Mindfulness in physical therapy

originally written on May 10 2019

Ahh the dreaded word, mindfulness! The minute I mention it, some people run away. If you don’t consider yourself a yogi, super zen, or lover of all things ohmmm, it might sound daunting. Especially when your physical therapist throws it out to you.

Well, I’m not your typical physical therapist. I usually let my patients know pretty quickly that I am also a yoga instructor and personal trainer. I do this because both of these influence the way I practice. I like to think that being a yoga instructor and personal trainer keeps me creative in my physical therapy practice, and that being a physical therapist keeps me safe and smart in my yoga and personal training practice.

Back to mindfulness….

Mindfulness plays a huge role in rehabilitation and healing and I want to begin to show you how. To start off, one of my favorite quotes about mindfulness is:

"Between stimulus and response there's a space, in that space lies our power to choose our response, in our response lies our growth and our freedom.“

- Holocaust survivor, Viktor Frankl-

The space between stimulus and response is where you can decide to respond or react. It’s the space where you can tune in and breathe. To know that space is mindfulness. To be able to connect to that space between stimulus and response, is mindfulness. Mindfulness is the awareness of your mind, body, and space around you. It’s awareness of choice. Mindfulness is being in tune with your body and mind. It’s about being present. Right here. Right Now.

Mindfulness is NOT a blank mind or a disconnection. It is not just thinking about the good things you do. It‘s not keeping constant tabs on yourselves and others. Mindfulness is not nothingness either.

IT IS EXACTLY WHAT IS NEEDED IN PHYSICAL THERAPY TO TRULY HEAL.

ohmmmmmm

BUT HOW DOES THIS PERTAIN TO PHYSICAL THERAPY?

Well there are a couple of ways mindfulness can be incorporated into physical therapy. Let’s talk about being the patient first….

First of all, injuries can take a mental toll on our patients. At times, injuries can be more challenging mentally than physically.

Take for example your college athlete who is in their senior year and worried if they will get to play their final year. The mental aspects of recovery might be taking a larger toll than the physical aspects of pain, decrease strength and decreased range of motion. You have to take into account that your college athlete might feel a lost sense of self. When they had previously had their time tied up in practices, running drills and games they are now regulated to rest, physical therapy exercises and pain science. This same college athlete might be feeling socially isolated from their team and lost that social connection that helps them get through the tough times.

Another patient example, your super mom whose weekly yoga class is her place of peace, comfort and most importantly, alone time. Your super mom might need her weekly yoga class to keep her peace of mind and to unwind after a stressful week. Take that away and the stress could affect her injury more than the injury itself.

So how does mindfulness play a role in this? A couple of ways:

As their physical therapist, can you bring a sense of mindfulness into your practice and programming? Can you recognize that by taking away ALL of their activities does not make them more compliant with their rehab program? So how do you mindfully decrease their load, promote healing, and NOT take everything away from them. This takes time to sit down and evaluate what is important to you and what is important to them to create a plan of care.

Can you encourage the patient to bring parts of their favorite activity into their rehabilitation? Can they relate their physical therapy exercises directly to their favorite activity in order to keep that feeling of connection? Helping them take part in choosing exercises that make them more connected to their end goals can help your patients be more invested in their progress. This in itself makes their program more mindful.

Can you take into account their mental state and how that might be affecting their pain? Is your patient more stressed? Are the depressed? Are they anxious? Is their injury causing these stressors or are other stressors causing an increase in their pain? The scale can swing both ways so check in with your patient and see how you can support them in and out of the clinic.

There is no right way to address the mental side of injuries. The best you can do is actively listen to your patients and help meet them where they are. You can do your best to make activities meaningful for patients. You learn what is important to patients and how to incorporate that into your daily life. You ask questions and ACTUALLY listen.

Breathing, moving, feeling,

SO NOW THAT YOU’VE WORKED ON THE MENTAL SIDE OF INJURIES, WHAT ABOUT MINDFUL PARTICIPATION IN THEIR REHABILITATION PROGRAM?

I cannot tell you how many times patients come into my clinic and just go through the motions. They power through exercise after exercise, stretch after stretch. Don’t get me wrong, they usually get better but I find they don’t really know what they are doing or why. And to me, that is a flaw of the system. It leads to a disconnection between the mind and body, risk of re-injury and a lack of involvement in their care.

SO HOW DO YOU GET A PATIENT TO MINDFULLY PARTICIPATE IN THEIR REHABILITATION?

First of all, create a buy in. Why do they need to mindfully participate in their rehab program?

Mindful participation in rehabilitation can improve outcomes and help patients be more in tune with their body. It can help them differentiate the difference between pain and normal discomfort. It can help decrease the risk of re-injury as the patient is more in tune with their body and what is going on. Mindful participation builds body awareness and honestly, makes patients happy.

Second, explaining to the patient why they are doing an exercise can go a long way to encouraging them to mindfully participate. Bonus points for tying that why back to their activity of choice or goals. The more the patient understands, the more likely they will be involved.

Another way to engage patients is visual aids. Pictures, diagrams, metaphors. Some people work better from visual aids and some work better with words. I find for visual aids, this is where mirrors can really come in handy. When a patient can see where their body is in space and where they need their adjustments, they can make adjustments on their own (and not being totally reliant on their PT). On the other side of visual is imagery and visualization. Sometimes imagery and visualization can go a long way to help a patient connect to their body. Make up different metaphors for each patient or re-use the same ones over and over again. Find what works for you and use it.

Other times, tactile cues work best. This one depends on the patient and you definitely want to ask permission before touching anyone (and I tell the patient where and why I am touching them). I find tactile cues help bring the patient into their body and connect to the exercise they are doing. Its brings awareness to the muscles you are working or the motion you want. I can’t tell you the amount of times I have thought I was performing the exercise one way and a someone would give me a slight adjustment that enhanced my movement that much more. My only hesitancy with tactile cues is that some patients become to reliant on them. I like using tactile cues at first to help a patient come into their body and slowly transitioning them to more visual cues.

Another useful tool I use has to do with proprioception and body mapping. I take a lot of cues from Jill Miller and her book The Roll Model and frequently use her yoga tune up balls with patients and clients. I, like Jill, believe that a lot of musculoskeletal pain has to do with lack of body awareness. So what is proprioception and what does it mean to have body awareness?

Proprioception: “Your body’s sense of itself, your inner GPS system. The ability to sense the position, location and orientation, and movement of your body and its parts.” *** see footnote

Body awareness, to me, is having knowledge of your body and it’s sense of self as well as being in tune with this sense of self. It is knowing where your muscles are working, feeling when they are lengthening, and overall just being in your body in the moment.

Like Miller recommends, I use “therapy balls” (soft roller balls- pictured below) to help patients get a sense of their body and figure out where they are in space. I teach them sequences to get in tune with the muscles that are affected by their injury, while simultaneously teaching them self myofascial release and self soothing techniques (two birds, one stone!). Adding this piece into my clinical practice has helped TREMENDOUSLY with patients. They learn how to ease their discomfort on their own which leads to self efficacy and they feel like they are capable of healing themselves. They also develop a deeper understanding of where their muscles attach to bones, how they move in their body, and where they might be holding onto tension. It is one of my favorite “modalities” for lack of a better word, to share with patients. Best part is-- these balls are super portable! I travel EVERYWHERE with them!

The last piece of mindfulness that I use with patients is breathwork. Not deep meditative, intimidating breathwork, although that is good too, but timed breathing with exercises and diaphragmatic breathing. I find patients too often hold their breath during exercises and I find it really limits them in being able to fully participate in activities. While usually it is because they are focusing (which is great!), holding their breath can take away from the exercise and cause pressure changes internally (won’t go too much into this here-- post for another time). Most patients, I cue just general breathing throughout their exercises. If a patient struggles with timing or gets caught up in thinking about breathing too much, I will cue inhales and exhales as appropriate.

Another way I use breathwork is teaching patients diaphragmatic breathing. I do this for concussion patients primarily to help decrease the stress response in the body and increase their body awareness. I will also add this into patients plans if I think stress or tension is playing role in their recovery (or lack thereof). I find this especially useful for upper back and neck patients. If are looking for some good examples of diaphragmatic breathing, check out this video.

These are just a couple of ways I integrate mindfulness into my physical therapy practice. I think it is incredibly important that as a profession we become more mindful. There are TOO many PT mills that churn through patients at an exponential rate. There are too many patients that fall through the cracks or get passed around from doctor to doctor and pt to pt. There are too many physical therapists experiencing burnout and running themselves into the ground trying to help more people. I truly believe that by infusing our physical therapy practice and even medical fields with more mindfulness we can create a better world for ourselves and our patients. So yes, that means slowly done.

For my potential patients out there, my vow is to listen, care and educate you. I promise to slow down and be there for you through the highs and lows rehabilitation. I promise to be a sounding board and a source of support. Each and every aspect of your care will be handled mindfully.

My favorite place to find a moment of stillness… the mountains

***Jaap C. van der WAl, “proprioception, mechanoreception and the anatomy of fascia. “In Fascia: The tensional Network of the Human Body (Elsevier, 2012): 81 adapted from The Roll Model, By Jill Miller Page 109.