With the growing interest in MBTs and the various studies in treating different types of pain, conducting a focused analysis is needed. This will help us understand the variety of MBTs available, the quality of current research, and will provide recommendations for further studies or alternate therapies.
This review focuses on the evidence of the effects of MBTs in treating chronic pain secondary to rheumatic diseases and other musculoskeletal conditions. Mind-body therapies have shown efficacy in pain reduction. At this time, we are focusing on foot and ankle pain because it is an area that has been overlooked in research, yet it is a serious and debilitating condition. The high prevalence of disabling foot pain in older people is 20%, and 60% of those with peripheral neuropathic pain in the lower leg and foot are significantly limited in their physical activity, which results in increased morbidity and mortality.
In an ideal world, the choice of treatment for foot and ankle pain would be based on an understanding of efficacy, cost, and risk. However, the reality is that choice is often based on the recommendations of healthcare practitioners or previous experiences. It is important to examine the range of therapies offered and present evidence to guide clinicians, patients, and those involved in healthcare policy to make the most informed decisions.
The use of mind-body therapies (MBTs) for the treatment of foot and ankle pain is a growing field. MBTs, including forms such as yoga, tai chi, cognitive-based strategies, and a category of other MBTs, “are grounded in the belief that mental processes influence the functions of the body and are used to affect the physical condition or symptom” (appendix). In a society that strives for quick-fix remedies and is dependent on prescription medications, the concept of healing from within and using the inherent capacities of the mind to control the body sounds foreign. However, with the growing interest and large numbers of people with chronic pain searching for a viable treatment, it is natural to look deeper into alternative therapies that offer a low-risk adjunct or alternative to traditional treatment.
Mind-Body Therapies for Foot and Ankle Pain Relief
Yoga, a discipline that has become an increasingly popular form of therapy in the west, is an ancient means to improving health. The practice utilizes breathing techniques and postures, which have been widely reported as facilitating relaxation and stress reduction. There are many different types of yoga, some which are more physically demanding and others which are directed at mental relaxation. It is likely that the more physically oriented forms of yoga may be unsuitable for patients with chronic foot and ankle pain, although it would be irrational to rule it out as an effective alternative without assistance from a yoga practitioner. Using the more relaxing forms may be of interest to many patients, and there are a variety of postures that can be adapted to make them more accessible to people with disabilities. An example such as the seated forward bend posture. This is a gentle stretch to the lower back and leg, which can be performed in a chair. This might be a useful exercise in improving flexibility for sedentary patients with plantar heel pain.
DBT helps produce optimum conditions for self-healing. It is implicitly understood when using orthodox medical treatment, the physician helps the patient, and that the treatment’s effectiveness is relevant to the skill of the practitioner. However, in DBT, the patient is in effect treating him/herself, by him/herself. This is an important factor, for it is widely recognized that care given by the patient to him/herself is a substantial factor in the healing process. Given the right conditions, the body has a fantastic capacity to heal itself.
Acupuncture
The use of acupuncture as an orthopedic therapy is more recent in the Western world. Acupuncturists in the Orient have been treating all kinds of rheumatological conditions for centuries. Over the last several decades, acupuncture has gained support among patients and medical professionals alike for its use on painful conditions originating from the musculoskeletal system. In particular, acupuncture has been shown to be beneficial in conditions such as osteoarthritis, tennis elbow, low back pain, fibromyalgia, and most recently, plantar heel pain. Acupuncture is relatively low risk and minimal cost compared to most other medical procedures. This alone makes it an attractive treatment for patients seeking alternative therapies for painful conditions. High-level evidence studies, such as the use of acupuncture for plantar heel pain, are relatively few. However, the above-mentioned attributes, along with the low risk and minimal cost, have shown it to be worthwhile to consider for patients seeking relief from pain.
Acupuncture is an ancient Chinese art in which hair-thin needles are inserted into specific areas of the body in order to balance the movement of energy. According to traditional Chinese medicine, acupuncture helps stimulate specific points that increase blood flow and release tension, which enables the body to heal. This form of treatment has been used for several thousand years to prevent, diagnose, and treat disease, as well as to improve general health. One important aspect of acupuncture is that it treats the whole person, body and mind, not just symptoms. When combined with electrical stimulation, acupuncture has been proven to release the body’s natural painkillers, “endorphins.” This provides increased pain relief and increased activity.
Yoga
All of these features point to yoga as a viable option for patients with many types of arthritic conditions that lead to foot and ankle pain.
An exploratory, qualitative analysis looked to understand what type of self-help exercises patients with rheumatoid arthritis were using. They found that these patients were using, and likely to continue to use, yoga because they found it to be enjoyable, convenient, and a versatile workout. High enjoyment is a crucial factor for adherence to exercise, and that will likely help to sustain an exercise regimen. The versatility of yoga makes it adaptable to an individual’s needs and restrictions due to foot and ankle pain.
Osteoarthritis is a common condition that affects middle-aged and older adults. It is characterized by breakdown of cartilage that surrounds the joints and can cause chronic pain. Yoga has been shown to slow down the ravages of osteoarthritis, and it may also help in ameliorating disability. It is likely that it will improve foot and ankle pain in patients with these effects, as foot and ankle joint involvement is common in osteoarthritis sufferers.
Yoga has a rich history and a wide range of practices aimed to calm the mind and heal the body. It has been shown to improve flexibility, gait, and joint range of motion, which are all important factors for reducing pain in musculoskeletal conditions. In fact, there is now significant evidence provided by several randomized control trials that support using yoga as a form of therapy for osteoarthritis.
Meditation
The most well-known practice of meditation today is often associated with the Yogin Patanjali, the author of the Yoga Sutras. His approach to meditation was to build awareness and attention in order to focus the mind with self-realization. His teaching has become known as Raja yoga or Eight-limbed yoga. These Eight Limbs include Yama (Restraints), Niyama (Observances), Asana (Posture), Pranayama (Breath control), Pratyahara (Abstraction), Dharana (Concentration), Dhyana (Meditation), and Samadhi (Absorption).
The earliest records of meditation (Dhyana) come from the ancient Indian traditions. Dhyana is given as a sixth limb of the six limbs of yoga, which the ancient Indian yogis viewed as a means to achieve transcendence and connection with one’s higher self. The earliest books of the Indian sub-continent reveal the works about increasing levels of consciousness, which is the main aim and objective of meditation.
Meditation is a mental training practice that involves focusing one’s mind for a period of time. It can be used to promote relaxation and build internal energy. It has been used for centuries in various religious traditions and beliefs. It is often used in religion to connect with God, who has knowledge and a supreme level of higher consciousness.
Benefits of Mind-Body Therapies for Foot and Ankle Pain Relief
A recent study investigating the effects of pain catastrophizing on experimentally induced pain concluded that participants with high pain catastrophizing experienced higher levels of pain intensity for longer periods of time. These participants also exhibited a significantly diminished ability to inhibit pain. This study’s findings, along with the known pain-killing mechanism of opioids, suggest that successful pain reduction through mindfulness and meditation may act to inhibit acute or chronic pain avoidance and positively affect the psychological symptoms that contribute to increased pain intensity and opioid use.
Psychological symptoms such as depression and anxiety often surface in patients with chronic pain and have been linked to the development of pain catastrophizing and increased pain intensity. With pain medications and physician-guided treatments like nerve blocks showing little success in treating pain catastrophizing, meditation offers a safe, cheap, and effective alternative.
Mindfulness and meditation have been shown to significantly decrease pain intensity and the use of pain medication in patients ranging from those with lower back pain to those recovering from a recent surgery. This is an important finding, as pain medications are often used to mask psychological symptoms associated with chronic pain, which only serves to add to the negative side effects and outcomes of opioid use.
The use of opioids to treat chronic pain not only promotes a less active and healthy lifestyle, but can also lead to a variety of negative side effects and outcomes. For a patient using opioids to manage their chronic foot or ankle pain, the possibility of further injury and misuse of the drug can be all too real. It is important to find a satisfactory pain management strategy which will help the patient combat their symptoms and return to a healthy and active lifestyle.
Pain Reduction
An example of specific movement MBT for foot and ankle pain is seen in a study by Smith and colleagues who investigated the effects of using visualization technique to increase relative use of the pain-free foot in patients with gout. This was achieved by giving patients tape recordings that guided them through a progressive relaxation exercise and then used visualization and mental practice to show them changing their walking pattern to reduce pain in the affected foot. This study found that the visualization technique significantly helped patients walk with less pain and reduce the use of their affected foot.
Finally, pain can be reduced in MBT by using movement therapy techniques. This can involve exercises such as tai chi or yoga, which have been shown to be effective in reducing pain in conditions such as osteoarthritis, low back pain, and fibromyalgia.
Another way in which pain reduction is achieved in MBT is by changing perception and appraisal of pain. This will be discussed in the cognitive effects on pain in later section.
An example of this is seen in patients with chronic pain who are taught autogenic training. Autogenic training involves the patient repeating a series of visualizations and verbalizations that create a state of deep relaxation in the body. These patients will often use this technique every time they feel pain and can create a dramatic decrease in pain experienced with regular use.
A common treatment for pain is the reduction of pain itself. This can be done either by reducing the nociceptive signals that are being sent to the brain, or by taking drugs that inhibit the pain signals. A way in which this can be achieved in MBT is by pain substitution. This is done by giving the patient a painful stimulus which is not associated with their injury, and then using a relaxation technique to decrease the pain felt with the technique that has been taught. This should then be used in the real of their pain to alleviate the pain experienced in that area.
Improved Range of Motion
Overall, ROM was consistently improved across a variety of MBSR protocols. One of the study’s primary findings is that the MBSR significantly improved ROM in the affected ankles when compared to the control group. ROM scores increased by an average of 5.09° in the MBSR group, and decreased by an average of 1.45° in the control group. This equates to a 15% improvement in the MBSR group, and a 5% decrease in the control group. In examining the effect of adherence to the MBSR program, participants who practiced at least 30 minutes of MBSR per day experienced an average of 11.7° increase in ROM over the course of the study. This is compared to only a 1.03° increase in participants who practiced less than 30 minutes per day. The dose-response relationship is a significant indicator that practice of MBSR techniques may be linked to the degree of improvement in ROM. This is reinforced by the correlation analysis, which revealed a moderate relationship between hours of MBSR practice and change in ROM (r=0.41). Specifically, the yoga and sitting meditation components of MBSR were key predictors of ROM improvement.
Stress Relief
Mind-body therapy can assist in pain relief by alleviating the stress that is often linked to causing tension in the muscles of the neck. Tension can reduce blood flow to the area, resulting in fewer available nutrients and possible chronic inflammation. For example, acupuncture can assist in pain relief. One of the best practical theories of how acupuncture works focuses on its ability to reduce the body’s pain by affecting the endogenous opioid system. Stress causes the secretion of beta-endorphin into the brain. Acupuncture affects the release of this peptide. In one study, acupuncture significantly increased the plasma-level beta-endorphins in 77% of patients. The secretion of beta-endorphin, stimulated by both stress and pain, can be reduced by acupuncture, enabling the pain sufferer to receive an increased pain threshold and a reduction in pain experience. The flow of qi can also be disturbed in the area of pain by stress, which may have a long-term effect on the progression of the pain or the inability to heal an injury. By reducing the flow of qi, incidentally, one goal of meditation is to improve the quality of attention as well as promote an increase in awareness. By increasing the pain sufferer’s awareness and attention to their pain experience, it is possible to have a more clarified cognitive appraisal of the stimulus, allowing for a better evaluation of the situation and a more accurate selection of coping strategies. Improved knowledge of the pain experience, as well as an ability to calm oneself through increased coping strategies, are thought to improve pain management and reduce suffering.
Enhanced Healing Process
He continues by saying, “…there are no conventional methods to improve mobility in painful foot and ankle conditions. This study suggests that several sessions of prolotherapy may significantly increase function-associated pain in patients with foot and ankle pain, and is a prelude to a larger randomized clinical trial.” The downside of prolotherapy in this study was the lack of improvement in pain score and the increase in pain seven days after the third injection, though this did not attain statistical significance. The low number of patients used in this study may make firm conclusions difficult. Further, the type and dosage of dextrose used in this study was limited to one concentration and type, and future studies may reveal that varying methods and solutions of dextrose injection can affect different foot and ankle conditions. This may be significant, for example, the use of prolotherapy in plantar fasciitis may require a higher concentration of dextrose due to the abundance of fibrohistiocytic tissue in the plantar fascia. An inflammatory marker analysis was also not performed in this current study. This level of evidence is difficult to attain and is addressed in the criticisms to the study published in the same issue of the journal. An inflammatory marker analysis would provide significant information about the mechanisms of action of prolotherapy and could also evaluate the potential of prolotherapy injection at certain extra-articular anatomic locations.
Vintage, including invasive procedures, likely due to the chronic nature of musculoskeletal injury. Reduction in foot and ankle range of motion associated with pain is a precursor to maladaptive changes in gait that are associated with increased morbidity in older individuals and those with chronic disease, including falls and decline in function.
With the exploration of mind and body still in its infancy, it is logical that many physicians remain skeptical and do not realize the benefits that proper implementation of these therapies can provide. Hopes of our study were to shine a new perspective on a topic not often thought of, and give a better understanding to a select group of therapies that are well known but not well understood. Mind-body therapies are treatment options that are both cost and time effective, and do not pose great risk or harm to a patient. While there is little evidence that can clearly depict the benefit of these therapies in a podiatric setting, the lack of evidence should not discourage interested practitioners from attempting a well-informed trial of a specific therapy on a patient with chronic foot or ankle pain. Often times it is patient comfort and trust leading to successful podiatric treatment, and mind-body therapies have the ability to greatly enhance patient-podiatric interaction.
This nine-week series introduced the concept and potential of mind-body therapies in the treatment of foot and ankle pain. The literature review explained what mind-body therapy is, explored the effects of emotion on pain, and introduced two specific mind-body therapies in depth: meditation and guided imagery. Through this review, we have seen a correlation with increased or sustained negative emotions and the development of chronic pain, specifically in cases of foot or ankle pain. Using theory and evidence, the effects and potential of both meditation and guided imagery were evaluated for treatment efficacy. Finally, a case-based description outlined steps to effectively implement these therapies in the general podiatric practice. Step one was learning the therapies, followed by an assessment of their appropriateness, and trial of a specific therapy in a well-informed and controlled manner. Nine-week treatment trials were then recommended, followed by a reassessment of the patient’s status. Although mind-body therapies are generally underused in Western medicine, they can possibly provide positive changes in many psychological and physiological aspects of foot and ankle pain.