Monday, March 10, 2008

The pain of living with rheumatoid arthritis isn't only physical. People living with RA commonly experience emotional pain related to their condition as well. Research led by Dr. Elizabeth Pradhan suggests that form of meditation known as Mindfulness-Based Stress Reduction (MBSR) can help people cope with their RA pain in a healthy way, reducing their frustration, anxiety and depression. In this interview, Dr. Pradhan describes the connection between physical and emotional pain and how practicing meditation can help separate the two so that your aching joints don't leave you with an aching heart.

How Are Physical and Emotional Pain Connected?

Dr. Pradhan:
Pain certainly is related to emotions, and pain really involves cognition and awareness. For example, during an operation you don't feel pain, right? There needs to be consciousness and awareness in order to feel pain. It's also related to our emotions and behaviors. Pain affects all of those and is affected by our emotions and behaviors as well.

I think we all know that intuitively, but it turns out that there are actual physical connections in the physiology of the body that connect everything. In the brain, for example, there are areas in the limbic system, particularly the cingulate gyrus, that process both the emotions and the physical pain signals that come from the body.

As well, there is a body of research that has looked at the relationship of inflammatory pain, and some of the inflammatory markers called cytokines that arise in the body during inflammation, and how those are received in the brain, causing physiological changes that relate to depression. That's been seen in many different kinds of patient populations, for example, among cardiac patients and cancer patients and so forth. So there's a relationship between a pro-inflammatory state and depression.

It's also been seen that stress causes increases of flares in RA. So there's another level on which things are connected.

Pain triggers sensation of fear, thoughts of fear, predictions of negative consequences. That's part of the work of pain. It protects us. But the problem is when you continue on in a state of fear or expectation of negative consequences, and the physical pain and the emotional thoughts that arise from that are sustained longer than is beneficial. So by uncoupling the fear from the physical pain there can be a little bit of an attenuation of the perception of the whole experience.

Meditation Research and Rheumatoid Arthritis

Dr. Pradhan:
The study that we did was based on the work of Dr. Jon Kabat-Zinn and his colleagues at the University of Massachusetts Medical School. What he did back in the '70s was go around to the various doctors in the medical school and say, 'Give me the patients for whom you can do no more, the chronic pain patients, the people for whom the medications just aren't working anymore and send them to me.' He began working with patients from the hospital, and he began working with them using mindfulness meditation techniques and some gentle yoga. He worked with them over a period of weeks and began to have quite amazing success with people in terms of alleviating depression and anxiety and also changing their relationship with pain and sensation of pain.

This program was called the Mindfulness-Based Stress Reduction program, or MBSR for short, and since that time the effect of MBSR in different patient populations has been studied. However, it had never been studied among people with arthritis and more specifically rheumatoid arthritis, so in our center we thought that this would be an important study to do.

We took rheumatoid arthritis patients, and those who were eligible were randomized into two groups. One group had the MBSR training and one group was waiting for the training, so they were given the MBSR training after the study was over. Meanwhile they served as the controls.

Those in the MBSR group had the class for two months, and they met once a week for two and a half hours, and then during the week they practiced at home using audio CDs that guided them through some meditation.We assessed people at two months. Then for the next four months, we had a maintenance period where people came to some more classes but on a less frequent schedule and still continued to practice at home. Then we met people and measured them at six months.

What Is Mindfulness and How Does It Help RA?

Dr. Pradhan:
How we define mindfulness is moment to moment attention and awareness that's actively cultivated through meditation. The idea is that bringing the mind back to the present moment over and over again actually results in increased clarity and calmness. There's also a kind of atmosphere of compassion for yourself and for others that underlies this endeavor.

So it's practiced through meditation. Of course, the thought is and the hope is that you carry some of that mindfulness with you in your daily life, but it's really a sense of just being able to be in this moment without being distracted by worries about the future, worry about the present moment, worry about the past that kind of often overlays our thinking. That's what we mean by mindfulness.

An Example of Guided Meditation Used in MBSR

Dr. Pradhan:
There are many different kinds of meditation techniques, and in the MBSR course one runs the gamut from more clearly guided meditations to actual meditations that include longer periods of silence where one is just sitting silently by oneself. This is a meditation that is done in the MBSR class. It's called a loving-kindness meditation.

Just gently close your eyes and sit quietly and feel the breath going through your body. You might feel your abdomen slowly rising; don't need to do anything special - just feel yourself in the chair, feel the weight of your body being supported by the chair. Relax. Feel your breath.

Now I'd like you to bring to mind somebody in your life who has meant a lot to you, a good friend, someone who's helped you in life, someone who inspires you, in the past or in the present. Just bring that person to mind. You might visualize them, say their name to yourself. Get a feeling for them. Feel their presence. What I would like you to do is, in your mind offer these phrases to them: May you be happy. May you be safe. May you be healthy. May you live with ease.

Now I would like you to call to mind somebody you know who's having a difficult time right now. They've experienced a loss or are going through some kind of painful situation. Somebody like that comes to mind. Bring them in. Imagine them sitting in front of you. Say their name. Get a feeling for them. And say in your mind these phrases for them: May you be safe. May you be happy. May you be healthy. May you live with ease.

Now I'd like you to think of somebody with whom you are having a difficult time, somebody in your life with whom things aren't so smooth right now. Imagine that person. Feel their presence. Say their name. When you have a feeling for them, then offer this person these phrases: May you be happy. May you be safe. May you be healthy. May you live with ease.

Now I'd like you to think of being open to all beings everywhere, without distinction, without separation.

Open your heart to all beings, those who are known to you and those who are unknown to you, all around you. And holding all beings in your heart, all vastly in front of you, behind you and all sides of you, offer these phrases: May you be happy. May you be safe. May you be healthy. May you live with ease. May all living, all beings be safe and happy and healthy and live with ease. And when you're ready, you can open your eyes and see if you can bring this energy with you.

Results of the Meditation Study for Rheumatoid Arthritis

Dr. Pradhan:
What we saw in our study was that there was a significant reduction in psychological distress among our participants, and there were significant increases in well-being or more positive emotions. And there was also a decrease in depressive symptoms and an increase in a scale that's meant to measure mindfulness, so the degree that we are able to attend more clearly moment to moment to moment.

People also had a very good experience in the class, which was good to see. The MBSR participants reported very high value received from using the mindfulness techniques in everyday life. Something like 71 percent of them reported having this be useful in terms of everyday life, 86 percent of them reported very high value in terms of learning and personal growth, and so forth. So people did continue meditating through till the end, and 85 or 86 percent of the participants reported meditating up to within two weeks of the last visit with us.

How Does Meditation Help RA Patients?

Dr. Pradhan:
There is an obvious, overwhelmingly physical component to rheumatoid arthritis. Then there's the part that's the overlay on top that comes from a lot of the anxiety that's associated with RA: the fear of getting worse, of disability. What will happen to me in my job? What will happen to me in my family? Will I need someone to take care of me? What are the financial implications? There are lots of worries that go along with rheumatoid arthritis, and I think being able to work with one's thoughts about rheumatoid arthritis is distinct from the pain and the physical experience of arthritis.

In other words, being able to work with the part that you can work with, which is what you think about it and how you relate to it and how you interact with your day having RA, how you face the day with RA. Being able to work with the thoughts about RA as much as with the physical RA, if that makes sense, is something that I think patients were able to learn over time.

I think they began to relate to the pain in a different way. For example, one of the things that happened in our study was that amongst those who were in the highest rankings of pain in the MBSR group, at the beginning their depression level was correlated with their pain levels. In other words, both were high. But what we saw over time was that even if their pain levels were high, the depression levels came down.

Other Ways to Cope with RA

Dr. Pradhan:
There are probably a number of tacks that people could take. If people are interested in mindfulness meditation or are interested in what this Mindfulness-Based Stress Reduction might be about, I'd certainly recommend looking into programs in the community that offer this class, of which there are many all across the country.

There is a Web site at the University of Massachusetts Medical School where you can go and search by city or ZIP code to see if there are any classes nearby you. It's

Of course, as any person with RA, I'm sure is aware of, one of the best things you can do is take care of yourself by making sure you get enough sleep, that you rest, that you don't overdo things, that you're mindful of your body and what your body can do, and watch your diet – the kinds of quality of life factors that all of us really need to pay attention to.

I think community participation may be helpful to people. For example, I know there are support groups for people with chronic pain or for people with rheumatoid arthritis, perhaps through the Arthritis Foundation. Being able to support each other might be a way that people could cope.

Personally I feel that being able to relax the mind a bit and being able to be a little gentler on yourself in terms of your thinking is a good way to cope with the emotional pain of RA.

Take Steps to Improve Your Quality of Life with RA

Dr. Pradhan:
The first step is really important, and in our study that was one of the positive results we saw. The control group, if I can remind you, was composed of people who were anticipating doing the Mindfulness-Based Stress Reduction program when the study ended, so they had already taken a positive step in their life.

What we saw in our study was that both those in the meditation group as well as the control group improved by two months. Both of them improved to the extent that it was not possible to see a difference between them. However, what we saw from two months until six months was that those in the meditation group maintained the improvements that they had realized while those in the control group returned to where they were at baseline by the end. They returned to where they started from.

What that might indicate is that taking a positive step and making a positive change in your life are really important. But there probably is some regularity, some practice that you put into your life as a change, whether it's exercise or meditation, that is needed to sustain those improvements. You need something to fall back on when times get tougher, and having some habits in your life that support you in terms of meditation or exercise or whatever it is, that sustains you in the long run, so it's not just a quick-fix positive effect.

To learn more about improving the way you cope with RA pain through meditation, listen to the Headaches and Heartaches: The Emotional Pain of RA webcast, which includes one woman's story about how meditation changed her life as well as expert answers to questions from the audience.

To learn more about rheumatoid arthritis, check out these other HealthTalk resources: