR CLIENT are the four channel of nonverbal communication (Benemeglio, 1986).

 

Consequently, the patient must be sure that you trust them and that you understand them completely. You have to convince them that you understand their problem entirely.  Making sure that you are not underestimating the problem otherwise, they will not trust you.  A lot of people are alone or they have no one to speak with. Their relatives or partners whom demises their genuine sufferance or do not trust at all. So, if you don’t trust your patient you will loose them.

 

Be empathetic! Recognise and understand your patient’s ideas and feelings without a judgemental attitude.

 

You have to be friendly and warm and professional of course. Being friendly doesn’t mean being unprofessional.

There must be a barrier between the therapist and the client but when this barrier becomes too strong you ultimately loose connection with the patient.

 

Despite of our developed and rational mind we are still animals driven by emotions and we have to take care of this aspect during our treatment.

 

Hypnosis is an excellent tool to build up a strong therapist-patient relationship and I use it very often.

Even the placebo effect, that is present in every treatment, is much stronger if the therapist-patient relationship is solid.  (Bensing and Verheul, 2010).

 

These aspects are often not considered by the therapist that prefers to treat the client like a car that has to be fixed. However this is the key for a successful outcome and the approach and the management and consideration of the client is the most important thing…..

…..then comes the treatment…

AFTER…

Thanks for reading

Davide

Education and advice: the foundations of our profession

“A well designed Randomised Controlled Trial (RCT) regarding acute WAD, demonstrated recently that 6 sessions of multimodal physiotherapy (advice, exercise, manual therapy) were slightly more effective, but not on a significant level, than just one physiotherapy session that focused mainly on offering advice (Lamb et al., 2013).

In concordance with the previous findings, Michaleff et al., (2014) in a pragmatic RCT found that a 30-minute educational session containing a package of consultation, informational booklets and simple advice can be as efficient as a 12 week exercise program delivered by physiotherapists, including manual therapy, CBT, posture education and sensorimotor training. The authors emphasised the impact these findings can have on the current cost of WAD treatment as they could potentially decrease the number of unnecessary visits to healthcare practitioners”

Thanks to my friend Vasil for these papers

 

Bloody hell! It is the first thing I thought when I read it.  Basically it is saying that education & advice are as important as the treatment.

Unfortunately there are a lot of practicioners who spend thousand of pound in courses, medical instruments and electro-medicals and loose the contact with the most important part of our job, the foundation of our profession: EDUCATION AND ADVICE.

What do I mean?

I mean trying to understand patient’s beliefs (regarding the issue) and expectations (regarding the rehabilitation) and to use them in order to get a successfull outcome.

As Prof. Lorimer Moseley said: “Anything that changes your brain’s evaluation of danger will change the pain”. Most of the patients come to the initial assessment very scared and worried, especially after  road traffic accident. Few days ago a client of mine told me: “I cannot believe I can feel so much pain at this age: I damaged something”.

After a proper initial assessment, after you realise there is nothing major, the first thing you must do is to calm down the client, explain that pain is not synonym of damage, that is influenced by several factors that are not strictly body related (especially after a road traffic accident) etc…

Middle age people are very concerned about the MRI and XRAY findings. Expressions like “degenerated spine”, “degenerated discs”, “bulging”, “osteoarthritis” , “sprained ligaments” etc.. are all expressions that poison the mind of the client making him think that there is a certain connection between the physical damage and the pain he/she is experiencing.

“So if my spine is degenerated how can I get better? Am I doomed to pain for the rest of my life?” that is what lot of people ask me at the initial assessment.

Until you don’t change these beliefs there is no way to make him/her feeling better.

That is why, as my friend Giancarlo Russo says, if you approach the client in the right way and if you communicate properly 90% of the job is already done; what you do on the treatment couch is not so  important anymore.

However, there  cases in which it is impossible to change people’s belief. If you treat a 70 years old client with pain on the left sacro-iliac joint is very difficult for that person to accept the idea that the site of the pain is not where the problem is. It is difficult for that person to accept the idea that if you treat the thoracic spine and the diaphragm the pain will calm down.  In this case if you don’t manage to change his/her beliefs you have to be smart and to use them to fix the problem.

A 10 minutes massage on the painful area will be enough to make the client happy and to get “potential” on him/her (we will explain this topic in another post) and you will still have time enough to do all the techniques that you believe are necessary.

Treatment is very important but it becomes meaningless without the initial interview. On the other side a profitable interview could be not enough without a proper treatment.

I don’t really know what a “proper treatment” is, I can just tell you that, with the right advice and education even a normal massage could be enough to fix a non-specific-low-back pain or a non-specific-neck pain.

You can spend thousand of euro, quid or bucks in courses with pretentious and exotic names but, if you are not able to deal with people, to approach them properly and to give the right advice you will not go any further: you will always be a mediocre therapist.

Thanks to my colleague Adam Meakins to let me share his beautiful picture: the physio treatment pyramid

Thanks for reading

Davide