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Back Clinic Stress And Anxiety Chiropractic Functional Medicine Team. People experience stress and anxiety from time to time. Stress is any demand placed on our brain or physical body. People can report feeling stressed with multiple demands placed on them. It can be triggered by an event that makes one feel frustrated or nervous. Anxiety is a feeling of fear, worry, or unease. This can be a reaction, and it can also happen in people who cannot identify significant stressors and are not sure of what to do.

Stress and anxiety are not always bad. They help overcome challenges or dangerous situations. Examples of everyday anxiety include worrying about finding a job, feeling nervous before a big test, or being embarrassed in certain social situations. If there were no anxiety, there would be no motivation to do certain things that need to be done ( i.e., studying for a big test).

However, if stress and anxiety start to interfere with one’s daily life, it may indicate a much more serious issue. For example, if avoiding situations due to irrational fears, constantly worrying, or experiencing severe anxiety about traumatic event/s weeks after it happened, it may be time to seek help.

Drained Energy: Boost The Central Nervous System

Drained Energy: Boost The Central Nervous System

The body needs consistent energy to get through the day. The central nervous system runs from the brain, down through the spine, and then towards every organ and region of the body. The central nervous system works by sending signals to the organs or the body’s moving parts. But when there is a kink, misalignment, damage, or injury in the spine or other joints, the signals don’t get sent or received correctly.

Pressure builds on the nerves causing the signals/messages sent from the brain to the body to start to slow down and the body’s responses. This includes not just physical reactions but the body’s metabolism. Slow metabolism causes the body to become sluggish and slow. Regular chiropractic adjustments can remove the kinks restoring proper energy flow. When the body’s cells and organs are sending and receiving the signals correctly, the body gets the full force of the energy that the body has stored.

Drained Energy: Boost The Central Nervous System

Energy Drain

Spinal misalignments can cause a multitude of symptoms. The most common problem is pain. Misalignments can also lead to energy-draining problems. These include:

  • Headaches
  • Difficulty concentrating
  • Joint pain
  • Inflammation

The body absorbs toxins from the air, water, food, or direct contact. A buildup of toxins can make the body sluggish. Chiropractic adjustments release these toxins so that the body can rid itself of them. Being out of alignment and balance requires the body to use more energy to get anything done. Even easy to do activities, chores, tasks, etc. When the body’s natural balance is restored, the result is more available energy.

Stress Management

Stress management is vital as chronic stress increases the risk of developing health problems. Learning to manage stress can help increase energy. Therapeutic massage can help with stress relief. A chiropractor will determine the best type of massage for each individual’s situation. The physiological effects of massage to reduce stress include:

  • Increased endorphins, serotonin, dopamine.
  • Decreased cortisol.
  • Increased tissue elasticity.

Endorphins, serotonin, and dopamine are neurotransmitters that are released by the autonomic system when stimulated.

  • Endorphins are responsible for relieving anxiety.
  • Serotonin prevents depression and gives a sense of well-being.
  • Dopamine increases motivation and prevents self-doubt.

When the body lacks these positive hormones, an individual can become stressed, anxious, and overwhelmed. A therapeutic massage stimulates the autonomic system, increasing the release of positive hormones. Increasing the level of positive hormones reduces stress and anxiety and improves overall mood.

When a decrease in cortisol occurs, stress is also reduced. Cortisol is a negative hormone released from the adrenal gland when stimulated by the brain’s hypothalamus region. The adrenal gland is located on top of the kidneys. Cortisol is released into the blood and is transported around the body. Cortisol increases:

  • Stress
  • Anxiety
  • Depression
  • Responsible for the fight or flight response.

When large amounts of cortisol are released in response to pain, stress levels increase, and the immune system is suppressed. A massage helps flush out the cortisol from the blood and replace it with the positive hormone endorphins, serotonin, and dopamine, decreasing stress and increasing relaxation.

Central Nervous System and Chiropractic

Chiropractic looks for the root cause of the problem and addresses that issue. Individuals can keep their bodies stay in balance by:

  • Getting the proper amount of sleep.
  • Staying hydrated.
  • Scheduling at least 30 minutes of exercise.
  • Making healthy diet adjustments.

Chiropractic treatment can help improve quality of life and overall health.

Body Composition

Neglecting A Healthy Diet

Individuals might begin a weight loss journey by going to the gym, which is great, but neglecting a healthy diet is just wasting energy. Fat loss happens when the body is in a caloric/energy deficit. This means an individual has to take in fewer calories than the body is using. According to the CDC, individuals need to reduce food intake by at least 500 calories a day to lose around a pound of body fat a week.

  • Individuals that start increasing exercise/workouts make the body instinctively want to increase calorie intake.
  • Eating more calories than are burned means the individual is wasting the workout.
  • For example, the body needs a 2,100 calorie diet to maintain its weight, and on average, an individual eats 2,100 calories.
  • This means the weight won’t change much, if at all.
  • If an individual burns 300 calories from a workout, the body needs 2,400 calories to maintain weight.
  • If no changes are made to the diet, the individual will be in a negative -300 caloric deficit.
  • Suppose an individual starts increasing their caloric intake because they think their metabolism is speeding up, which is not how it works, then the individual negates any energy deficit that they worked for, leading to no fat loss.

Carlson, Linda E et al. “Integrative Approaches to Stress Management.” Cancer journal (Sudbury, Mass.) vol. 25,5 (2019): 329-336. doi:10.1097/PPO.0000000000000395

Kültür, Turgut et al. “Evaluation of the effect of chiropractic manipulative treatment on oxidative stress in sacroiliac joint dysfunction.” Turkish Journal of physical medicine and rehabilitation vol. 66,2 176-183. 18 May. 2020, doi:10.5606/tftrd.2020.3301

Salleh, Mohd Razali. “Life event, stress, and illness.” The Malaysian Journal of medical sciences: MJMS vol. 15,4 (2008): 9-18.

Workplace Stress Management

Workplace Stress Management

Stress in the workplace is a serious issue. Working is rewarding, but it can become a cause for major stress as well. Studies have shown that more than 40% of workers find their job to be a workplace stressor. Stress takes a toll on the body both mentally and physically. Numerous factors can result in being stressed. This includes:

  • Working for long hours regularly
  • Large amounts of work to complete
  • Meeting deadlines
  • Job insecurity

Workplace Stress Management

Workplace Stress Can Hurt The Body

Workplace stress fatigues and agitates the body and can cause major health issues. These include:

  • Headaches
  • Insomnia
  • Gastrointestinal problems
  • Muscle tension
  • Palpitations
  • Anxiety
  • Depression

Stress Management Guidance

Breathing Exercises

Sometimes stress can be so intense that the heart races. For some, this can lead to panic attacks. To help calm the body down, breathing exercises can help.

  • One exercise to relieve stress is to take one deep inhale and hold it for three seconds.
  • After three seconds, with the front teeth over the edge of the upper lip.
  • Slowly exhale.
  • Wait a few seconds
  • Repeat until you feel calm.
  • Second exercise
  • Close your eyes and breathe in and out like blowing up a balloon.
  • Take a long inhale, pretend the stomach is a balloon and hold the air for seconds.
  • Exhaling, pretend the air escaping is like a balloon releasing the air.
  • This helps to slow down the heart and releases tension.

Stay Aware of Body Posture

When intensely working on something standing or hunched over for a long time, muscle tension is occurring.

  • When sitting, make sure the feet are planted firmly on the floor.
  • Keep the shoulders back and aligned.
  • Investing in an ergonomic chair with lumbar support can help.
  • Low back support will automatically encourage the body to maintain proper posture while also providing comfort.
  • Never cross the legs when sitting. This can place pressure on the pelvis that can lead to low back pain.
  • When standing change postures and positions frequently.
  • If possible, do standing stretches.

Take Short Walks

It’s important to keep the body moving as it promotes circulation and maintains muscle strength and flexibility. Not moving around can make the body feel lethargic and irritated.

  • By getting up and walking around, tension is released, which helps reduce stress.
  • Make an effort to get out and walk regularly.
  • Walking has been proven to reduce stress and strengthen the bones.

Therapeutic Massage

Another way to manage stress in the workplace is to get a therapeutic massage. It will soothe and relax the body, helping you feel more at ease at work and home. Benefits of massage include:

  • Improves flexibility
  • Boosts immune system function
  • Increases energy
  • Reduces anxiety symptoms

Types of massages that help with reducing tension and stress are:

Diet and Nutrition

Fast food and junk food can bring temporary/false relief, but eating poorly regularly will increase stress in the body. The food does not supply the body with the nutrients it needs to get large amounts of work done. Individuals get a quick jolt of energy then crash rapidly and feel worse creating an unhealthy cycle. To help manage stress, some of the best foods include:

  • Citrus fruit
  • Bananas
  • Carrots
  • Turkey
  • Salmon
  • Spinach
  • Tea
  • Yogurt

Stretch Out

When busy working individuals usually do not realize how tense their muscles can become.

Chiropractic Adjustments

Adjustments can be helpful to manage workplace stress. The benefits are able to release tension throughout the body and increase flexibility. Chiropractic can improve blood circulation which can reduce symptoms caused by hypertension and nerve damage. Some chiropractic techniques used include:

This can improve how the body responds to stress. Keeping the body stress-free while working will help to be more productive, and encouraged to live healthier. The nervous system is responsible for adapting to the environment, especially a stressful environment. A properly aligned spine and nervous system allow the body to manage stress better.

Body Composition

High blood pressure and diabetes prevention

Living a healthy lifestyle reduces the risk of chronic diseases, that includes diabetes and hypertension. Too much:

  • Sodium
  • Alcohol
  • Saturated fat
  • Combined with:
  • Smoking
  • Lack or no physical activity
  • Mental stress
  • These are all factors that can affect overall health and longevity.

The American Heart Association recommends at least 150 minutes a week of moderate-intense aerobic activity or 75 minutes a week of intense aerobic activity. Moderate-intense activities include:


Jamison, J R. “Stress management: an exploratory study of chiropractic patients.” Journal of manipulative and physiological therapeutics vol. 23,1 (2000): 32-6. doi:10.1016/s0161-4754(00)90111-8

Stress Management and The Body’s Health

Stress Management and The Body’s Health

More individuals are reporting extreme levels of stress. Studies indicate that an increasing number of individuals are feeling worried, anxious, or depressed regularly from various stressors. Maintaining the body’s health includes:

  • Following a balanced diet
  • Getting enough exercise
  • Taking vitamins or supplements to ensure the body gets what it needs for optimal function.

However, research has found that a sudden increase in stress, specifically stress associated with anger, can trigger:

This type of stress can affect individuals that did not know they had heart disease. Intense short-term stress can have dangerous effects on the body’s health, leading to chronic stress. Chronic stress continues at a low level for weeks, months, or years. It can significantly change the way the body functions. Stress management is very important for overall well-being. Learning how to handle stress properly is the goal.

Stress Management and The Body's Health

Poor Stress Management

When stress hits it triggers the brain to release various hormones. These hormones increase heart rate and raise blood pressure. This comes from evolution that helped early humans escape from predators and stay safe from different types of physical danger. This same stress reaction is what we go through, however, it is not to escape danger but to deal with work, family, school, commuting, and social issues, etc. And when the stress response happens on a regular basis it can have serious and long-term effects on the body’s ability to function properly. Stress includes mental, behavioral, and physical symptoms. The effects of stress that are most familiar are related to mood. Mood changes that can result from chronic low-level stress include:

  • Feelings overwhelmed
  • Increased anxiety
  • Generalized anxiety that is not connected with anything specific
  • Unmotivated or unfocused
  • Sadness
  • Depression
  • Irritability
  • Impatience
  • Unusually quick to anger
  • Restlessness

These mood changes can be tied to changes in behavior. The following behaviors are associated with increased stress levels:

  • Alcohol and/or drug abuse
  • Starting or increasing tobacco use
  • Eating changes – undereating or overeating
  • Withdrawing from friends and family
  • Avoiding social interaction
  • Little to no physical activity

Physical effects that are associated with long-term stress.

Chronic stress that lasts for a long period can affect the whole body. The immune system, digestive system, sleep cycles, etc. Physical symptoms include:

  • Tension in the neck and back
  • Persistent headaches
  • Stomach aches
  • Constant fatigue, even after waking up
  • Sleeping pattern changes
  • Insomnia
  • Muscle pain
  • Changes in libido
  • Being more prone to infections because of a weakened immune system
  • Chest pain

Learning Healthy Stress Management

Mental health is now an important part of living a healthy life. Stress comes from all kinds of different places. We can’t always change these moments, but we can change our reactions to reduce the negative effects and results. To manage stress, it is important to know what is causing it.

  • It could be an argument with a boss, co-worker, family member, or significant other.
  • Work deadlines
  • School grades, teachers, kids, etc
  • Bills
  • Repairs

Clearly identifying the main stressors will help individuals anticipate them and form a plan. There are different ways of dealing with it. The different strategies need to be researched and tried by individuals to see what works for them. Think about what helps the mind and body relax and unwind. A few recommended ways include:

  • Watching favorite shows or movies
  • Listening to music
  • Breathing techniques
  • Spend time with friends or family
  • Make time for yourself to do something you love – alone time
  • Unplug from devices like phones, tablets, or computer
  • Play a sport
  • Practice yoga
  • Physical activity
  • Take a nature hike
  • Write, paint, sculpt, knit, sew, crafts, make music, play instrument/s – real media or digital
  • Meditate and practice mindfulness techniques

These are strategies that can be incorporated into regular daily life. Be sure to set time aside to focus on mental wellbeing. Learn to recognize the signs when getting overwhelmed. Don’t hesitate to ask for help when needed. This can be a support system or mental health professional. This is to empower individuals to take better care of themselves in both body and mind.

Body Composition

Setting Attainable Goals

Individuals that have trouble achieving health goals might want to look at the goals themselves. Individuals typically have a general idea of their fitness journey. However, it is hard to reach those goals without a map. Losing weight or getting healthy is the goal but these goals are not measurable. This is too broad that can be different things to different people. Trying to accomplish a vague goal makes it hard to plan, making it happen, or seeing progress. A recommended strategy for goal setting is to use the SMART system. The acronym stands for:

  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Timed

When goals fall into these parameters, it provides a clear picture of what is trying to get accomplished and the ability to plan accordingly. An example could be: An individual will work out at home or the gym for one hour, five days a week for one month. This is a specific and measurable goal when compared to I’m going to work out more. This provides clear guidelines of what needs to happen to achieve success.


Bailey, Ryan R. “Goal Setting and Action Planning for Health Behavior Change.” American journal of lifestyle medicine vol. 13,6 615-618. 13 Sep. 2017, doi:10.1177/1559827617729634

Carlson, Linda E et al. “Integrative Approaches to Stress Management.” Cancer journal (Sudbury, Mass.) vol. 25,5 (2019): 329-336. doi:10.1097/PPO.0000000000000395

Jamison, J R. “Stress management: an exploratory study of chiropractic patients.” Journal of manipulative and physiological therapeutics vol. 23,1 (2000): 32-6. doi:10.1016/s0161-4754(00)90111-8

Jamison, J. “Stress: the chiropractic patients’ self-perceptions.” Journal of manipulative and physiological therapeutics vol. 22,6 (1999): 395-8. doi:10.1016/s0161-4754(99)70085-0

Injury Related Stress And Anxiety Addressed With Chiropractic Care

Injury Related Stress And Anxiety Addressed With Chiropractic Care

Going through traumatic accidents that result in injuries can cause injury-related stress and anxiety for individuals. It is understandable that stress and anxiety are high as individuals figure out how to navigate through the situation. Therefore, it is very important to find ways to manage stress and anxiety because if they go unchecked it could become chronic leading to poor health and quality of life.

Stress/Anxiety Affects Health

Injury related stress and anxiety can be exacerbated through different factors. These can include:

  • Medical bills
  • Employment
  • Relationships
  • Independence

The causes/reasons can vary however, the physical response the body goes through is the same. A stress-inducing situation can leave an individual feeling threatened and generate a physical stress response. The body responds to stress by releasing hormones that shift the body into survival mode. This requires a lot of energy placing massive strain on the body. This is an important mechanism for healthy living. However, if it begins to present on a regular basis it can lead to negative health issues that include:

  • Depression
  • Chronic anxiety
  • Heart disease
  • High blood pressure
  • Abnormal heart rhythm
  • Heart attack
  • Stroke
  • Personality disorder
11860 Vista Del Sol, Ste. 128 Injury Related Stress And Anxiety Addressed With Chiropractic Care

The body needs time every day to recover and rejuvenate. This is not possible when the body is constantly entering a heightened state of stress. Traditional treatment can lead to the over-prescription of medications that come with their own side effects. Effective injury-related stress treatment addresses issues like:

Health problems

Injury-related stress and anxiety affect mental health and can lead to physical symptoms and disease. These include:

  • Chronic pain
  • Sleep problems
  • Gastrointestinal issues
  • Obesity
  • Asthma and breathing problems
  • Alzheimer’s, dementia, and memory loss
11860 Vista Del Sol, Ste. 128 Injury Related Stress And Anxiety Addressed With Chiropractic Care

Chiropractic Treatment and Care

A healthy brain and spinal cord are vital to the body’s optimal health. When nerve energy and blood flow get blocked it can worsen injury-related stress and anxiety. Chiropractic delivers results helping to better manage mental health by addressing underlying issues with spinal misalignment. When the spine is properly aligned neural health is optimized for everyday functions. This increases vitality and an overall sense of well-being. With brain function improved adjusting to the injury and its effects no longer cause intense stress. Individuals cannot remove all the stressors and anxiety-inducing events from their lives, but proper spinal alignment can help build resilience for whatever situations life throws.

Body Composition

Recovery and Swelling

Recovery is an essential part of maintaining optimal body health. This goes for regular work, working out, athlete’s training, and just participating in physical activity. A significant sign that the body has gone through intense physical exertion and needs recovery time is swelling. Swelling presents for different reasons. It is the body’s response to tiny, microscopic tears in the muscle that happens from constant and intense use. Running or lifting heavy objects are two examples that cause swelling. Swelling can be seen in body composition analysis results. An increase in Lean Body Mass reflects an increase in water. Recovery is about giving the body a chance to:

  • Relax
  • Recuperate
  • Recover from the swelling with the end goal of resuming physical activities


The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the musculoskeletal system’s injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

phone: 915-850-0900
Licensed in Texas & New Mexico


Pickar, Joel G. “Neurophysiological effects of spinal manipulation.” The spine journal : official journal of the North American Spine Society vol. 2,5 (2002): 357-71. doi:10.1016/s1529-9430(02)00400-x

Coleman, Brian C et al. “Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.” Journal of manipulative and physiological therapeutics vol. 43,8 (2020): 753-759. doi:10.1016/j.jmpt.2019.10.016

Jamison, J R. “Stress management: an exploratory study of chiropractic patients.” Journal of manipulative and physiological therapeutics vol. 23,1 (2000): 32-6. doi:10.1016/s0161-4754(00)90111-8

Ease Stress and Anxiety With Natural Medicine

Ease Stress and Anxiety With Natural Medicine

Natural medicine for dealing with stress and taking initial steps can also help prevent and alleviate stress pain. With age, the body becomes more vulnerable to emotional and physical stress. The spine endures the effects of stress and can lead to back and/or neck pain. Chronic stress can also lead to chemical imbalances in the brain and overreaction/s. This produces a Hyperarousal or anxious state of mind. If frequent bouts of anxiety or stress are occurring the body is signaling that balance needs to be restored.  

11860 Vista Del Sol, Ste. 128 Ease Stress and Anxiety With Natural Medicine

Steps to Control Stress


Take frequent physical and mental breaks

Throughout a day, there can be several and various stressful situations. Not letting the stress build-up is a skill that needs to be practiced. Every 50 minutes of work, take a 10-minute break to reduce any stress. This will increase productivity. In the middle or last break, practice deep breathing.

  • Inhale slowly until the air reaches the bottom of the stomach.
  • Exhale slowly like a balloon slowly releasing the air.
  • To achieve the full potential of deep breathing, every exhalation should last twice as long as each inhalation.

Caffeine reduction

Caffeine can be medicinal in small doses. It increases bile flow. This stimulates the gall bladder and reduces cholesterol. However, too much can interfere with the body’s systems that are responsible for stress response. Try to limit to one to two caffeinated drinks a week.


Regular physical activity

Physical activity is what helps remove waste products, specifically lactic and uric acids, from the muscles and nervous system. An excess of these acids makes the body edgy. Moderate activity prevents and reduces anxiety. Try to get in at least 10 to 15 minutes of activity in the morning and afternoon. A quick walk combined with deep breathing is perfect.


Plenty of sleep

Hard work and playing hard help the body to sleep to the fullest. An irregular sleep pattern or poor-quality sleep confuses the body. The body reacts abnormally. Examples like confusion, tension, an adrenaline rush kicks in when it is not needed. Chronic poor sleep makes the body more vulnerable to disease and chronic conditions.  

11860 Vista Del Sol, Ste. 128 Ease Stress and Anxiety With Natural Medicine

Natural Medicine Supplements

Natural medicine supplements have been shown to reduce mild to moderate stress and anxiety.

  • Before trying any vitamins, minerals, or herbal therapies check with a doctor. This is to ensure safety with any medical conditions like pregnancy, that could prevent an individual from taking certain supplements.
  • Also, make sure if taking any medications that could cause natural medicine supplements ineffective or create a dangerous situation.
  • The reason for this is if an individual takes several supplements and develops side effects, it becomes a challenge to figure out which is responsible.
  • Quality herbs and supplements can be purchased from a licensed naturopath physician, nutritionist, health coach, or from a health store.

Herbal supplements listed below can be taken for three months and then a two-week break should be implemented. This minimizes the potential for negative effects.


Vitamin B

The B vitamins, especially B6 and B12 help regulate the body’s response to stress and keeps the nervous system healthy.

  • Vitamin B complex formula that has at least 25 mg of B6 and also 1 mg of B12 can be taken twice a day.
  • These vitamins are optimized when used in combination with other nutrients like a multivitamin-mineral supplement also twice a day.
  • B12 in the form of hydroxocobalamin or methylcobalamin is better absorbed than the more common cyanocobalamin.
11860 Vista Del Sol, Ste. 128 Ease Stress and Anxiety With Natural Medicine


This is herbal supplement helps with anxiety and insomnia. It can help relieve acute and chronic anxiety without causing drowsiness or brain fog. Kava is effective for settling anxiety with no dependence potential. Kava should be avoided if there is regular alcohol consumption or if taking Valium, Xanax, sleeping pills, like Seconal or Halcion, or anti-depressants, like Prozac or Zoloft.



This is a natural sedative. It is used for relieving anxiety because it helps with sleep. The ingredients are similar to Valium. It is not addictive and does not cause grogginess the next day like sleeping pills. Recommended intake is one 150mg capsule twice a day. However, low doses can cause drowsiness. Therefore it is best used for sleep, one 300mg capsule one hour before sleeping is recommended. Do not use if taking sedatives, like phenobarbital or benzodiazepines.  


The Body’s Composition


Stress Can Throw Off Diet and Sleep

Achieving healthy body composition is more than just building muscle and losing fat. Proper diet and getting enough sleep are necessary to make meaningful progress. With chronic stress or poor sleep, this cannot be achieved. Depressive symptoms can be associated with obesity, and anxiety and depression can trigger emotional eating and weight gain. Proper stress management means making sure there are positive strategies, techniques that can be turned to in time of need. Without a plan, stress will cause health problems and will be a significant barrier when trying to achieve fitness and health goals.

Dr. Alex Jimenez’s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*

Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*


Boyle, Neil Bernard et al. The Effects of Magnesium Supplementation on Subjective Anxiety and Stress-A Systematic Review.Nutrients vol. 9,5 429. 26 Apr. 2017, doi:10.3390/nu9050429

Chiropractic Treatment For Chronic Stress Relief

Chiropractic Treatment For Chronic Stress Relief

Chronic stress is a continued and constant feeling of stress that negatively affects the body’s health if left untreated. It is caused by everyday pressures from work, family, or trauma, but instead of calming down and going back to a neutral demeanor, the worry and anxiety keep going. Chronic stress happens when the body experiences stressors to an intense degree, that the nervous system is not able to activate the relaxation response regularly.  


Normal stress is an essential part of the body�s fight or flight response that keeps an individual safe from danger and ensures survival when something threatening occurs. If the stress becomes chronic and is not managed appropriately it can be detrimental causing or exacerbating serious health problems that include:

  • Mental health problems
  • Depression
  • Anxiety
  • Disorders
  • Cardiovascular disease/s
  • Heart disease
  • High blood pressure
  • Abnormal heart rhythms
  • Heart attack
  • Stroke

This affects almost every system in the body, directly and indirectly. The body can handle acute/short-term stress, but not chronic stress. Despite how chronic stress can damage overall health, chiropractic can bring the body back into balance and help manage the stress.  

11860 Vista Del Sol, Ste. 128 Chiropractic Treatment For Chronic Stress Relief

Chronic Stress Health

There are a variety of factors that can lead to the onset of chronic stress and include:

  • Mental health problems related to depression, anxiety, etc
  • Traumatic events like natural disasters, automobile accident, injuries
  • Caring for a family member or elder that is sick
  • Continued exposure to negativity from social media, news, etc
  • Chronic blue light exposure from electronic devices
  • Unhealthy habits related to poor sleep, unhealthy diet, and lack of exercise
  • Chronic illness
  • Having no stress management techniques or unhealthy coping methods

The body is not meant to be in a constant state of stress, as it does not allow the body to repair itself and rest properly. This can lead to the breakdown of cellular processes, proper organ functions, and lead to disease. Chronic stress has been linked to heart disease, diabetes, and depression.



It is not easy to recognize chronic stress. This is because of its long-lasting nature that individuals get so accustomed to, that it becomes normal. Symptoms to look for when identifying chronic stress:

  • Mood fluctuations and/or irritability
  • Always worrying about something
  • No time to take care of oneself or take part in enjoyable activities
  • Little inconveniences become too much to handle
  • Constantly getting colds or infections
  • Rely on unhealthy coping mechanisms like junk food, or alcohol to manage the stress
11860 Vista Del Sol, Ste. 128 Chiropractic Treatment For Chronic Stress Relief

Management Techniques

The ability to properly manage chronic stress is crucial for achieving optimal health. Management can be simple and straightforward. Options for management include:

  • Chiropractic
  • Healthy diet
  • Sleep improvement
  • Regular physical activity
  • Relaxation techniques like massage and heat therapy
  • Time management skills improvement
  • Reduced screen exposure specifically at night
  • Less time on social media
  • Mindfulness practice like meditation


Spinal Alignment

The techniques listed address reducing the external cues that affect internal health brought on by the stress response. Addressing internal imbalances will help the body return to a state of homeostasis. A common underlying imbalance that contributes to chronic stress is spinal misalignment. This is a root cause that could be over-activating the stress response which limits the body’s ability to return to a relaxed state.  


Chiropractic Management

Spinal misalignment/s hinders the nervous system’s ability to regulate the body’s stress response. This is due to improper nerve signaling and poor blood, and energy flow. Chiropractic is a research-oriented, science-based natural medical approach that specializes in addressing spinal issues. It gets the body’s natural healing ability to activate returning the body’s natural state of balance.



Dr. Alex Jimenez’s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*

Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*


Abdallah, Chadi G, and Paul Geha. Chronic Pain and Chronic Stress: Two Sides of the Same Coin?.Chronic stress (Thousand Oaks, Calif.) vol. 1 (2017): 2470547017704763. doi:10.1177/2470547017704763

Relieve Stress With Chiropractic!

Relieve Stress With Chiropractic!

Everyone experiences stress at some point in their life. In fact, it is becoming a sort of new normal in today�s hectic, fast paced, high pressure society. Chiropractic treatment can help relieve stress symptoms and achieve optimal health!

However, a large percentage of the United States population is feeling a significant impact from the stress in their lives; 77 percent say they experience physical stress related symptoms on a regular basis. Additionally, 73 percent report experiencing stress related psychological symptoms including anxiety and depression. These are not accurate numbers though because many people never seek help for their stress issues.

Stress symptoms should not be taken lightly. It is important to address the symptoms and find ways to reduce the stress. Chiropractic is an effective stress reliever.

What Is Stress?

In literal terms, stress is the state of emotional or mental strain, pressure, or tension that result from difficulties, adverse situations, or extremely demanding circumstances. However, the very nature of stress by definition makes it very subjective. What is an adverse situation to one person may not even faze another. What one person finds to be an extremely demanding circumstance would to another barely warrant a second thought. This makes it difficult to pin down a precise, universal definition. More often, the term stress is more often used to describe the set of symptoms that are caused by stress and those symptoms can be as varied as the people who experience them.

What Are The Symptoms Of Stress?

Stress symptoms can affect the entire body, both physically and mentally. Common symptoms of stress include:

  • Sleep problems
  • Depression
  • Anxiety
  • Muscle tension
  • Lower back pain
  • Gastrointestinal problems
  • Fatigue
  • Lack of motivation
  • Irritability
  • Headache
  • Restlessness
  • Chest pain
  • Feelings of being overwhelmed
  • Decrease or increase in sex drive
  • Inability to focus
  • Undereating or overeating

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How Do Stress Symptoms Affect Health?

Technically, stress itself does not have a negative impact on health. Some people deal with situations that others would consider to be stressful, yet they never exhibit the first symptom. This again speaks to the subjective nature of stress. Different people experience different symptoms and it is a combination of the stress symptoms and how the person handles those symptoms that adversely affect health.

Ultimately, stress symptoms can lead to some very serious conditions including heart disease, hypertension, diabetes, obesity, and even certain cancers. Psychologically, it can lead to social withdrawal and social phobias. It is also often directly linked to alcohol and drug abuse.

How Can Chiropractic Help Relieve Stress Symptoms?

Chiropractic cannot get rid of stress, but it can help relieve stress symptoms. The more stress the body endures, the more sensitive it becomes to pain and physical imbalances. Chiropractic can help with bringing the body back into balance, aligning the spine, and relieving pain.

On a larger scale, the simple act of aligning the spine helps to relieve stress in the body that the person may not even be aware of experiencing. The physical stress of a misaligned spine can exacerbate stress symptoms and make a person more susceptible to stressful stimuli in their environment.

Chiropractic helps to improve circulation which is essential in relieving muscle tension. This is integral in achieving and maintaining a relaxed, balanced state. It shuts down the fight or flight response that is a common accompaniment to stress, and allows the body to rest and heal.

Stress symptoms are should not be ignored. They can lead to several very serious health conditions. If you are experiencing stress in your life or stress symptoms (you don�t have to recognize that you are under stress to experience its symptoms) pay attention. Those symptoms aren�t likely to go away but instead get worse. Take care of yourself; get help for your stress.

Injury Medical Clinic:�Whiplash Pain Treatment Chiropractor

Mattress Shopping? What To Know

Mattress Shopping? What To Know

Getting a good night�s sleep is absolutely integral to good spinal health. Sometimes, though that isn�t possible. According to the National Sleep Foundation, 92 percent of people believe that a�comfortable mattress is important for good, restful sleep. A bad mattress, or one that is old, or one that is simply wrong for your body can contribute to sleep deprivation, lower back pain, headaches, stiff neck, and anxiety and depression. With so much at stake, it�s easy to see just how important it is to select a good mattress.

Ask About How The Mattress Is Made

Learn about the construction� and what the different components mean for your comfort. Different mattresses have different coils and they are arranged differently. The padding can vary in thickness. The depth can range from 7 inches to 18 inches on the average. Understanding the various components can make it easier for you to find the one that is right for you.

Look For Comfort, As Well As, Support

A good mattress is comfortable and has good support. Support is good but if you don�t have comfort then it won�t be effective.

If it is too firm (too much support) it will cause pain on your body�s pressure points. You want your hips and shoulders to slightly sink into the mattress. However, if you prefer a mattress that is firmer to support your back, you can get one with padding on top.

Don�t Let Price Be The Determining Factor

You naturally want to get the most for your dollar, but remember that you get what you pay for. A cheap mattress can translate to a poor quality one.

Look for quality and value rather than price. If money is an issue, do some comparison shopping to find the mattress you want for the best price.

Sales are another way to save money on a purchase, but look out for advertising gimmicks. Know the meaning of the terms that are used and know what you are looking for before you go for that so-called great deal.

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Educate Yourself On The Different Mattress Types

Do you want a memory foam or would latex work better for you? What exactly is an innerspring mattress? Are adjustable beds really all they are cracked up to be? Do some research and brush up on the different�types of mattresses�so that you can approach your shopping trip with confidence and as an educated consumer. It will definitely work in your favor.

In The End, It�s All About Personal Preference

There is no mattress that is a one size (or type) fits all. Different people will respond differently to mattresses. The best thing to do is try them out. Spend at least 20 minutes laying down before you make the decision to purchase or not.

Finally, if you find that your�quality of sleep�has recently gotten worse, that you are tossing and turning or wake up with pain in your back, neck, or head, it could be time to change your mattress � or pillow. If you can see your mattress sagging, that could be another indication that it is time to get a new one.

Mattresses are designed to withstand a certain degree of wear and tear, but they don�t last forever. The quality, the weight and other factors contribute to how quickly it wears out. So if you notice any of the warning signs it may be time to get a new mattress so that you can get back to peaceful, restful sleep.

Injury Medical Clinic: Back Pain Care & Treatments

CBD – Cannabidiol’s Life Changing Properties

CBD – Cannabidiol’s Life Changing Properties

CBD�research currently being conducted is showing its medical potential. This has opened doors for antipsychotic, anticancer and anti-inflammatory�treatment options among a variety of others. Scientists from all over are publishing studies that are proving CBD is one of the most effective and favorable cannabinoids that promotes proper function of the body’s systems.

Five Properties Of CBD

CBD Medical Benefits

cbd - cannabidiol el paso tx.

1. Inhibits Cancer Cell Growth

Studies have supported this claim. By way of Proapoptotic action or apoptosis, Cannabidiol, Tetrahydrocannabinol, Cannabigerol and Cannabichromene�in this order are extremely effective in tumor growth reduction in rats and cancerous human prostate cells. Research is still ongoing, but understanding that these cannabinoids stimulate the body�s process of killing cells that no longer function properly or at their optimal level. In traditional chemotherapy both�healthy and cancerous cells�are destroyed and only works when the cancer cells are replicating more frequently than healthy cells. CBD treatment promotes the body�s natural immune response to cells that are not functioning properly, which eradicates tumors.

2. Pain Reducer

The most common reason people start using marijuana despite its psychoactive affects, is that it also functions, as a pain reliever! People with chronic pain that are tired of taking pain killing opiates, rely on cannabinoid products to deal with pain and eliminate its source, commonly inflammation. Inflammation is the body�s natural response to injury, which floods the injured area with blood and nutrients to aid in rehabilitation. But inflammation creates secondary problems, among them�pain and discomfort. Through stimulation of nutrients in the area that is injured, CBD creates negative feedback to inflammatory reactions, as the nutrients that came with the inflammation are already there.

cbd - cannabidiol el paso tx.

3. Treats Anxiety

Anxiety along with PTSD affects over 40 million adults in the U.S. Valium and Xanax is what is normally used to treat these conditions. However, CBD products are becoming the preferred treatment, as they have none of the side effects or dependency issues. The effects of CBD have been observed thoroughly by experts and studies have proved its effectiveness, as a dependable alternative for mental disorders. Two receptors in the human brain responsible for sending out Adrenaline and Serotonin are the�?2-adrenergic receptor agonist and 5-HT1A receptor antagonist. These receptors both are related to anxiety, depression, insomnia, and other mental disorders when imbalanced.

4. Strengthens The Immune System

Phytocannabinoids are able to balance, reinforce and strengthen the immune system. Cannabinoid products taken daily, work in regulating the immune system. This increases the body�s detection of foreign and potentially dangerous organisms, which include cancer cells.

5. Prevents Muscle Spasms

CBD contains�chemically antispasmodic properties. Athletes from all sports love CBD and what it can do. It is a preferred supplement and these oils have proven to prevent muscle spasms and soreness. This is done through�lubricating the potassium and calcium pumps within the muscle tissue.

CBD is finding its place, slowly, but surely. It is one of natures own medicines and it is our job to discover and figure how to utilize these properties. Consult a doctor before beginning any treatment of diagnosed or undiagnosed diseases with CBD. For the more severe diseases like diabetes, schizophrenia, epilepsy, which, CBD can treat, but only when used properly.

Medical Benefits

cbd - cannabidiol el paso tx.

Pain Anxiety Depression In El Paso, TX.

Pain Anxiety Depression In El Paso, TX.

Pain Anxiety Depression�Everyone has experienced pain, however, there are those with depression, anxiety, or both. Combine this with pain and it can become pretty intense and difficult to treat. People that are suffering from depression, anxiety or both tend to experience severe and long term pain more so than other people.

The way anxiety, depression, and pain overlap each other is seen in chronic and in some disabling pain syndromes, i.e. low back pain, headaches, nerve pain and fibromyalgia. Psychiatric disorders contribute to the pain intensity and also increase the risk of disability.

Depression:�A (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how an individual feels, thinks, and how the handle daily activities, i.e. sleeping, eating and working. To be diagnosed with depression, the symptoms must be present for at least two weeks.

  • Persistent sad, anxious, or �empty� mood.
  • Feelings of hopelessness, pessimistic.
  • Irritability.
  • Feelings of guilt, worthlessness, or helplessness.
  • Loss of interest or pleasure in activities.
  • Decreased energy or fatigue.
  • Moving or talking slowly.
  • Feeling restless & having trouble sitting still.
  • Difficulty concentrating, remembering, or making decisions.
  • Difficulty sleeping, early-morning awakening & oversleeping.
  • Appetite & weight changes.
  • Thoughts of death or suicide & or suicide attempts.
  • Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease with treatment.

Not everyone who is depressed experiences every symptom. Some experience only a few symptoms while others may experience several. Several persistent symptoms in addition to low mood are�required�for a diagnosis of major depression. The severity and frequency of symptoms along with the duration will vary depending on the individual and their particular illness. Symptoms can also vary depending on the stage of the illness.



  • What is the relationship?
  • What is the neurophysiology behind it?
  • What are the central consequences?

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.pain anxiety depression el paso tx.pain anxiety depression el paso tx.pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

Brain Changes In Pain

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.

Figure 1 Brain pathways, regions and networks involved in acute and chronic pain

pain anxiety depression el paso tx.

Davis, K. D. et al. (2017) Brain imaging tests for chronic pain: medical, legal and ethical issues and recommendations Nat. Rev. Neurol. doi:10.1038/nrneurol.2017.122

pain anxiety depression el paso tx.

pain anxiety depression el paso tx.



  • Pain, especially chronic is associated with depression and anxiety
  • The physiological mechanisms leading to anxiety and depression can be multifactorial in nature
  • Pain causes changes in brain structure and function
  • This change in structure and function can alter the ability for the brain to modulate pain as well as control mood.

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Psychology, Headache, Back Pain, Chronic Pain and Chiropractic in El Paso, TX

Psychology, Headache, Back Pain, Chronic Pain and Chiropractic in El Paso, TX

Everyone experiences pain from time to time. Pain is a physical feeling of discomfort caused by injury or illness. When you pull a muscle or cut your finger, for instance, a signal is sent through the nerve roots to the brain, signaling you that something is wrong in the body. Pain may be different for everyone and there are several ways of feeling and describing pain. After an injury or illness heals, the pain will subside, however, what happens if the pain continues even after you’ve healed?


Chronic pain is often defined as any pain which lasts more than 12 weeks. Chronic pain can range from mild to severe and it can be the result of previous injury or surgery, migraine and headache, arthritis, nerve damage, infection and fibromyalgia. Chronic pain can affect an individual’s emotional and mental disposition, making it more difficult to relieve the symptoms. Research studies have demonstrated that psychological interventions can assist the chronic pain recovery process. Several healthcare professionals, like a doctor of chiropractic, can provide chiropractic care together with psychological interventions to help restore the overall health and wellness of their patients. The purpose of the following article is to demonstrate the role of psychological interventions in the management of patients with chronic pain, including headache and back pain.



The Role of Psychological Interventions in the Management of Patients with Chronic Pain




Chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient�s physiological state, thoughts, emotions, behaviors, and sociocultural influences. A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain. Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress � improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, psychologists can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives.


Keywords: chronic pain management, psychology, multidisciplinary pain treatment, cognitive behavioral therapy for pain


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Dr. Alex Jimenez’s Insight

Chronic pain has previously been determined to affect the psychological health of those with persistent symptoms, ultimately altering their overall mental and emotional disposition. In addition, patients with overlapping conditions, including stress, anxiety and depression, can make treatment a challenge. The role of chiropractic care is to restore as well as maintain and improve the original alignment of the spine through the use of spinal adjustments and manual manipulations. Chiropractic care allows the body to naturally heal itself without the need for drugs/medications and surgical interventions, although these can be referred to by a chiropractor if needed. However, chiropractic care focuses on the body as a whole, rather than on a single injury and/or condition and its symptoms. Spinal adjustments and manual manipulations, among other treatment methods and techniques commonly used by a chiropractor, require awareness of the patient’s mental and emotional disposition in order to effectively provide them with overall health and wellness. Patients who visit my clinic with emotional distress from their chronic pain are often more susceptible to experience psychological issues as a result. Therefore, chiropractic care can be a fundamental psychological intervention for chronic pain management, along with those demonstrated below.




Pain is a ubiquitous human experience. It is estimated that approximately 20%�35% of adults experience chronic pain.[1,2] The National Institute of Nursing Research reports that pain affects more Americans than diabetes, heart disease, and cancer combined.[3] Pain has been cited as the primary reason to seek medical care in the United States.[4] Furthermore, pain relievers are the second most commonly prescribed medications in physicians� offices and emergency rooms.[5] Further solidifying the importance of adequate assessment of pain, the Joint Commission on the Accreditation of Healthcare Organizations issued a mandate requiring that pain be evaluated as the fifth vital sign during medical visits.[6]


The International Association for the Study of Pain (IASP) defines pain as �an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage�.[7] The IASP�s definition highlights the multidimensional and subjective nature of pain, a complex experience that is unique to each individual. Chronic pain is typically differentiated from acute pain based on its chronicity or persistence, its physiological maintenance mechanisms, and/or its detrimental impact on an individual�s life. Generally, it is accepted that pain that persists beyond the expected period of time for tissue healing following an injury or surgery is considered chronic pain. However, the specific timeframe constituting an expected healing period is variable and often difficult to ascertain. For ease of classification, certain guidelines suggest that pain persisting beyond a 3�6 month time window is considered chronic pain.[7] Nevertheless, classification of pain based solely on duration is a strictly practical and, in some instances, arbitrary criterion. More commonly, additional factors such as etiology, pain intensity, and impact are considered alongside duration when classifying chronic pain. An alternative way to characterize chronic pain has been based on its physiological maintenance mechanism; that is, pain that is thought to emerge as a result of peripheral and central reorganization. Common chronic pain conditions include musculoskeletal disorders, neuropathic pain conditions, headache pain, cancer pain, and visceral pain. More broadly, pain conditions may be primarily nociceptive (producing mechanical or chemical pain), neuropathic (resulting from nerve damage), or central (resulting from dysfunction in the neurons of the central nervous system).[8]


Unfortunately, the experience of pain is frequently characterized by undue physical, psychological, social, and financial suffering. Chronic pain has been recognized as the leading cause of long-term disability in the working- age American population.[9] Because chronic pain affects the individual at multiple domains of his/her existence it also constitutes an enormous financial burden to our society. The combined direct and indirect costs of pain have been estimated to range from $125 billion to $215 billion, annually.[10,11] The widespread implications of chronic pain include increased reports of emotional distress (eg, depression, anxiety, and frustration), increased rates of pain-related disability, pain-related alterations in cognition, and reduced quality of life. Thus, chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient�s physiological state, thoughts, emotions, behaviors, and sociocultural influences.


Pain Management


Given the widespread prevalence of pain and its multi-dimensional nature, an ideal pain management regimen will be comprehensive, integrative, and interdisciplinary. Current approaches to the management of chronic pain have increasingly transcended the reductionist and strictly surgical, physical, or pharmacological approach to treatment. Current approaches recognize the value of a multidisciplinary treatment framework that targets not only nociceptive aspects of pain but also cognitive-evaluative, and motivational-affective aspects alongside equally unpleasant and impacting sequelae. The interdisciplinary management of chronic pain typically includes multimodal treatments such as combinations of analgesics, physical therapy, behavioral therapy, and psychological therapy. The multimodal approach more adequately and comprehensively addresses pain management at the molecular, behavioral, cognitive-affective, and functional levels. These approaches have been shown to lead to superior and long-lasting subjective and objective outcomes including pain reports, mood, restoration of daily functioning, work status, and medication or health care use; multimodal approaches have also been shown to be more cost-effective than unimodal approaches.[12,13] The focus of this review will be specifically on elucidating the benefits of psychology in the management of chronic pain.


Dr. Jimenez performing physical therapy on a patient.


Patients will typically initially present to a physician�s office in the pursuit of a cure or treatment for their ailment/acute pain. For many patients, depending on the etiology and pathology of their pain alongside biopsychosocial influences on the pain experience, acute pain will resolve with the passage of time, or following treatments aimed at targeting the presumed cause of pain or its transmission. Nonetheless, some patients will not achieve resolution of their pain despite numerous medical and complementary interventions and will transition from an acute pain state to a state of chronic, intractable pain. For instance, research has demonstrated that approximately 30% of patients presenting to their primary-care physician for complaints related to acute back pain will continue to experience pain and, for many others, severe activity limitations and suffering 12 months later.[14] As pain and its consequences continue to develop and manifest in diverse aspects of life, chronic pain may become primarily a biopsychosocial problem, whereby numerous biopsychosocial aspects may serve to perpetuate and maintain pain, thus continuing to negatively impact the affected individual�s life. It is at this point that the original treatment regimen may diversify to include other therapeutic components, including psychological approaches to pain management.


Psychological approaches for the management of chronic pain initially gained popularity in the late 1960s with the emergence of Melzack and Wall�s �gate-control theory of pain�[15] and the subsequent �neuromatrix theory of pain�.[16] Briefly, these theories posit that psychosocial and physiological processes interact to affect perception, transmission, and evaluation of pain, and recognize the influence of these processes as maintenance factors involved in the states of chronic or prolonged pain. Namely, these theories served as integral catalysts for instituting change in the dominant and unimodal approach to the treatment of pain, one heavily dominated by strictly biological perspectives. Clinicians and patients alike gained an increasing recognition and appreciation for the complexity of pain processing and maintenance; consequently, the acceptance of and preference for multidimensional conceptualizations of pain were established. Currently, the biopsychosocial model of pain is, perhaps, the most widely accepted heuristic approach to understanding pain.[17] A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain.[17] As the utility of a broader and more comprehensive approach to the management of chronic pain has become evident, psychologically-based interventions have witnessed a remarkable rise in popularity and recognition as adjunct treatments. The types of psychological interventions employed as part of a multidisciplinary pain treatment program vary according to therapist orientation, pain etiology, and patient characteristics. Likewise, research on the effectiveness of psychologically based interventions for chronic pain has shown variable, albeit promising, results on key variables studied. This overview will briefly describe frequently employed psychologically based treatment options and their respective effectiveness on key outcomes.


Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. As such, they target the frequently overlooked behavioral, emotional, and cognitive components of chronic pain and factors contributing to its maintenance. Informed by the framework offered by Hoffman et al[18] and Kerns et al,[19] the following frequently employed psychologically-based treatment domains are reviewed: psychophysiological techniques, behavioral approaches to treatment, cognitive behavioral therapy, and acceptance-based interventions.


Psychophysiological Techniques




Biofeedback is a learning technique through which patients learn to interpret feedback (in the form of physiological data) regarding certain physiological functions. For instance, a patient may use biofeedback equipment to learn to recognize areas of tension in their body and subsequently learn to relax those areas to reduce muscular tension. Feedback is provided by a variety of measurement instruments that can yield information about brain electrical activity, blood pressure, blood flow, muscle tone, electrodermal activity, heart rate, and skin temperature, among other physiological functions in a rapid manner. The goal of biofeedback approaches is for the patient to learn how to initiate physiological self-regulatory processes by achieving voluntary control over certain physiological responses to ultimately increase physiological flexibility through greater awareness and specific training. Thus a patient will use specific self-regulatory skills in an attempt to reduce an undesired event (eg, pain) or maladaptive physiological reactions to an undesired event (eg, stress response). Many psychologists are trained in biofeedback techniques and provide these services as part of therapy. Biofeedback has been designated as an efficacious treatment for pain associated with headache and temporomandibular disorders (TMD).[20] A meta-analysis of 55 studies revealed that biofeedback interventions (including various biofeedback modalities) yielded significant improvements with regard to frequency of migraine attacks and perceptions of headache management self-efficacy when compared to control conditions.[21] Studies have provided empirical support for biofeedback for TMD, albeit more robust improvements with regard to pain and pain-related disability have been found for protocols that combine biofeedback with cognitive behavioral skills training, under the assumption that a combined treatment approach more comprehensively addresses the gamut of biopsychosocial problems that may be encountered as a result of TMD.[22]


Behavioral Approaches


Relaxation Training


It is generally accepted that stress is a key factor involved in the exacerbation and maintenance of chronic pain.[16,23] Stress can be predominantly of an environmental, physical, or psychological/emotional basis, though typically these mechanisms are intricately intertwined. The focus of relaxation training is to reduce tension levels (physical and mental) through activation of the parasympathetic nervous system and through attainment of greater awareness of physiological and psychological states, thereby achieving reductions in pain and increasing control over pain. Patients can be taught several relaxation techniques and practice them individually or in conjunction with one another, as well as adjuvant components to other behavioral and cognitive pain management techniques. The following are brief descriptions of relaxation techniques commonly taught by psychologists specializing in the management of chronic pain.


Diaphragmatic breathing. Diaphragmatic breathing is a basic relaxation technique whereby patients are instructed to use the muscles of their diaphragm as opposed to the muscles of their chest to engage in deep breathing exercises. Breathing by contracting the diaphragm allows the lungs to expand down (marked by expansion of abdomen during inhalation) and thus increase oxygen intake.[24]


Progressive muscle relaxation (PMR). PMR is characterized by engaging in a combination of muscle tension and relaxation exercises of specific muscles or muscle groups throughout the body.[25] The patient is typically instructed to engage in the tension/relaxation exercises in a sequential manner until all areas of the body have been addressed.


Autogenic training (AT). AT is a self-regulatory relaxation technique in which a patient repeats a phrase in conjunction with visualization to induce a state of relaxation.[26,27] This method combines passive concentration, visualization, and deep breathing techniques.


Visualization/Guided imagery. This technique encourages patients to use all of their senses in imagining a vivid, serene, and safe environment to achieve a sense of relaxation and distraction from their pain and pain-related thoughts and sensations.[27]


Collectively, relaxation techniques have generally been found to be beneficial in the management of a variety of types of acute and chronic pain conditions as well as in the management of important pain sequelae (eg, health-related quality of life).[28�31] Relaxation techniques are usually practiced in conjunction with other pain management modalities, and there is considerable overlap in the presumed mechanisms of relaxation and biofeedback, for instance.


Operant Behavior Therapy


Operant behavior therapy for chronic pain is guided by the original operant conditioning principles proposed by Skinner[32] and refined by Fordyce[33] to be applicable to pain management. The main tenets of the operant conditioning model as it relates to pain hold that pain behavior can eventually evolve into and be maintained as chronic pain manifestations as a result of positive or negative reinforcement of a given pain behavior as well as punishment of more adaptive, non-pain behavior. If reinforcement and the ensuing consequences occur with sufficient frequency, they can serve to condition the behavior, thus increasing the likelihood of repeating the behavior in the future. Therefore, conditioned behaviors occur as a product of learning of the consequences (actual or anticipated) of engaging in the given behavior. An example of a conditioned behavior is continued use of medication � a behavior that results from learning through repeated associations that taking medication is followed by removal of an aversive sensation (pain). Likewise, pain behaviors (eg, verbal expressions of pain, low activity levels) can be become conditioned behaviors that serve to perpetuate chronic pain and its sequelae. Treatments that are guided by operant behavior principles aim to extinguish maladaptive pain behaviors through the same learning principles that these may have been established by. In general, treatment components of operant behavior therapy include graded activation, time contingent medication schedules, and use of reinforcement principles to increase well behaviors and decrease maladaptive pain behaviors.


Graded activation. Psychologists can implement graded activity programs for chronic pain patients who have vastly reduced their activity levels (increasing likelihood of physical deconditioning) and subsequently experience high levels of pain upon engaging in activity. Patients are instructed to safely break the cycle of inactivity and deconditioning by engaging in activity in a controlled and time-limited fashion. In this manner, patients can gradually increase the length of time and intensity of activity to improve functioning. Psychologists can oversee progress and provide appropriate reinforcement for compliance, correction of misperceptions or misinterpretations of pain resulting from activity, where appropriate, and problem-solve barriers to adherence. This approach is frequently embedded within cognitive-behavioral pain management treatments.


Time-contingent medication schedules. A psychologist can be an important adjunct healthcare provider in overseeing the management of pain medications. In some cases, psychologists have the opportunity for more frequent and in-depth contact with patients than physicians and thus can serve as valuable collaborators of an integrated multidisciplinary treatment approach. Psychologists can institute time-contingent medication schedules to reduce the likelihood of dependence on pain medications for attaining adequate control over pain. Furthermore, psychologists are well equipped to engage patients in important conversations regarding the importance of proper adherence to medications and medical recommendations and problem-solve perceived barriers to safe adherence.


Fear-avoidance. The fear-avoidance model of chronic pain is a heuristic most frequently applied in the context of chronic low back pain (LBP).[34] This model draws largely from the operant behavior principles described previously. In essence, the fear-avoidance model posits that when acute pain states are repeatedly misinterpreted as danger signals or signs of serious injury, patients may be at risk of engaging in fear-driven avoidance behaviors and cognitions that further reinforce the belief that pain is a danger signal and perpetuate physical deconditioning. As the cycle continues, avoidance may generalize to broader types of activity and result in hypervigilance of physical sensations characterized by misinformed catastrophic interpretations of physical sensations. Research has shown that a high degree of pain catastrophizing is associated with maintenance of the cycle.[35] Treatments aimed at breaking the fear-avoidance cycle employ systematic graded exposure to feared activities to disconfirm the feared, often catastrophic, consequences of engaging in activities. Graded exposure is typically supplemented with psychoeducation about pain and cognitive restructuring elements that target maladaptive cognitions and expectations about activity and pain. Psychologists are in an excellent position to execute these types of interventions that closely mimic exposure treatments traditionally used in the treatment of some anxiety disorders.


Though specific graded exposure treatments have been shown to be effective in the treatment of complex regional pain syndrome type I (CRPS-1)[36] and LBP[37] in single-case designs, a larger-scale randomized controlled trial comparing systematic graded exposure treatment combined with multidisciplinary pain program treatment with multidisciplinary pain program treatment alone and with a wait-list control group found that the two active treatments resulted in significant improvements on outcome measures of pain intensity, fear of movement/injury, pain self-efficacy, depression, and activity level.[38] Results from this trial suggest that both interventions were associated with significant treatment effectiveness such that the graded exposure treatment did not appear to result in additional treatment gains.[38] A cautionary note in the interpretation of these results highlights that the randomized controlled trial (RCT) included a variety of chronic pain conditions that extended beyond LBP and CRPS-1 and did not exclusively include patients with high levels of pain-related fear; the interventions were also delivered in group formats rather than individual formats. Although in-vivo exposure treatments are superior at reducing pain catastrophizing and perceptions of harmfulness of activities, exposure treatments seem to be as effective as graded activity interventions in improving functional disability and chief complaints.[39] Another clinical trial compared the effectiveness of treatment-based classification (TBC) physical therapy alone to TBC augmented with graded activity or graded exposure for patients with acute and sub-acute LBP.[40] Outcomes revealed that there were no differences in 4-week and 6-month outcomes for reduction of disability, pain intensity, pain catastrophizing, and physical impairment among treatment groups, although graded exposure and TBC yielded larger reductions in fear-avoidance beliefs at 6 months.[40] Findings from this clinical trial suggest that enhancing TBC with graded activity or graded exposure does not lead to improved outcomes with regard to measures associated with the development of chronic LBP beyond improvements achieved with TBC alone.[40]


Cognitive-Behavioral Approaches


Cognitive-behavioral therapy (CBT) interventions for chronic pain utilize psychological principles to effect adaptive changes in the patient�s behaviors, cognitions or evaluations, and emotions. These interventions are generally comprised of basic psychoeducation about pain and the patient�s particular pain syndrome, several behavioral components, coping skills training, problem-solving approaches, and a cognitive restructuring component, though the exact treatment components vary according to the clinician. Behavioral components may include a variety of relaxation skills (as reviewed in the behavioral approaches section), activity pacing instructions/graded activation, behavioral activation strategies, and promotion of resumption of physical activity if there is a significant history of activity avoidance and subsequent deconditioning. The primary aim in coping skills training is to identify current maladaptive coping strategies (eg, catastrophizing, avoidance) that the patient is engaging in alongside their use of adaptive coping strategies (eg, use of positive self-statements, social support). As a cautionary note, the degree to which a strategy is adaptive or maladaptive and the perceived effectiveness of particular coping strategies varies from individual to individual.[41] Throughout treatment, problem-solving techniques are honed to aid patients in their adherence efforts and to help them increase their self-efficacy. Cognitive restructuring entails recognition of current maladaptive cognitions the patient is engaging in, challenging of the identified negative cognitions, and reformulation of thoughts to generate balanced, adaptive alternative thoughts. Through cognitive restructuring exercises, patients become increasingly adept at recognizing how their emotions, cognitions, and interpretations modulate their pain in positive and negative directions. As a result, it is presumed that the patients will attain a greater perception of control over their pain, be better able to manage their behavior and thoughts as they relate to pain, and be able to more adaptively evaluate the meaning they ascribe to their pain. Additional components sometimes included in a CBT intervention include social skills training, communication training, and broader approaches to stress management. Via a pain-oriented CBT intervention, many patients profit from improvements with regard to their emotional and functional well-being, and ultimately their global perceived health-related quality of life.


Dr. Alex Jimenez engaging in fitness exercise and physical activity.


CBT interventions are delivered within a supportive and empathetic environment that strives to understand the patient�s pain from a biopsychosocial perspective and in an integrated manner. Therapists see their role as �teachers� or �coaches� and the message communicated to patients is that of learning to better manage their pain and improve their daily function and quality of life as opposed to aiming to cure or eradicate the pain. The overarching goal is to increase the patients� understanding of their pain and their efforts to manage pain and its sequelae in a safe and adaptive manner; therefore, teaching patients to self-monitor their behavior, thoughts, and emotions is an integral component of therapy and a useful strategy to enhance self-efficacy. Additionally, the therapist endeavors to foster an optimistic, realistic, and encouraging environment in which the patient can become increasingly skilled at recognizing and learning from their successes and learning from and improving upon unsuccessful attempts. In this manner, therapists and patients work together to identify patient successes, barriers to adherence, and to develop maintenance and relapse-prevention plans in a constructive, collaborative, and trustworthy atmosphere. An appealing feature of the cognitive behavioral approach is its endorsement of the patient as an active participant of his/her pain rehabilitation or management program.


Research has found CBT to be an effective treatment for chronic pain and its sequelae as marked by significant changes in various domains (ie, measures of pain experience, mood/affect, cognitive coping and appraisal, pain behavior and activity level, and social role function) when compared with wait-list control conditions.[42] When compared with other active treatments or control conditions, CBT has resulted in notable improvements, albeit smaller effects (effect size ~ 0.50), with regard to pain experience, cognitive coping and appraisal, and social role function.[42] A more recent meta-analysis of 52 published studies compared behavior therapy (BT) and CBT against treatment as usual control conditions and active control conditions at various time-points.[43] This meta-analysis concluded that their data did not lend support for BT beyond improvements in pain immediately following treatment when compared with treatment as usual control conditions.[43] With regard to CBT, they concluded that CBT has limited positive effects for pain disability, and mood; nonetheless, there are insufficient data available to investigate the specific influence of treatment content on selected outcomes.[43] Overall, it appears that CBT and BT are effective treatment approaches to improve mood; outcomes that remain robust at follow-up data points. However, as highlighted by several reviews and meta-analyses, a critical factor to consider in evaluating the effectiveness of CBT for the management of chronic pain is centered on issues of effective delivery, lack of uniform treatment components, differences in delivery across clinicians and treatment populations, and variability in outcome variables of interest across research trials.[13] Further complicating the interpretation of effectiveness findings are patient characteristics and additional variables that may independently affect treatment outcome.


Acceptance-Based Approaches


Acceptance-based approaches are frequently identified as third-wave cognitive-behavioral therapies. Acceptance and commitment therapy (ACT) is the most common of the acceptance-based psychotherapies. ACT emphasizes the importance of facilitating the client�s progress toward attaining a more valued and fulfilling life by increasing psychological flexibility rather than strictly focusing on restructuring cognitions.[44] In the context of chronic pain, ACT targets ineffective control strategies and experiential avoidance by fostering techniques that establish psychological flexibility. The six core processes of ACT include: acceptance, cognitive defusion, being present, self as context, values, and committed action.[45] Briefly, acceptance encourages chronic pain patients to actively embrace pain and its sequelae rather than attempt to change it, in doing so encouraging the patient to cease a futile fight directed at the eradication of their pain. Cognitive defusion (deliteralization) techniques are employed to modify the function of thoughts rather than to reduce their frequency or restructure their content. In this manner, cognitive defusion may simply alter the undesirable meaning or function of negative thoughts and thus decrease the attachment and subsequent emotional and behavioral response to such thoughts. The core process of being present emphasizes a non-judgmental interaction between the self and private thoughts and events. Values are utilized as guides for electing behaviors and interpretations that are characterized by those values an individual strives to instantiate in everyday life. Finally, through committed action, patients can realize behavior changes aligned with individual values. Thus, ACT utilizes the six core principles in conjunction with one another to take a holistic approach toward increasing psychological flexibility and decreasing suffering. Patients are encouraged to view pain as inevitable and accept it in a nonjudgmental manner so that they can continue to derive meaning from life despite the presence of pain. The interrelated core processes exemplify mindfulness and acceptance processes and commitment and behavior change processes.[45]


Results of research on the effectiveness of ACT-based approaches for the management of chronic pain are promising, albeit still warranting further evaluation. A RCT comparing ACT with a waitlist control condition reported significant improvements in pain catastrophizing, pain-related disability, life satisfaction, fear of movements, and psychological distress that were maintained at the 7 month follow-up.[46] A larger trial reported significant improvements for pain, depression, pain-related anxiety, disability, medical visits, work status, and physical performance.[47] A recent meta-analysis evaluating acceptance-based interventions (ACT and mindfulness-based stress reduction) in patients with chronic pain found that, in general, acceptance-based therapies lead to favorable outcomes for patients with chronic pain.[48] Specifically, the meta-analysis revealed small to medium effect sizes for pain intensity, depression, anxiety, physical wellbeing, and quality of life, with smaller effects found when controlled clinical trials were excluded and only RCTs were included in the analyses.[48] Other acceptance-based interventions include contextual cognitive-behavioral therapy and mindfulness-based cognitive therapy, though empirical research on the effectiveness of these therapies for the management of chronic pain is still in its infancy.




An important and vastly overlooked common underlying element of all treatment approaches is consideration of the patient�s expectation for treatment success. Despite the numerous advances in the formulation and delivery of effective multidisciplinary treatments for chronic pain, relatively little emphasis has been placed on recognizing the importance of expectations for success and on focusing efforts on enhancement of patients� expectations. The recognition that placebo for pain is characterized by active properties leading to reliable, observable, and quantifiable changes with neurobiological underpinnings is currently at the vanguard of pain research. Numerous studies have confirmed that, when induced in a manner that optimizes expectations (via manipulation of explicit expectations and/or conditioning), analgesic placebos can result in observable and measurable changes in pain perception at a conscious self-reported level as well as a neurological pain-processing level.[49,50] Analgesic placebos have been broadly defined as simulated treatments or procedures that occur within a psychosocial context and exert effects on an individual�s experience and/or physiology.[51] The current conceptualization of placebo emphasizes the importance of the psychosocial context within which placebos are embedded. Underlying the psychosocial context and ritual of treatment are patients� expectations. Therefore, it is not surprising that the placebo effect is intricately embedded in virtually every treatment; as such, clinicians and patients alike will likely benefit from recognition that therein lies an additional avenue by which current treatment approaches to pain can be enhanced.


It has been proposed that outcome expectancies are core influences driving the positive changes attained through the various modes of relaxation training, hypnosis, exposure treatments, and many cognitive-oriented therapeutic approaches. Thus, a sensible approach to the management of chronic pain capitalizes on the power of patients� expectations for success. Regrettably, too often, health care providers neglect to directly address and emphasize the importance of patients� expectations as integral factors contributing to successful management of chronic pain. The zeitgeist in our society is that of mounting medicalization of ailments fueling the general expectation that pain (even chronic pain) ought to be eradicated through medical advancements. These all too commonly held expectations leave many patients disillusioned with current treatment outcomes and contribute to an incessant search for the �cure�. Finding the �cure� is the exception rather than the rule with respect to chronic pain conditions. In our current climate, where chronic pain afflicts millions of Americans annually, it is in our best interest to instill and continue to advocate a conceptual shift that instead focuses on effective management of chronic pain. A viable and promising route to achieving this is to make the most of patients� positive (realistic) expectations and educate pain patients as well as the lay public (20% of whom will at some future point become pain patients) on what constitutes realistic expectations regarding the management of pain. Perhaps, this can occur initially through current, evidence-based education regarding placebo and nonspecific treatment effects such that patients can correct misinformed beliefs they may have previously held. Subsequently clinicians can aim to enhance patients� expectations within treatment contexts (in a realistic fashion) and minimize pessimistic expectations that deter from treatment success, therefore, learning to enhance their current multidisciplinary treatments through efforts guided at capitalizing on the improvements placebo can yield, even within an �active treatment�. Psychologists can readily address these issues with their patients and help them become advocates of their own treatment success.


Emotional Concomitants of Pain


An often challenging aspect of the management of chronic pain is the unequivocally high prevalence of comorbid emotional distress. Research has demonstrated that depression and anxiety disorders are upward to three times more prevalent among chronic pain patients than among the general population.[52,53] Frequently, pain patients with psychiatric comorbidities are labeled �difficult patients� by healthcare providers, possibly diminishing the quality of care they will receive. Patients with depression have poorer outcomes for both depression and pain treatments, compared with patients with single diagnoses of pain or depression.[54,55] Psychologists are remarkably suited to address most of the psychiatric comorbidities typically encountered in chronic pain populations and thus improve pain treatment outcomes and decrease the emotional suffering of patients. Psychologists can address key symptoms (eg, anhedonia, low motivation, problem-solving barriers) of depression that readily interfere with treatment participation and emotional distress. Moreover, irrespective of a psychiatric comorbidity, psychologists can help chronic pain patients process important role transitions they may undergo (eg, loss of job, disability), interpersonal difficulties they may be encountering (eg, sense of isolation brought about by pain), and emotional suffering (eg, anxiety, anger, sadness, disappointment) implicated in their experience. Thus, psychologists can positively impact the treatment course by reducing the influence of emotional concomitants that are addressed as part of therapy.




Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain are abundant. These include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress-improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, a psychologist can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives. Additional benefits of an integrated and holistic approach to the management of chronic pain may include increased rates of return to work, reductions in health care costs, and increased health-related quality of life for millions of patients throughout the world.


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Disclosure: No conflicts of interest were declared in relation to this paper.


In conclusion, psychological interventions can be effectively used to help relieve symptoms of chronic pain along with the use of other treatment modalities, such as chiropractic care. Furthermore, the research study above demonstrated how specific psychological interventions can improve the outcome measures of chronic pain management. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .


Curated by Dr. Alex Jimenez




Additional Topics: Back Pain


According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.


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EXTRA IMPORTANT TOPIC: Managing Workplace Stress



MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor


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Psychological Therapy for Chronic Pain Management in El Paso, TX

Psychological Therapy for Chronic Pain Management in El Paso, TX

Psychological therapy, also known as psychotherapy, refers to the use of psychological methods to help change an individual’s way of thinking as well as improve their coping skills in order for them to learn how to best deal with stress. Psychological therapies have widely been utilized as a part of the multidisciplinary management of chronic pain. Common psychotherapies include, cognitive-behavioral therapy, mindfulness-based stress reduction and even chiropractic care. The connection between the mind and the body in relation to disease and illness have long been discussed in many research studies.


Evidence-based research studies have demonstrated that proper stress management through the use of psychological therapy as well as mindfulness interventions can effectively benefit patients with chronic pain. By way of instance, chiropractic care can safely and effectively help reduce stress, anxiety and depression by correcting spinal misalignments, or subluxation. A balanced spine can improve mood and mental health. Chiropractic care can include lifestyle modifications, such as nutritional advice, physical activity and exercise recommendations, and promote better sleeping habits, to further enhance the benefits of the treatment. The purpose of the following article is to demonstrate how psychological therapies impact the management of chronic pain.




Psychological Therapies for the Management of Chronic Pain




Pain is a complex stressor that presents a significant challenge to most aspects of functioning and contributes to substantial physical, psychological, occupational, and financial cost, particularly in its chronic form. As medical intervention frequently cannot resolve pain completely, there is a need for management approaches to chronic pain, including psychological intervention. Psychotherapy for chronic pain primarily targets improvements in physical, emotional, social, and occupational functioning rather than focusing on resolution of pain itself. However, psychological therapies for chronic pain differ in their scope, duration, and goals, and thus show distinct patterns of treatment efficacy. These therapies fall into four categories: operant-behavioral therapy, cognitive-behavioral therapy, mindfulness-based therapy, and acceptance and commitment therapy. The current article explores the theoretical distinctiveness, therapeutic targets, and effectiveness of these approaches as well as mechanisms and individual differences that factor into treatment response and pain-related dysfunction and distress. Implications for future research, dissemination of treatment, and the integration of psychological principles with other treatment modalities are also discussed.


Keywords: pain management, multidisciplinary pain treatment, psychological therapy


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Dr. Alex Jimenez’s Insight

Chiropractic care is an alternative treatment option which utilizes spinal adjustments and manual manipulations to treat injuries and/or conditions associated with the musculoskeletal and nervous system. Chiropractic treatment primarily focuses on spinal health, however, because the spine is the root of the nervous system, chiropractic care can also be effectively used to treat a variety of mental health issues. As a chiropractor, I make sure to focus on the body as a whole, rather than treating the symptoms of a single injury and/or condition. The truth of the matter is, chiropractic treatment must also deal with the emotional component of each health issue in order to provide overall relief. Psychosomatic disorders, refers to a physical illness caused or aggravated by a mental factor, such as stress. Chiropractic care can be utilized as a psychological therapy, in which, a chiropractor may recommend a series of lifestyle modifications to help reduce stress, anxiety and depression, together with spinal adjustments and manual manipulations to reduce symptoms associated with mental health issues. Furthermore, the understanding of the connection between the mind and body is essential in chiropractic treatment towards overall health and wellness.


Introduction to the Non-Pharmacological Treatment of Pain


Pain is an essential biological function that signals disturbance or damage in the body, prevents further harm through overuse of the afflicted area, and promotes physiological homeostasis.[1] Whether through abnormal healing, additional bodily damage, or failed medical intervention, pain may become chronic. Chronic pain no longer signals damage to the body and is instead a detriment to the physical and psychological well-being of the sufferer. Unfortunately, medical intervention frequently cannot resolve chronic pain, resulting in increased need for management approaches to pain, as is the approach to other chronic medical conditions.[2] In recent years, the biopsychosocial model has informed research and intervention in pain psychology, wherein physical, cognitive, affective, and interpersonal factors are used to inform treatment.[2] Currently, psychological interventions for chronic pain target a variety of domains, including physical functioning, pain medication use, mood, cognitive patterns, and quality of life, while changes in pain intensity may be secondary.[3] As such, psychological interventions for pain are ideally suited as complementary treatments to medical treatment.[4] In order to articulate the distinct philosophies and effects of each psychological intervention, it is important to first consider the variety of ways that pain affects psychological functioning.


Psychological Reactions to Pain


Recurrent pain may contribute to development of maladaptive cognitions and behavior that worsen daily functioning, increase psychiatric distress, or prolong the experience of pain.[5] Individuals suffering from chronic pain tend to show increased vulnerability to a variety of psychiatric conditions, including depressive disorders,[6] anxiety disorders,[7] and posttraumatic stress disorder.[7] However, the relationship between depression and pain is likely bidirectional, as the presence of a major depressive disorder has been identified as a key risk factor in the transition from acute pain to chronic pain.[8] Additionally, individuals with pain may suffer from significant anxiety and depressive symptomatology that does not reach the severity of a clinical diagnosis.[9] Further, chronic pain negatively impacts quality of life[10] and contributes to higher levels of disability.[10] Individuals with chronic pain are also vulnerable to higher rates of obesity,[11] sleep disturbance,[12] and fatigue,[13] show greater rates of medical utilization,[10] and are vulnerable to problematic pain medication use.[14] Given the negative psychological consequences of chronic pain, it is worthwhile to consider three psychological mechanisms related to pain-related distress that have proven to be suitable targets for intervention: pain catastrophizing, fear of pain, and pain acceptance.


Pain catastrophizing is defined as a negative cognitive and affective mental set related to expected or actual pain experience.[15] Pain catastrophizing is characterized by magnification of the negative effects of pain, rumination about pain, and feelings of helplessness in coping with pain.[16] Pain catastrophizing has been associated with various forms of dysfunction, including increased rates of depression[17] and anxiety,[16] greater functional impairment and disability due to pain,[17] and lower overall quality of life.[18] Individuals who catastrophize about their pain report lower levels of perceived control over pain,[19] poorer emotional and social functioning,[20] and poorer responses to medical intervention.[21] Pain catastrophizing also contributes to poorer pain coping and overall functioning, making pain catastrophizing a viable target for psychological intervention. Addressing catastrophic thoughts about pain improves physical and psychological functioning in the short term[22] and improves the likelihood of returning to work despite the presence of persistent pain.[23]


Pain-related fear is another psychological mechanism that has significant implications for physical and psychological functioning in chronic pain. Pain-related fear reflects a fear of injury or worsening of one�s physical condition through activities that may trigger pain.[24] Pain-related fear is associated with increased pain intensity[25] and increased disability.[26] Pain-related fear contributes to disability by fostering passive or avoidant pain-coping behaviors that contribute to physical deconditioning and pain.[27] If left unaddressed, fear of pain can impair gains in physical rehabilitation settings.[28] Evidence suggests that pain catastrophizing precedes pain-related fear,[24] but both of these mechanisms uniquely contribute to pain and physical disability.[5,29]


Recently, there has been increased attention to the psychological flexibility model, which extends the fear-avoidance model of chronic pain and proposes to improve treatment outcomes through fostering of accepting attitudes towards pain.[30] Psychological flexibility has been defined as an ability to engage in the present moment in a way that allows the individual to either maintain or adjust his or her behavior in the way that is most consistent with internally held goals and values;[31] this idea is especially important in times of greater pain, given the narrowing of focus that is common during times of pain.[32] Similar to psychological acceptance, which fosters a nonjudgmental approach to distressing thoughts and emotions, pain acceptance is defined as a process of nonjudgmentally acknowledging pain, stopping maladaptive attempts to control pain, and learning to live a richer life in spite of pain.[33] Pain acceptance influences emotional functioning through two distinct mechanisms: a willingness to experience pain, which buffers against negative emotional reactions to pain, and continued engagement in valued activities despite the presence of pain, which bolsters positive emotions.[34] Acceptance of pain is theorized to uncouple the occurrence of catastrophic thoughts about pain from subsequent emotional suffering[35] and reduces reliance on control- or avoidance-based coping,[36] thereby freeing cognitive and emotional resources for more meaningful pursuits.[33] Pain acceptance has demonstrated positive associations with cognitive, emotional, social, and occupational functioning in chronic pain populations.[36] Acceptance of pain predicts lower levels of pain catastrophizing[37] and greater levels of positive affect, which in turn reduce the association between pain intensity and negative emotions.[38] Pain acceptance is a particularly salient target for intervention in mindfulness- and acceptance-based therapies for chronic pain, which will be discussed later (see Table 1).


Table 1 Descriptions of Psychological Therapies for Pain

Table 1: Descriptions of psychological therapies for pain.


Psychological Intervention as an Approach to Pain Management


Operant Behavioral Approaches


Fordyce[39] proposed a behavioral model of pain adaptation in which maladaptive behavioral responses to pain develop through contingent relief from pain or pain-related fear. According to this theory, a behavioral drive to avoid pain leads individuals to avoid behaviors that are painful but maintain their physical and emotional health; this avoidance contributes to the development and maintenance of pain chronicity, deconditioning, and depression.[40] Operant therapy for chronic pain utilizes reinforcement and punishment contingencies to reduce pain-related behaviors and foster more adaptive behaviors, including graded patterns of activity, activity pacing, and time-contingent medication management.[40] Behavioral therapy for pain has shown positive effects on a variety of domains, including pain experience, mood, negative cognitive appraisals, and functioning in social roles.[3]


A recent application of learning theory to chronic pain involves in vivo exposure treatment for pain-related fear, which focuses on decreasing the perceived harmfulness of physical activity.[41] Learning theory posits that the aversive signal of pain may be passed to neutral stimuli (like physical movement behaviors), which contributes to avoidant behavior. In vivo exposure therapy extinguishes threat, fear, and behavioral avoidance through progressively increasing engagement in painful behaviors in the absence of catastrophic outcomes; when these behaviors are performed without serious negative consequences, patients may realize that their expectations about the consequences of physical movement and pain are unrealistic.[24,42] Consistent with exposure treatments for phobias and other anxiety disorders, in vivo exposure treatment for fear of pain involves development of a personalized, graded hierarchy of activities that elicit a fearful response, psychoeducation related to pain, fear, and behavior, and ultimately slow and systematic exposure to activities related to the individual�s fear hierarchy.[41] In vivo exposure treatment for pain-related fear has demonstrated efficacy in improving pain, pain catastrophizing, and functional disability,[41] and in decreasing pain-related fear and anxiety, depression, and anxiety.[43] Exclusively behavioral approaches to pain have been less prevalent in recent years but have demonstrated efficacy in lower back pain samples, among others (see Table 2). The effects of in vivo exposure on functional disability appear to be mediated by decreased catastrophizing and perceived harmfulness of activity[41] but may be differentially effective for patients of differing baseline levels of functionality.[40]


Table 2 Demonstrated Efficacy of Psychological Interventions

Table 2: Demonstrated efficacy of psychological interventions by pain population.


Cognitive-Behavioral Therapy


Cognitive-behavioral therapy (CBT) adopts a biopsychosocial approach to the treatment of chronic pain by targeting maladaptive behavioral and cognitive responses to pain and social and environmental contingencies that modify reactions to pain.[44] CBT principles have demonstrated efficacy for a variety of psychiatric disorders and physical illnesses, in addition to pain.[45] CBT for pain develops coping skills intended to manage pain and improve psychological functioning, including structured relaxation, behavioral activation and scheduling of pleasurable events, assertive communication, and pacing of behavior in order to avoid prolongation or exacerbation of pain flares. Unlike operant-behavioral approaches, CBT for pain also addresses maladaptive beliefs about pain and pain catastrophizing through formal use of cognitive restructuring: identification and replacement of unrealistic or unhelpful thoughts about pain with thoughts that are oriented towards adaptive behavior and positive functioning.[44] CBT for pain has been widely implemented as a standard treatment for pain and constitutes the current �gold standard� for psychological intervention for pain.[44]


According to recent meta-analytic studies,[45] CBT for pain demonstrates small-to-medium effect sizes in a variety of domains and shows effects on pain and functioning comparable to standard medical care for pain.[3] CBT significantly improves disability and pain catastrophizing after treatment and yields longer-term improvements in disability, above and beyond the effects of usual medical care,[3] as well as smaller effects on pain, catastrophizing, and mood when compared to no treatment.[3] CBT-related changes in helplessness and catastrophizing are uniquely predictive of later changes in pain intensity and pain-related interference in daily functioning.[22] CBT is also a valuable adjunct treatment in physical rehabilitation programs.[46] The benefits of CBT for pain have been noted in many chronic pain populations (see Table 2) but may not be as robust in some populations, including fibromyalgia.[47] Further, some have suggested that the effects of CBT are at best moderately sized and not maintained long-term.[30] The intractable nature of chronic pain may make adaptation difficult as attempts to control pain may prove ineffectual, ultimately contributing to greater psychological distress.[36] Recent efforts have thus expanded the cognitive-behavioral model of pain intervention to address these issues, which has yielded two newer treatment modalities: mindfulness-based stress reduction (MBSR) and acceptance and commitment therapy (ACT). Unlike CBT, these approaches focus on fostering acceptance of chronic pain rather than emphasizing strategies for controlling pain, thereby improving emotional well-being and greater engagement in nonpain-related pursuits. Though these interventions both target acceptance of pain, they differ in their therapeutic implementation and approach to meditation and daily practice.


Mindfulness-Based Stress Reduction


Mindfulness-based interventions approach seeks to uncouple the sensory aspects of pain from the evaluative and emotional aspects of pain,[48] and promote detached awareness of the somatic and psychological sensations within the body.[48] As the chronic pain signal often cannot be extinguished, this detachment may enhance individual responses to chronic pain.[48] Through mindful awareness and meditation, thoughts about pain can be viewed as discrete events rather than an indication of an underlying problem that necessitates immediate and possibly maladaptive responses.[49] An individual may then recognize these sensations or thoughts as something familiar, which may serve to ameliorate emotional or maladaptive behavioral responses to pain.


MBSR is a form of meditation developed in Eastern philosophy and later adapted to Western intervention that enhances awareness and acceptance of physical, cognitive, and emotional states and disconnects psychological reactions from the uncontrollable experience of pain flares.[44] MBSR interventions have traditionally been structured as 2-hour sessions occurring weekly over 10 weeks that develop awareness of the body and proprioceptive signals, awareness of the breath and physical sensations, and development of mindful activities (such as eating, walking, and standing).[48] MBSR promotes mindfulness through daily meditation, which is a requisite component of the treatment.[50] The mechanisms underlying effective MBSR intervention may be similar to desensitization to pain, as meditations involve motionless sitting practices that expose participants to painful sensations in the absence of catastrophic consequences.[48,50] In this way, MBSR interventions may function similarly to in vivo exposure for pain but serve the additional purpose of increasing tolerance for negative emotions, thereby fostering more adaptive responses to pain.[50] MBSR also reduces rumination[51] and interoception of distressing physical signals[52] and increases mindful awareness[51] and acceptance of pain.[53] MBSR necessitates cultivation of daily mindfulness practices,[48] yet compliance rates of MBSR have been found to compare favorably to behavioral pain management techniques.[54] However, evidence on the importance of daily practice is mixed; the amount of time devoted to these mindful activities correlates with symptom improvement in some studies,[55] yet compliance rates appear to correlate only modestly with improvement in others.[54] Unlike CBT, which identifies thoughts as distorted and in need of change, practitioners of mindfulness adopt a nonjudgmental approach to thoughts as �discrete events� that encourage emotional distance from thoughts.[44,50] Further, CBT is a goal-oriented treatment modality, targeting an increased relaxation response or an altered behavioral or thought response, whereas mindfulness does not prescribe specific goals, relying instead on nonjudgmental observation.[50] Further, mindfulness instructors are expected to engage in their own daily mindfulness practices, whereas CBT practitioners do not necessarily need daily practice in CBT to teach it effectively.[50]


MBSR has demonstrated efficacy in addressing the severity of medical symptoms and psychological symptoms,[48] pain intensity,[56] and coping with stress and pain;[54] these treatment gains may last up to 4 years after intervention in many domains.[54] MBSR has been effective in diverse pain samples,[48,54,56] and in individuals with irritable bowel syndrome,[52] neck pain,[57] migraine,[57] fibromyalgia,[58] and chronic musculoskeletal pain.[59] Additionally, MBSR addresses co-occurring symptoms of depression in individuals with some chronic pain conditions like fibromyalgia[60] and enhances the effects of multidisciplinary treatment on disability, anxiety, depression, and catastrophizing.[61] Meta-analytic studies of MBSR in chronic pain have shown small to moderate effects of MBSR on anxiety, depression, and psychological distress in patients with chronic illnesses including pain,[62] and these benefits tend to be robust across studies.[63] However, as with CBT, MBSR may be differentially effective across populations; a recent longitudinal study noted greater improvements in pain, health-related quality of life, and psychological well-being for back or neck pain than in fibromyalgia, chronic migraine, or headache.[57]


Acceptance and Commitment Therapy


ACT adopts a theoretical approach that thoughts do not need to be targeted or changed; instead, responses to thoughts may be altered so that their negative consequences are minimized.[31] ACT interventions improve well-being through nonjudgmental and purposeful acknowledgment of mental events (ie, thoughts and emotions), fostering acceptance of these events, and increasing the ability of the individual to remain present and aware of personally relevant psychological and environmental factors; in doing so, individuals are able to adjust their behavior in a way that is consistent with their goals or values, rather than focusing on immediate relief from thoughts and emotions.[31] In the treatment of pain, ACT fosters purposeful awareness and acceptance of pain, thereby minimizing the focus on reducing pain or thought content and instead directing efforts towards fulfilling behavioral functioning.[44] ACT shares conceptual similarity with MBSR due to shared goals of promoting mindfulness and acceptance of pain but, unlike MBSR, ACT does not utilize daily mindful meditation and instead focuses on identification of the values and goals of the individual, which serve to direct behavior.[64] ACT-based interventions have demonstrated benefits on various aspects of mental health in chronic pain populations, including mental health quality of life, self-efficacy, depression, and anxiety.[65] Some studies of ACT interventions for chronic pain have reported medium or larger effect sizes for improvements in pain-related anxiety and distress, disability, number of medical visits, current work status, and physical performance,[66,67] with smaller effects of this intervention noted on pain and depression.[64] However, meta-analytic studies of acceptance-based therapies for pain have revealed that ACT does not show incrementally greater efficacy in comparison to other established psychological treatments for chronic pain.[64]


Future Directions and Remaining Questions


The extant literature suggests that each of the previously reviewed psychological interventions has retained value for the treatment of chronic pain. At present, there is little evidence of the superiority of any treatment approach, with one exception: CBT has demonstrated incrementally greater benefit in many areas than the effects of behavioral therapy.[3] As previously noted, however, operant-behavioral principles have been adopted for newer treatment approaches like in vivo exposure for fear of pain, which has demonstrated good benefit in multidisciplinary treatment with some pain populations.[41] Recent reviews have concluded that MBSR and ACT are promising but yield generally comparable effects to CBT, despite their distinct intervention methods.[64] The ability to draw conclusions regarding treatment superiority is further limited by the smaller number of high-quality studies of ACT or MBSR compared to the more robust CBT literature.[64]


Some critical questions remain regarding the comparative effectiveness of these interventions. First, the effects of CBT are significant in the short term but are not consistently maintained across time, possibly due to decreased adherence.[3] It is conceivable that acceptance-based approaches, which are predicated less on mechanistic coping strategies and instead foster accepting attitudes towards pain, may show greater rates of long-term adherence and longer-term benefits than CBT, though future study of this question is needed. Further, some pain disorders (such as fibromyalgia) have shown comparatively poorer treatment response to CBT than other pain disorders in some studies, which highlights the possible benefit of alternative interventions in such populations. Indeed, ACT and MBSR have also shown efficacy in fibromyalgia populations, though there remains a need to identify predictors of differential treatment response.[65]


Safety and Tolerability of Psychological Therapies


Psychological therapies for pain are presumed to be at low risk for adverse effects to the recipient; as a result, there is a dearth of empirical evidence regarding the risks of psychological interventions.[68] Some have suggested that patients who enter psychological treatment face risks of incorrect psychological diagnosis, psychological dependence, undermining of a patient�s ability to make their own decisions, or manipulation by the therapist to achieve nontherapeutic goals.[69,70] However, these concerns are alleviated through proper clinical and ethical training of practitioners and are not typically considered salient risks of psychological therapies when they are properly administered.[70] Recently, there has been a call for additional research to address the possibility of adverse psychotherapeutic effects[71] as well as a more systematic method of monitoring and identifying adverse events related to psychotherapy.[68] Though the rates of adverse effects of psychotherapy are still largely unknown, it is encouraging that recent studies have begun to specifically report the incidence of adverse events directly.[72]


Factors Affecting the Outcomes of Psychological Intervention


Practitioners should be cautioned against the assumption of homogeneity among patients with pain disorders, as a variety of factors may predict treatment response.[69,71] Turk[73] proposed that individuals coping with comparable levels of pain show distinct patterns of response that could be clustered into recognizable subclasses: �dysfunctional� patients, who report high levels of pain-related interference and distress; �interpersonally distressed� patients, who report lacking the support of loved ones in coping with their pain; and �adaptive copers,� who report notably higher levels of function and perceived social support and lower levels of pain-related dysfunction. Turk proposed that these patient subgroups respond differently to psychological intervention, and subsequent findings have supported this idea: �dysfunctional� patients have demonstrated greater response to interdisciplinary treatment involving psychological care than �interpersonally distressed� patients.[74] Identification of patient subgroups may be accomplished using instruments like the Multidisciplinary Pain Inventory[75] and through detailed assessment of chronic pain intensity and disability.[76] Additionally, patients� readiness to adopt a self-management approach to their own chronic pain appears to have significant implications for treatment response;[77] patients who are in the precontemplation stage of treatment readiness may benefit more from insight-focused therapy, versus those in an action stage, who may benefit more from establishing relaxation-based and other active coping strategies.[77] Patient readiness to self-manage pain may be assessed using the Pain Stages of Change Questionnaire.[77] Additionally, treatment response may be subject to patient beliefs about the importance of intervention-specific behaviors and about one�s own ability to perform these actions.[78]


Additionally, there may be demographic, psychological, and medical differences among patients that are relevant to treatment response, including the etiology of pain conditions, socioeconomic status, and cultural and ethnic background; these factors require further empirical research in order to optimize clinical outcomes but have not yet received adequate attention in the clinical literature.[79] For example, baseline levels of physical functioning appear to predict response to certain psychological treatment modalities like in vivo exposure for fear of pain.[40] Further, baseline levels of pain, depression, and anxiety have been found to predict dropout rates in some samples,[80,81] though these effects are not apparent in all samples.[3] In addition to being an important mechanism of treatment, there is evidence that baseline levels of fear of pain may also predict differential treatment response; individuals more fearful of pain at the outset of a multidisciplinary pain treatment program showed greater responsiveness to in vivo exposure for this problem.[28] The presence of medical comorbidities that are likely to impact future functioning is also important to consider; recently, psychological interventions have been developed that address comorbid symptoms of sleep,[82] obesity,[29] and fatigue[83] that may accompany chronic pain. Hybrid treatments may be more important in independent clinical practice, where comorbidity is more common.[82] Notably, there is little evidence that personality variables factor significantly into treatment response; most of the connections between personality traits and variables relevant to psychological intervention for pain are theoretical and have not consistently emerged in empirical research.[84,85]


Patient age is also an important consideration in examining responses to interventions for pain. Older adults have increased risks of various ailments related to pain, including arthritis and osteoporosis, but may have poor tolerance to medications for these conditions.[86] Further, age may alter psychological reactions to pain; the emotional aspects of pain are more strongly correlated with pain catastrophizing in younger adults than older adults while sensory aspects of pain appear more strongly related to pain catastrophizing in older adults.[87] Additionally, treatment protocols may require accommodation for elderly populations; addressing an elderly patient�s fear of movement may be complicated by a fear of falling that is absent in younger populations.[88] As memory concerns are more common in older adulthood, treatment protocols may be improved if they minimize the demand for memorized tasks.[89] Unfortunately, research is lacking for specific psychological interventions in elderly populations.[86] In general, psychological interventions are presumed to be of low risk for older adults,[90] and CBT for pain has received comparatively greater empirical support for older adults.[88] Overall, the efficacy of psychological intervention for pain in older adults is an area that warrants additional study in the future.


Treatment availability is a key consideration for psychological intervention, especially for patients in poverty or living in remote geographical locations. Though it is beyond the scope of this paper to review ethnic and socioeconomic contributors to health, low socioeconomic status is a significant risk factor for the development of chronic pain and factors heavily into racial disparities in health outcomes.[91] As financial challenges may restrict access to traditional psychological interventions, the importance of alternative modalities for provision of mental health interventions for chronic pain is paramount. Teleinterventions[92] and Internet-based interventions[93] may be viable for psychological treatment of chronic pain; Internet-based programs delivering ACT,[94] CBT,[46] and mindfulness interventions[95] have demonstrated benefits in psychosocial functioning, mood, and pain coping. However, methodologically rigorous clinical trials and evidence for maximally effective and efficient implementation of these programs are needed, as many interventions have shown modest effects and comparatively high dropout rates.[96]


Combining psychological treatment modalities with one another and with other medical interventions may constitute the next logical step in enhancing treatment outcomes. Institution of a flexible, goal-oriented approach, akin to ACT, may enhance engagement and adherence in CBT.[97] Additionally, a combination of graded in vivo exposure and ACT may show incremental benefit in addressing pain-related fear and anxiety.[98] Effects of CBT may also be enhanced in conjunction with treatments like biofeedback[99] and hypnosis.[100] A word of caution: presentation of psychological treatment by nontraditional practitioners may show variable effectiveness unless treatment approaches are adjusted appropriately.[101] If trained properly, however, appropriately-designed cognitive-behavioral interventions can be effectively administered by physiotherapists,[102] physical therapists,[103] nurses, and occupational therapists.[104]




Psychotherapy constitutes a valuable modality for addressing the behavioral, cognitive, emotional, and social factors that both result from and contribute to pain-related dysfunction and distress through enhancement of self-management strategies. There are several distinct psychological interventions that differ in their theoretical approaches, therapeutic targets, and areas of efficacy, but CBT, ACT, MBSR, and operant behavioral approaches to pain may all play important roles for enhancing the self-management abilities of individuals with chronic pain. However, there remains a need to identify predictors of differential treatment response and salient patient subgroups to optimize treatment outcomes, as well as additional and alternative means to provision of psychological services for those who are unwilling or unable to engage in traditional psychotherapy. More empirical research into contributing factors of differential treatment response and the dissemination of psychological treatment for pain may result in significant savings to the physical, emotional, and financial costs of chronic pain.




Disclosure:�The author reports no conflicts of interest in this work.


In conclusion, psychological therapies, such as cognitive-behavioral therapy, mindfulness-based stress reduction and even chiropractic care, have been demonstrated to effective help treat chronic pain, according to research studies. The connection between the mind and body has previously been referenced as a cause for a variety of health issues, including chronic pain. Finally, the article above demonstrated the effects of psychological therapy for chronic pain management. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .


Curated by Dr. Alex Jimenez



Additional Topics: Back Pain


According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.


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Mindfulness Interventions for Chronic Headache in El Paso, TX

Mindfulness Interventions for Chronic Headache in El Paso, TX

If you’ve experienced a headache, you’re not alone. Approximately 9 out of 10 individuals in the United States suffer from headaches. While some are intermittent, some frequent, some are dull and throbbing, and some cause debilitating pain and nausea, getting rid of the head pain is an immediate response for many. But, how can you most effectively relieve a headache?


Research studies have demonstrated that chiropractic care is an effective alternative treatment option for many types of headaches. A 2014 report in the Journal of Manipulative and Physiological Therapeutics (JMPT) discovered that spinal adjustments and manual manipulations used in chiropractic care improved outcome measures for the treatment of chronic and acute neck pain as well as improved the benefits of a variety of treatment approaches for neck pain. Furthermore, a 2011 JMPT study found that chiropractic care can improve and reduce the frequency of migraine and cervicogenic headaches.


How Does Chiropractic Care Treat Headaches?


Chiropractic care focuses on the treatment of a variety of injuries and/or conditions of the musculoskeletal and nervous system, including headache. A chiropractor utilizes spinal adjustments and manual manipulations to carefully correct the alignment of the spine. A subluxation, or a spinal misalignment, has been demonstrated to cause symptoms, such as neck and back pain, and headache and migraine. A balanced spine can improve spine function as well as alleviate structural stress. In addition, a doctor of chiropractic can help treat headaches and other painful symptoms by supplying nutritional advice, offering posture and ergonomics advice and recommending stress management and exercise advice. Chiropractic care can ultimately ease muscle tension along the surrounding structures of the spine, restoring the spine’s original function.


Dr. Alex Jimenez performs a chiropractic adjustment on a patient.


Dr. Alex Jimenez offers fitness advice to patient.


Furthermore, chiropractic care can safely and effectively treat other spinal health issues, including symptoms of neck and lower back pain due to cervical and lumbar herniated discs, among other injuries and/or conditions. A chiropractor understands how a spinal misalignment, or subluxation, can affect different areas of the body and they will treat the body as a whole rather than focusing on the symptom alone. Chiropractic treatment can help the human body naturally restore its original health and wellness.


Trainer and patient interaction at rehabilitation center.


It is well-known that chiropractic care is effective for a variety of injuries and/or conditions, however, over the last few years, research studies have found that chiropractic can enhance our well-being by managing our stress. A number of these recent research studies demonstrated that chiropractic care can alter immune function, affect heart rate, and also reduce blood pressure. A 2011 research from Japan indicated that chiropractic may have a much bigger influence on your body than you believe.


Stress is an essential indicator of health, and chronic pain symptoms can tremendously affect wellness. Researchers in Japan sought to check whether chiropractic could alter stress levels in 12 men and women with neck pain and headache. But scientists at Japan wanted to find a more objective picture of how chiropractic spinal adjustments and manual manipulations affect the nervous system, so they used PET scans to monitor brain activity and salvia trials to monitor hormone changes.


After chiropractic care, patients had altered brain activity in the areas of the brain responsible for pain processing and stress reactions. They also had significantly reduced cortisol levels, indicating decreased stress. Participants also reported lower pain scores and a greater quality of life after treatment. Mindfulness interventions, such as chiropractic care, are fundamental stress management methods and techniques. Chronic stress can lead to a variety of health issues, including neck and back pain as well as headache and migraine. Other mindfulness interventions can also safely and effectively help improve symptoms. The purpose of the following article is to demonstrate the effectiveness of another mindfulness intervention, known as mindfulness-based stress reduction, on perceived pain intensity and quality of life in patients previously diagnosed with chronic headache.


The Effectiveness of Mindfulness-Based Stress Reduction on Perceived Pain Intensity and Quality of Life in Patients With Chronic Headache




The aim of this study was to determine the effectiveness of Mindfulness-Based Stress reduction (MBSR) on perceived pain intensity and quality of life in patients with chronic headache. Thus, forty patients based on the diagnosis of a neurologist and diagnostic criteria of the International Headache Society (IHS) for migraine and chronic tension-type headache were selected and randomly assigned to the intervention group and control group, respectively. The participants completed the Pain and quality of life (SF-36) questionnaire. The intervention group enrolled in an eight-week MBSR program that incorporated meditation and daily home practice, per week, session of 90-minutes. Results of covariance analysis with the elimination of the pre-test showed significantly improvement of pain and quality of life in the intervention group compared with the control group. The findings from this study revealed that MBSR can be used non-pharmacological intervention for improvement the quality of life and development of strategies to cope with pain in patients with chronic headache. And can be used in combination with other therapies such as pharmacotherapy.


Keywords: chronic pain, migraine headache, mindfulness, quality of life, tension headache


Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Chronic headache is a debilitating symptoms which affects many people. There are many different types of headaches, however, a majority of them often share a common trigger. Chronic stress can cause a variety of health issues of not properly managed, including muscle tension, which may lead to spinal misalignment, or subluxation, as well as other symptoms, such as neck and back pain, headaches and migraines. Stress management methods and techniques can ultimately help improve and manage stress associated symptoms. Mindfulness interventions like chiropractic care and mindfulness-based stress reduction have been determined to effectively help reduce stress and alleviate chronic headache symptoms.




Headache is one of the most common complaints investigated in adult and pediatric neurological clinics. The vast majority of these headaches are migraine and tension-type headaches (Kurt & Kaplan, 2008). Headaches are classified into two categories of main or primary and secondary headaches. Ninety percent of headaches are primary headaches, among which migraine and tension headaches are the most common types (International Headache Society [IHS], 2013). According to the definition, migraine headache is usually unilateral and pulsating in nature and lasts from 4 to 72 hours. The associated symptoms include nausea, vomiting, increased sensitivity to light, sound and pain, and it generally increases with increasing physical activity. Also, tension headache is characterized by bilateral, non-pulsating pain, pressure or tightness, blunt pain, like a bandage or a hat, and a continuum of mild to moderate pain, preventing daily life activities (IHS, 2013).


Stovner et al. (2007) using the IHS diagnostic criteria, estimated the percentages of the adult population with an active headache disorder about 46% for headache in general, 42% for tension-type headache. This suggests that the incidence and the prevalence of tension-type headache are much higher than it was predicted. It is estimated that about 12 to 18 percent of the people have migraines (Stovner & Andree, 2010). Women are more likely to experience migraines compared to men, migraine prevalence is about 6% for men and 18% for women (Tozer et al., 2006).


Migraine and tension-type headaches are common and well-documented responses to psychological and physiological stressors (Menken, Munsat, & Toole, 2000). Migraine is a periodic and debilitating chronic pain and has a negative impact on quality of life, relationships and productivity. The World Health Organization (WHO) has announced the severe migraine as one of the most debilitating diseases with the nineteenth rank (IHS, 2013; Menken et al., 2000).


Despite the development of many medications for treatment and prevention of migraine attacks, a number of patients find them ineffective and some other find them inappropriate because of their side effects and side-effects often times lead to early discontinuation of treatment. As a result, a great interest in the development of non-pharmacologic treatments can be observed (Mulleners, Haan, Dekker, & Ferrari, 2010).


Biological factors alone cannot explain vulnerability to the experience of the headache, the onset of the attack and its course, intensified attacks of headache, headache-related disability and also the quality of life in patients with chronic headache. Negative life events are (as psychosocial factor) often known as a key factor in the development and exacerbation of headache (Nash & Thebarge, 2006).


The program of Mindfulness-Based Stress reduction (MBSR) is among the treatments, which have been studied in the past two decades on a variety of chronic pain. MBSR developed by Kabat-Zinn and used in a wide range of population with stress-related disorders and chronic pain (Kabat-Zinn, 1990). Especially in recent years, many studies have been conducted to examine the therapeutic effects of MBSR. Most studies have shown the significant effects of MBSR on different psychological conditions including the reduction of psychological symptoms of distress, anxiety, rumination, anxiety and depression (Bohlmeijer, Prenger, Taal, & Cuijpers, 2010; Carlson, Speca, Patel, & Goodey, 2003; Grossman, Niemann, Schmidt, & Walach, 2004; Jain et al., 2007; Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney, 1985; Kabat-Zinn et al., 1992; Teasdale et al., 2002), pain (Flugel et al., 2010; Kabat-Zinn, 1982; Kabat-Zinn et al., 1985; La Cour & Petersen, 2015; Rosenzweig et al., 2010; Zeidan, Gordon, Merchant, & Goolkasian, 2010) and quality of life (Brown & Ryan, 2003; Carlson et al., 2003; Flugel et al., 2010; Kabat-Zinn, 1982; La Cour & Petersen, 2015; Morgan, Ransford, Morgan, Driban, & Wang, 2013; Rosenzweig et al., 2010).


Bohlmeijer et al. (2010) conducted a meta-analysis of eight randomized controlled studies on the effects of MBSR program, concluded that MBSR has small effects on depression, anxiety and psychological distress in people with chronic medical diseases. Also Grossman et al. (2004) in a meta-analysis of 20 controlled and uncontrolled studies on the effects of the MBSR program on physical and mental health of medical and non-medical samples, found an effect size of moderate for controlled studies on mental health. No effect sizes for specific symptoms such as depression and anxiety were reported. The most recent review includes 16 studies controlled and uncontrolled, This review reports that MBSR intervention decrease pain intensity, and most controlled trial studies (6 of 8) show higher reductions in pain intensity for intervention group compared with control group (Reiner, Tibi, & Lipsitz, 2013).


In another study, researchers found significant effect sizes for some subscales of quality of life for example vitality scale and bodily pain, nonsignificant effect sizes for pain and significant medium to large size effects for lower general anxiety and depression (La Cour & Petersen, 2015). Also in a study by Rosenzweig et al. (2010) on patients with chronic pain including those suffering from migraine, there were significant differences in pain intensity, pain-related functional limitations between patients. However, those suffering from migraine experienced the lowest improvement in pain and different aspects of quality of life. In general, different groups of chronic pain showed significant improvements in pain intensity and pain-related functional limitations in this study. Two other studies were conducted by Kabat-Zinn and using MBSR methods for treating patients with chronic pain, including a number of patients with chronic headaches. Statistical analysis showed a significant reduction in pain, pain interference with daily activities, medical and psychiatric signs and symptoms, anxiety and depression, negative body image, pain interference with daily activities, use of the drug and also increase in confidence (Kabat-Zinn, 1982; Kabat-Zinn et al., 1985).


Due to pain and loss of function and reduced work productivity and increased use of health care, chronic headache impose costs on individual and society, it seems that the chronic headache is a major health problem and finding ways to control and treat this problem could be of great importance. The main objective of this study was to evaluate the effectiveness of MBSR in addition to conventional pharmacotherapy in a clinical population sample of patients with chronic headache to show the effectiveness of this technique as a method of pain management and enhancement of the quality of life in patients with chronic headaches.




Participants and Procedure


This is a randomized controlled trial two- group �pretest-posttest� study design. Also an approval was obtained from the Ethics Committee of Zahedan University of Medical Sciences. The participants selected through convenience sampling method from patients with chronic migraine and tension-type headache, diagnosed by a neurologist and a psychiatrist using IHS diagnostic criteria-referred to university hospitals of Zahedan University of Medical Sciences, Zahedan-Iran.


After evaluating each patient for meeting the inclusion and exclusion criteria and taking an initial interview, 40 out of eighty-seven primary patients with chronic headache were selected and randomly assigned into two equal groups of intervention and control. Both the control and intervention groups received common pharmacotherapy under the supervision of the neurologist. During therapy sessions three subjects, due to the lack of a regular presence or exclusion criteria, opted out or were excluded from the study.


Inclusion Criteria


  • (1) Informed consent to participate in the sessions.
  • (2) Minimum age of 18 years.
  • (3) Minimum educational qualification of middle-school degree.
  • (4) The diagnosis of chronic headache (primary chronic migraine and tension-type headache) by the neurologist and according to IHS diagnostic criteria.
  • (5) 15 or more days per month for more than 3 months and least six months history of migraines and tension-type headache


Exclusion Criteria


  • (1) Subjects who were not willing to continue the participation in the study or leave the study for any reason.
  • (2) Other chronic pain problems.
  • (3) Psychosis, delirium and cognitive disorders.
  • (4) Cases of interpersonal difficulties interfering with teamwork.
  • (5) Drug and substance abuse.
  • (6) Mood disorder


Intervention Groups


Therapy sessions (MBSR) were held for 1.5 to 2 hours a week for the members of the intervention group (drug plus MBSR); While no MBSR was performed for the control group (only common drugs used) until the end of the research. The MBSR was carried out for 8 weeks. In this study, the 8-session MBSR program (Chaskalon, 2011) has been used. To do the meditation homework while training participants in sessions, the necessary measures have been provided in a CD and a booklet. If any one of subjects did not participate in a session or sessions, at the beginning of the next session the therapist would provide written notes of the sessions to the subjects, in addition to repeat the previous session summaries. MBSR program and discussions were presented to the patients in the eight sessions including: understanding pain and its aetiology, discuss about relationship stress, anger and emotion with pain, Understanding negative automatic thoughts, identyfying thoughts and feelings, introducing the concept of Acceptance, breathing space, three-minute breathing space, breath focus exercise, pleasant and unpleasant events daily, behavioral activation, mindfulness of routine activity, body scan practice, Seeing and hearing exercise, sitting meditation, mindful walking, reading poems related to mindfulness and also discuss how to keep up what has been developed over the whole course, discuss plans and positive reasons for maintaining the practice. Patients also received information about learning how to detect any future relapses as well as strategies and plans on which to base early detection of symptom pain attacks and for being self-directed towards new situations.


Control Group


Patients who were randomized in the control group were continuing usual pharmacotherapy(including specific and nonspecific drugs) by their neurologist until the end of the research.




Two main tools were used in the pre-test and post-test to collect data, in addition to demographic data form. Headache log was used to determine the perceived intensity of pain using three parts: (1) 10-point likert-scale ratings, (2) the number of hours of pain per day and (3) pain frequency during the month. Each part is scored from 0 to 100, the highest level being 100. Since each patient rates their perceived pain intensity in the questionnaire, validity and reliability are not considered. And the other was a short-form 36 questionnaire (SF-36). The questionnaire is applicable in the various age groups and different diseases. The reliability and validity of the questionnaire was approved by Ware et al (Ware, Osinski, Dewey, & Gandek, 2000). The SF-36 assesses the perception of the quality of life in 8 subscales include: physical functioning (PF), role limitations due to physical health (RP), bodily pain (PB), general health (GH), energy and vitality (VT), social functioning (SF), role limitations due to emotional problems (RE) and affect health (AH). The tool has also two summary scales for Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Each scale is scored from 0 to 100, the highest functional status level being 100. The validity and reliability of the SF-36 were examined in an Iranian population. Internal consistency coefficients were between 0.70 and 0.85 for the 8 subscales and test-retest coefficients were between 0.49 and 0.79 with an interval of one week (Montazeri, Goshtasebi, Vahdaninia, & Gandek, 2005).


Data Analysis


For analyzing the data, in addition to the use of descriptive indicators, to compare the results of the intervention and control groups, the analysis of covariance was used to determine the effectiveness and the removal of the pre-test results at 95% confidence level.




During therapy sessions three subjects, due to the lack of a regular presence or exclusion criteria, opted out or were excluded from the study. Thirty-seven out of 40 patients completed current study and the gathered data were then analyzed.




Analysis for comparison of demographic distribution between the two groups was performed using chi-square and independent t-test. Demographic data of both groups are shown in Table 1. Distribution of age, educational years, gender and marital status were the same in each group.


Table 1 Demographic Characteristics of Participants

Table 1: Demographic characteristics of participants.


Table 2 shows the results of analysis of covariance (ANCOVA). Levene�s test was non-significant, F (1, 35) = 2.78, P = 0.105, indicating that the assumption of homogeneity of variance had been approved. This finding shows that the variances across groups are equal and no difference was observed between two groups.


Table 2 The Results of Covarice Analysis

Table 2: The results of covariance analysis for the effectiveness of MBSR on pain intensity.


The main effect of MBSR intervention was significant, F (1, 34) = 30.68, P = 0.001, partial ?2 = 0.47, indicating that the pain intensity was lower after MBSR intervention (Mean = 53.89, SD.E = 2.40) than control group (Mean = 71.94, SD.E = 2.20). The covariate (pre-test of pain) was also significant, F (1, 34) = 73.41, P = 0.001, partial ?2 = 0.68, indicating that level of pain intensity before MBSR intervention had a significant effect on level of pain intensity. In other words, there was a positive relationship in the pain scores between pre-test and post-test. Therefore, the first research hypothesis is confirmed and MBSR treatment on perceived intensity was effective in patients with chronic headache and could reduce the intensity of perceived pain in these patients. All significant values are reported at p<0.05.


The second hypothesis of this study is the effectiveness of MBSR technique on quality of life in patients with chronic headache. To evaluate the effectiveness of MBSR technique on quality of life in patients with chronic headaches and eliminating the confounding variables and the effect of pre-test, for the analysis of data, multivariate covariance analysis (MANCOVA) of the dimensions of quality of life is used that Table 3 shows the results of analysis in the intervention group.


Table 3 The Results of Covariance Analysis

Table 3: The results of covariance analysis for the effectiveness of MBSR on quality of life.


The Table 3 shows the results of analysis of covariance (MANCOVA). The following information is needed to understand the results presented in Table 3.


The box�s test was non- significant, F = 1.08, P = 0.320, indicating that the variance�covariance matrices are the same in two groups and therefore the assumption of homogeneity is met. Also F (10, 16) = 3.153, P = 0.020, Wilks� Lambda = 0.33, partial ?2 = 0.66, indicating was a significant difference between the pre-test of the groups in the dependent variables.


Levene�s test was non-significant in some of dependent variables including [PF: F (1, 35) = 3.19, P = 0.083; RF: F (1, 35) = 1.92, P = 0.174; BP: F (1, 35) = 0.784, P = 0.382; GH: F (1, 35) = 0.659, P = 0.422; PCS: F (1, 35) = 2.371, P = 0.133; VT: F (1, 35) = 4.52, P = 0.141; AH: F (1, 35) = 1.03, P = 0.318], indicating that the assumption of homogeneity of variance had been approved in subscales of quality of life and Levene�s test was significant in some of dependent variables including [RE: F (1, 35) = 4.27, P = 0.046; SF: F (1, 35) = 4.82, P = 0.035; MCS: F (1, 35) = 11.69, P = 0.002], showing that the assumption of homogeneity of variance had been broken in subscales of quality of life.


The main effect of MBSR intervention was significant for some of dependent variables including [RP: F (1, 25) = 5.67, P = 0.025, partial ?2 = 0.18; BP: F (1, 25) = 12.62, P = 0.002, partial ?2 = 0.34; GH: F (1, 25) = 9.44, P = 0.005, partial ?2 = 0.28; PCS: F (1, 25) = 9.80, P = 0.004, partial ?2 = 0.28; VT: F (1, 25) = 12.60, P = 0.002, partial ?2 = 0.34; AH: F (1, 25) = 39.85, P = 0.001, partial ?2 = 0.61; MCS: F (1, 25) = 12.49, P = 0.002, partial ?2 = 0.33], these results indicating that subscales of RP, BP, GH, PCS, VT, AH, and MCS were higher after MBSR intervention [RP: Mean = 61.62, SD.E = 6.18; BP: Mean = 48.97, SD.E = 2.98; GH: Mean = 48.77, SD.E = 2.85; PCS: Mean = 58.52, SD.E = 2.72; VT: Mean = 44.99, SD.E = 2.81; AH: Mean = 52.60, SD.E = 1.97; MCS: Mean = 44.82, SD.E = 2.43] than control group [RP: Mean = 40.24, SD.E = 5.62; BP: Mean = 33.58, SD.E = 2.71; GH: Mean = 36.05, SD.E = 2.59; PCS: Mean = 46.13, SD.E = 2.48; VT: Mean = 30.50, SD.E = 2.56; AH: Mean = 34.49, SD.E = 1.80; MCS: Mean = 32.32, SD.E = 2.21].


Nonetheless, the main effect of MBSR intervention was non-significant for some of dependent variables including [PF: F (1, 25) = 1.05, P = 0.314, partial ?2 = 0.04; RE: F (1, 25) = 1.74, P = 0.199, partial ?2 = 0.06; SF: F (1, 25) = 2.35, P = 0.138, partial ?2 = 0.09]. These results indicating, although the means in these subscales of quality of life were higher [PF: Mean = 75.43, SD.E = 1.54; RE: Mean = 29.65, SD.E = 6.02; SF: Mean = 51.96, SD.E = 2.63] than the control group [PF: Mean = 73.43, SD.E = 1.40; RE: Mean = 18.08, SD.E = 5.48; SF: Mean = 46.09, SD.E = 2.40], But Mean difference was non-significant.


In summary, Covariance analysis (MANCOVA) results in Table 3 indicate a statistically significant difference in the scores of subscales of role limitation due to physical health (RP), bodily pain (BP), general health (GH), energy and vitality (VT), Affect health (AH) and sum of physical health dimensions (PCS) and mental health (MCS). And also indicates that there was not a statistically significant difference in subscale scores of physical functioning (PF), role limitations due to emotional problems (RE) and social functioning (SF) in the intervention group. All significant values are reported at p<0.05.




This study aimed to evaluate the effectiveness of MBSR on perceived pain intensity and quality of life in patients with chronic headache. The results showed that MBSR treatment was significantly effective on reduction of pain intensity perception. The results of current study are consistent with the results of other researchers who had used the same method for chronic pain (e.g. Flugel et al., 2010; Kabat-Zinn, 1982; Kabat-Zinn et al., 1985; La Cour & Petersen, 2015; Reibel, Greeson, Brainard, & Rosenzweig, 2001; Reiner et al., 2013; Rosenzweig et al., 2010; zeidan et al., 2010). For example, in two studies conducted by Kabat-Zinn, where the MBSR program was used for treating patients with chronic pain by physicians, a number of patients with chronic headache were also included. The first study of the two studies, showed a significant reduction in pain, pain interference with daily activities, medical signs and psychiatric disorders, including anxiety and depression (Kabat-Zinn, 1982). The results of second study showed significant reduction in pain, negative body image, anxiety, depression, pain interference with daily activities, medical symptoms, medication use, and also showed an increase in self-confidence (Kabat-Zinn et al., 1985).


Also, the findings of the current study are consistent with the results of Rosenzweig et al. (2010), their results suggest that MBSR program is effective for reduction, physical pain, quality of life and psychological well-being of patients with various chronic pains and mindfulness is effective on emotional and sensory components of pain perception by self-regulation of attention through meditation activities. Although the results of Rosenzweig et al. (2010) showed that among patients with chronic pain the minimal impact on the reduction in bodily pain and improvement in quality of life was related to patients with fibromyalgia, chronic headache. In another study conducted by Flugel et al. (2010), although positive changes were observed in the frequency and the intensity of pain, the pain reduction was not statistically significant.


In another study, pain severity significantly reduced after the intervention in patients with tension headache. In addition, the MBSR group showed higher scores in mindful awareness in comparison with the control group (Omidi & Zargar, 2014). In a pilot study by Wells et al. (2014), their results showed that MBSR with pharmacological treatment was possible for patients with migraines. Although the small sample size of this pilot study did not provide power to detect a significant difference in the pain severity and migraine frequency, results demonstrated this intervention had a beneficial effect on headache duration, disability, self-efficacy.


In explaining the results of the effectiveness of mindfulness based therapies for pain it can be said, psychological models of chronic pain such as fear-avoidance model showed that the ways by which people interpret their feelings of pain and respond to them are important determinants in the experience of pain (Schutze, Rees, Preece, & Schutze, 2010). Pain catastrophizing is significantly associated with fear and anxiety caused by pain, the cognitive paths through which the fear of pain can be caused and also the pain-related disability is associated and also because the negative cognitive assessment of pain explains 7 to 31% of the variance of the pain intensity. Therefore, any mechanism that can reduce pain catastrophizing or make changes in its process can reduce the perception of pain intensity and the disability caused by that. Schutz et al. (2010) argue that the little mindfulness is the primer of pain catastrophizing. In fact, it seems that the tendency of the individual to engage in the automatic processing processes rather than knowledge-based processes with attention of insufficient flexibility, and lack of awareness of the present moment (Kabat-Zinn, 1990), will cause people to think more about the pain and thus overestimate the resulting risk of it. Thus, little mindfulness allows for the development of negative cognitive evaluation of the pain (Kabat-Zinn, 1990).


Another possible reason may be that the pain acceptance and readiness for change increase positive emotions, leading to a reduction in pain intensity through effects on the endocrine system and the production of endogenous opioids and reduction in pain-related disability or preparing individuals for the use of effective strategies to deal with pain (Kratz, Davis, & Zautra, 2007). Another possible reason to explain the results of the present study in its effectiveness on pain reduction can be the fact that chronic pain is developed due to an overactive stress response system (Chrousos & Gold, 1992). The result is the disturbing of the physical and mental processes. Mindfulness can allow for the access to the frontal cortex and improve it, brain areas that integrate physical and mental functions (Shapiro et al., 1995). The result is the creation of a little stimulation that reduces the intensity and the experience of physical and mental pain. Thus, pain impulses are experienced as feeling of the real pain rather than a negative recognition. The result is the closing of the pain channels that can reduce pain (Astin, 2004).


Mindfulness meditation Reduces Pain Through several Brain Mechanisms and various pathways such as changing of attention in meditation practices might impress both sensory and affective components of pain perception. On the other hand, mindfulness reduces the reactivity to distressing thoughts and feelings that accompany pain perception and strengthen the pain. Also, mindfulness reduces psychological symptoms such as comorbid anxiety and depression and increases parasympathetic activity, which can promote deep muscle relaxation that may reduce pain. Finally, mindfulness may decrease stress and mood dysfunction-related psychophysiologic activation by strengthening reframing negative situation and self-regulation skills. Higher level of mindfulness predicted lower levels of anxiety, depression, catastrophic thinking and disability. Other research has showed that mindfulness has an important role in cognitive and emotional control, and may be useful in reframing negative situations (Zeidan et al., 2011; Zeidan, Grant, Brown, McHaffie, & Coghill, 2012).


The second aim of this study was to determine the effectiveness of the MBSR program on quality of life in patients with chronic headache. This study showed that this treatment was significantly effective on quality of life dimensions, including role limitations due to health status, bodily pain, general health, energy and vitality, emotional health and overall physical and mental health scales. However, the MBSR program could not significantly increase the quality of life in physical functioning, role limitations due to emotional problems and social functioning. It seems apparent from previous and current studies and as well as from the present study that MBSR no effect on physical and social functions. This is likely because that the effects on pain levels in patients with headache are small, and that change is slow. On the other hand, patients with chronic pain have often learned to ignore pain in order to function normally (La Cour & Petersen, 2015). Although, the changes have been in the desired direction and increased the mean scores of the intervention group compared with the control group. These findings are consistent with previous findings (Brown & Ryan, 2003; Carlson et al., 2003; Flugel et al., 2010; Kabat-Zinn, 1982; La Cour & Petersen, 2015; Morgan et al., 2013; Reibel et al., 2001; Rosenzweig et al., 2010).


With regard to the content of the MBSR sessions, this program emphasizes the application of techniques to reduce stress, deal with pain and the awareness of the situation. Giving up the fight and accepting the present situation, without judgment, is the main concept of the program (Flugel et al., 2010). In fact, changes in acceptance without judgment are associated with improvement in quality of life (Rosenzweig et al., 2010). MBSR is aimed to increase awareness of the present moment. The treatment plan is a new and personal way to deal with stress to the individual. External stressors are part of life and cannot be changed, but coping skills and how to respond to the stress can be changed (Flugel et al., 2010). McCracken and velleman (2010) showed that cognitive flexibility and higher mindfulness is associated with less suffering and disability in patients. Patients with chronic pain with higher levels of mindfulness reported less depression, stress, anxiety and pain and also improvement in the self-efficacy and quality of life. Morgan et al. (2013) studying arthritis patients achieved similar results, so that patients with higher levels of mindfulness reported lower stress, depression and higher self-efficacy and quality of life. As noted above it was expected that pain reduction in patients leads to reduced fear and anxiety associated with pain and thereby reduces the resulting functioning limitations. Also, the results of the several studies (Cho, Heiby, McCracken, Lee, & Moon, 2010; McCracken, Gauntlett-Gilbert, & Vowles, 2007; Rosenzweig et al., 2010; Schutz et al., 2010) confirm this finding.


Several studies have been done to evaluate the effectiveness of different types of mindfulness-based treatments on chronic pain, including patients with headache. Unlike other research that examined heterogeneous sets of patients with chronic pain, the advantage of this study is that, it has been only performed on patients with chronic headache.


In the end, it should be acknowledged that there are some limitations in this study such as small sample size, lack of a long-term follow-up program, participants� medication use and arbitrary treatments; and despite the efforts of researchers, the lack of fully similar pharmacotherapy for all participants can confound the test results and make it difficult to generalize the results. Since the present study is the first of its type in patients with chronic headache in Iran, it is suggested that similar studies should be carry out in this field, with larger sample sizes as possible. And further studies investigate the stability of the treatment results in long-term follow-up periods of time.




According to the findings of this study it can be concluded that MBSR methods generally are effective on perceived pain intensity and quality of life of patients with chronic headache. Although there was no statistically significant difference in some aspects of quality of life, such as physical functioning, role limitations due to emotional problems and social functioning, but overall changes in mean were desired to the study. Thus the integrating of MBSR treatment with conventional medical therapy in the treatment protocol for patients with chronic headache can be advised. The researcher also believes that despite the shortcomings and deficiencies of current research, this study could be a new approach to the treatment of chronic headache and could provide a new horizon in this field of treatment.




This research was supported (as a thesis) in part by Zahedan University of Medical Sciences. We would like to thank all participants in the study, local healers, the staff of hospitals- Ali -ebn-abitaleb, Khatam-al-anbia and Ali asghar- for their support and help.


In conclusion,�chiropractic care is a safe and effective alternative treatment option utilized to help improve as well as manage chronic headache symptoms by carefully and gently realigning the spine as well as providing stress management methods and techniques. Because stress has been associated with a variety of health issues, including subluxation, or misalignment of the spine, and chronic headache, mindfulness interventions like chiropractic care and mindfulness-based stress reduction (MBSR) are fundamental towards chronic headache. Finally, the article above demonstrated that MBSR can be effectively used as a mindfulness intervention for chronic headache and to improve overall health and wellness. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .


Curated by Dr. Alex Jimenez




Additional Topics: Back Pain


According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.


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EXTRA IMPORTANT TOPIC: Managing Workplace Stress



MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor



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Mindfulness for Headache and Cervical Disc Herniation in El Paso, TX

Mindfulness for Headache and Cervical Disc Herniation in El Paso, TX

Stress is a result of the human body’s “fight or flight” response, a prehistoric defense mechanism triggered by the sympathetic nervous system (SNS). Stress is an essential component of survival. When stressors activate the fight or flight response, a mixture of chemicals and hormones are secreted into the blood flow, which prepare the body for perceived danger. Although short-term stress is helpful, however, long-term stress can lead to a variety of health issues. Furthermore, stressors in modern society have changed and it’s become more difficult for people to manage their stress and maintain mindfulness.


How Does Stress Affect the Body?


Stress can be experienced through three different channels: emotion; body and environment. Emotional stress involves adverse situations which affect our mind and decision making. Bodily stress includes improper nutrition and a lack of sleep. And finally, environmental stress occurs based on external experiences. When you experience any of these types of stressors, the sympathetic nervous system will trigger the “fight or flight” response, releasing adrenaline and cortisol to increase heart rate and heighten our senses to make us more alert in order to face the situation ahead of us.


However, if perceived stressors are always present, the SNS’s fight or flight response can remain active. Chronic stress can then lead to a variety of health issues, such as anxiety, depression, muscle tension, neck and back pain, digestive problems, weight gain and sleep problems as well as impaired memory and concentration. In addition, muscle tension along the spine due to stress can cause a spinal misalignment, or subluxation, which may in turn lead to disc herniation.


Headache and Disc Herniation from Stress


A herniated disc occurs when the soft, gel-like center of an intervertebral disc pushes through a tear in its outer, cartilage ring, irritating and compressing the spinal cord and/or the nerve roots. Disc herniation commonly occurs in the cervical spine, or neck, and in the lumbar spine, or low back. Symptoms of herniated discs depend on the location of the compression along the spine. Neck pain and back pain accompanied by numbness, tingling sensations and weakness along the upper and lower extremities are some of the most common symptoms associated with disc herniation. Headache and migraine are also common symptoms associated with stress and herniated discs along the cervical spine, as a result of muscle tension and spinal misalignment.


Mindfulness Interventions for Stress Management


Stress management is essential towards improving as well as maintaining overall health and wellness. According to research studies, mindfulness interventions, such as chiropractic care and mindfulness-based stress reduction (MBSR), among others, can safely and effectively help reduce stress. Chiropractic care utilizes spinal adjustments and manual manipulations to carefully restore the original alignment of the spine, relieving pain and discomfort as well as easing muscle tension. Additionally, a chiropractor may include lifestyle modifications to help further improve symptoms of stress.�A balanced spine can help the nervous system respond to stress more effectively. MBSR can also help reduce stress, anxiety and depression.


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If you are experiencing symptoms of stress with headache or migraine as well as neck and back pain associated with disc herniation, mindfulness interventions such as chiropractic care can be a safe and effective treatment for your stress. Dr. Alex Jimenez’s stress management services can help you achieve overall health and wellness. Seeking the proper mindfulness interventions can get you the relief you deserve. The purpose of the following article is to demonstrate the effects of mindfulness-based stress reduction in patients with tension headache. Don’t just treat the symptoms, get to the source of the issue.


Effects of Mindfulness-Based Stress Reduction on Perceived Stress and Psychological Health in Patients with Tension Headache




Background: Programs for improving health status of patients with illness related to pain, such as headache, are often still in their infancy. Mindfulness-based stress reduction (MBSR) is a new psychotherapy that appears to be effective in treating chronic pain and stress. This study evaluated efficacy of MBSR in treatment of perceived stress and mental health of client who has tension headache.


Materials and Methods: This study is a randomized clinical trial. Sixty patients with tension type headache according to the International Headache Classification Subcommittee were randomly assigned to the Treatment As Usual (TAU) group or experimental group (MBSR). The MBSR group received eight weekly classmates with 12-min sessions. The sessions were based on MBSR protocol. The Brief Symptom Inventory (BSI) and Perceived Stress Scale (PSS) were administered in the pre- and posttreatment period and at 3 months follow-up for both the groups.


Results: The mean of total score of the BSI (global severity index; GSI) in MBSR group was 1.63 � 0.56 before the intervention that was significantly reduced to 0.73 � 0.46 and 0.93 � 0.34 after the intervention and at the follow-up sessions, respectively (P < 0.001). In addition, the MBSR group showed lower scores in perceived stress in comparison with the control group at posttest evaluation. The mean of perceived stress before the intervention was 16.96 � 2.53 and was changed to 12.7 � 2.69 and 13.5 � 2.33 after the intervention and at the follow-up sessions, respectively (P < 0.001). On the other hand, the mean of GSI in the TAU group was 1.77 � 0.50 at pretest that was significantly reduced to 1.59 � 0.52 and 1.78 � 0.47 at posttest and follow-up, respectively (P < 0.001). Also, the mean of perceived stress in the TAU group at pretest was 15.9 � 2.86 and that was changed to 16.13 � 2.44 and 15.76 � 2.22 at posttest and follow-up, respectively (P < 0.001).


Conclusion: MBSR could reduce stress and improve general mental health in patients with tension headache.


Keywords: Mental health, tension headache, mindfulness-based stress reduction (MBSR), perceived stress, treatment as usual (TAU)


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Dr. Alex Jimenez’s Insight

Chiropractic care is an effective stress management treatment because it focuses on the spine, which is the base of the nervous system. Chiropractic utilizes spinal adjustments and manual manipulations to carefully restore the alignment of the spine in order to allow the body to naturally heal itself. A spinal misalignment, or subluxation, can create muscle tension along the spine and lead to a variety of health issues, including headache and migraine, as well as disc herniation and sciatica. Chiropractic care can also include lifestyle modifications, such as nutritional advice and exercise recommendations, to further enhance its effects. Mindfulness-based stress reduction can also effectively help with stress management and symptoms.




Tension headache constitutes 90% of total headaches. About 3% of the population are suffering from chronic tension headache.[1] Tension headaches are often associated with lower quality of life and high levels of psychological discomforts.[2] In recent years, several meta-analyses evaluating the established pain treatments used today have shown that medical treatments, which may be effective in acute pain, are not effective with chronic pain and may, in fact, be causing further problems. Most of the pain treatments are designed for and useful for acute pain but if used in the long run may create more problems such as substance abuse and avoidance of important activities.[3] A common element in most of the pain treatments is that they emphasize on either avoiding pain or fighting to reduce pain. The pain in tension headache can be intolerable. Painkillers and pain management strategies can increase intolerance and sensitivity to pain. Therefore, the treatments that increase acceptance and tolerance to pain, especially chronic pain, are effective. Mindfulness-based stress reduction (MBSR) is a new psychotherapy that appears to be effective in improving physical performance and psychological well-being in patients with chronic pain.[4,5,6,7,8] In the past two decades, Kabat-Zinn et al. in the US successfully used mindfulness for the relief of pain and illness related to pain.[9] Recent studies on acceptance-based methods, such as mindfulness, show improved performance in patients with chronic pain. Mindfulness modulates the pain using nonelaborative awareness of thoughts, feelings and sensations, and an emotionally distanced relationship with internal and external experience.[10] Studies found that MBSR program can significantly alleviate medical illness related to chronic pains such as fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, chronic low back pain, and multiple sclerosis.[7,11,12,13] MBSR has significant changes in pain intensity, anxiety, depression, somatic complaints, well-being, adaptation, quality of sleep, fatigue, and physical functioning.[6,14,15,16,17] But the programs for improving health status of patients with illness related to pain, such as tension headache, are often still in their infancy. Therefore, the study was conducted to assess the effects of MBSR on perceived stress and general mental health in patients with tension headache.


Materials and Methods


This randomized controlled clinical trial was performed in 2012 in Shahid Beheshti Hospital in Kashan City. The Research Ethics Committee of the Kashan University of Medical Sciences approved this study (IRCT No: 2014061618106N1). The participants of the study included adults with tension headache who were referred by the psychiatrists and neurologists in Kashan. The inclusion criteria were as follows: Having tension headache according to the International Headache Classification Subcommittee, willing to participate in the study, not having a medical diagnosis of organic brain disorder or psychotic disorder, and not having a history of psychological treatment during the preceding 6 months. The patients who did not complete the intervention and missed more than two sessions were excluded from the study. The participants, who signed an informed consent form, completed the measures as a pretest. For estimating the sample size, we referred to another study in which changes in mean of scores of fatigue was 62 � 9.5 in the pretreatment period and 54.5 � 11.5 in the posttreatment period.[18] Then, by utilizing the sample size calculation, 33 participants (with attrition risk) in each group with ? = 0.95 and 1 � ? = 0.9 were segregated. After sample size calculation, 66 patients with tension headache were selected via convenient sampling according to the inclusion criteria. Then, the patients were called and invited to participate in the study. If a patient agreed to participate, then he/she was invited to attend the study-briefing session and if not another patient was selected similarly. Then using a random number table, they were assigned either to the experimental group (MBSR) or to the control group that treated as usual. Finally, 3 patients were excluded from each group and 60 patients were included (30 patients in each group). The TAU group was treated only by antidepressant medication and clinical management. The MBSR group received MBSR training in addition to TAU. The patients in MBSR group were trained for 8 weeks by a clinical psychologist with PhD degree. The Brief Symptom Inventory (BSI) and Perceived Stress Scale (PSS) were administered before the first treatment session in the MBSR group, after the eighth session (posttest), and 3 months after the test (follow-up) in both groups. The TAU group was invited to Shahid Beheshti Hospital to fill out the questionnaires. Figure 1 shows a Consolidated Standards of Reporting Trials (CONSORT) diagram depicting the flow of study participants.


Figure 1 CONSORT Diagram Depicting Flow of Study Participants

Figure 1: CONSORT diagram depicting flow of study participants.




The intervention group (MBSR) was trained in Shahid Beheshti Hospital. The eight weekly sessions (120 min) were held according to the standard MBSR protocol as developed by Kabat-Zinn.[11] Additional sessions were held for the participants who had missed one or two sessions. At the end of the training and 3 months later (follow-up), both MBSR and TAU groups were invited to Shahid Beheshti Hospital (the place of MBSR trial) and were instructed to complete the questionnaires. During the MBSR sessions, the participants were trained to be aware of their thoughts, feelings, and physical sensations nonjudgmentally. Mindfulness exercises are taught as two forms of meditation practices � formal and informal. Formal type exercises include trained sitting meditation, body scan, and mindful yoga. In informal meditation, attention and awareness are focused not only on daily activities, but also on thoughts, feelings, and physical sensation even they are problematic and painful. The overall content of the sessions were mentioned in Table 1.


Table 1 Agendas for Sessions of MBSR

Table 1: Agendas for sessions of mindfulness-based stress reduction.


Measurement Tools


International Headache Classification Subcommittee Diary Scale for Headache


Headache was measured by diary scale for headache.[19] The patients were asked to record the pain severity diary on a 0-10 rating scale. Absence of pain and the most intense disabling headache were characterized by 0 and 10, respectively. The mean of headache severity in a week was calculated by dividing the sum of the severity scores by 7. Moreover, the mean of headache severity in a month was calculated by dividing the sum of the severity scores by 30. The minimum and maximum scores of headache severity were 0 and 10, respectively. Headache diary was given to five patients and a neurologist and a psychiatrist confirmed the content validity of the instrument.[20] The reliability coefficient of Persian version of this scale was calculated as 0.88.[20]


Brief symptom Inventory (BSI)


Psychological symptoms were assessed with the BSI.[21] The inventory consist 53 items and 9 subscales that assess psychological symptoms. Each item scores between 0 and 4 (for example: I have nausea or upset in my stomach). BSI has a global severity index (GSI) achieved a total score of 53 items. The reliability of the test has reported a score of 0.89.[22] In our study, GSI test�retest estimate was .90 based on a sample of 60 patients with tension headache who completed the BSI.


Perceived Stress Scale (PSS)


Perceived stress was assessed using the PSS,[21,23] a 10-item scale that assesses the degree of uncontrollable and unpredictable situations of life during the past month (for example: Felt that you were unable to control the important things in your life?). Respondents report the prevalence of an item within the last month on a 5-point scale, ranging from 0 (never) to 4 (very often). Scoring is completed by reverse scoring of four positively worded items[4,5,7,8] and summing all item scores. The scale scores range from 0-40. Higher scores indicate higher levels of stress. It assumes that people depending on their coping resources evaluate level of threatening or challenging events. A higher score indicates a greater degree of perceived stress. Adequate test�retest reliability and convergent and discriminate validity have also been reported.[19] In our study, Cronbach’s alpha coefficients for assessing internal consistency of this scale were calculated to be 0.88.


The repeated measures analysis of variance was performed to compare the MBSR and TAU groups on measures of perceived stress and GSI at pretreatment, posttreatment, and 3-month follow-up. Also, Chi-square test was used to compare the demographics in the two groups. P value less than 0.05 was considered significant in all tests.




Among 66 subjects, 2 participants from the MBSR group were excluded because of missing more than 2 sessions. Also, three participants were excluded because of did not complete the questionnaires in post-test or follow-up who one of them were from MBSR group and three participants from TAU group. Table 2 showed demographic characteristics of the subjects and results of the randomization check. The results of t-test for differences between the MBSR and TAU groups in age variable and Chi-square test in other variables showed that there was no significant difference between demographic variables in two groups and the subjects were randomly assigned to two groups.


Table 2 Demographic Characteristics of the Subjects

Table 2: Demographic characteristics of the subjects a,b.


Table 3 provides the mean scores and standard deviations of the dependent variables (perceived stress and GSI) and comparison of outcome measures at pretreatment period, post-treatment period, and 3-month follow-up.


Table 3 Means, Standard Deviations and Comparison of Outcome Measures

Table 3: Means, standard deviations, and comparison of outcome measures at pretreatment, posttreatment, and follow-up stages in the MBSR and TAU groups a,b.


Table 3 shows the more reduction in received stress and GSI in the intervention group (MBSR) compared to TAU group, while the reduction in received stress and GSI were not observed in the TAU group. The results revealed the significant effect of time and interaction between time and type of treatment on the changes of scores (P < 0.001).


Figures ?2 and ?3 present mean received stress and GSI scores for MBSR and TAU groups at posttest and follow-up stages.


Figure 2 CONSORT Diagram Depicting Flow of Study Participants

Figure 2: CONSORT diagram depicting flow of study participants.


Figure 3 Mean of Perceived Stress in MBSR and Control Groups

Figure 3: Mean of perceived stress in MBSR and control groups in pretest, posttest, and follow-up.




This study compared efficacy of MBSR and Treatment As Usual (TAU) in perceived stress and mental health of patients with tension headache. Although MBSR is recognized as an effective treatment for stress symptoms and pain, there is a need to examine its efficacy for the treatment of mental health problems in patients with tension headache, which is one of the common complaints in the population.


The findings of our study demonstrate enhanced general mental health in the GSI index of BSI. In some study, significant improvements by MBSR intervention were reported on all indexes of the 36-item Short Form Health Survey (SF-36).[20,24] Studies showed significant reduction in psychological problems in the Symptom Checklist-90-Revised (SCL-90-R) subscale such as anxiety and depression by MBSR after intervention and 1-year follow-up.[5] Reibel et al. showed MBSR in patients with chronic pain reported a decrease in medical symptoms such as anxiety, depression, and pain.[5] It has been shown that tension headache and anxiety are accompanied with deficits in controlled cognitive processing such as sustained attention and working memory.[25] Negative emotions may amplify suffering associated with pain perception.


MBSR implements the following mechanisms to improve the patient’s mental status: First, mindfulness leads to increased awareness for what is happening in each moment, with an accepting attitude, without getting caught up in habitual thoughts, emotions, and behavior patterns. The increased awareness then gives rise to new ways to respond and cope in relation to oneself and the world around.[3] Mindfulness establishes a sense of self that is greater than one’s thoughts, feelings, and bodily sensation such as pain. Mindfulness exercises, learned clients develop an �observer�self�. With this ability, they can observe their thoughts and feelings in a nonreactive and nonjudgmental way that previously avoided, that previously avoided thoughts and feelings be observed in a nonreactive and nonjudgmental way. The clients learn to notice thoughts without necessarily acting on them, being controlled by them, or believing them.[3]


Second, mindfulness helps the client develop persistence in taking steps in valued directions that are important to them. Most clients with chronic pain want to become pain free rather than living the vital lives of their choice. But the MBSR program trained them to engage in valued action despite the the pain. Studies have shown attention and emotional reaction to pain has an important role in becoming persistent the pain.[26] Emotional and cognitive components can modulate attention to pain and worry about it that could intensify pain and disrupt the patients activities.[27,28]


Third, findings from some studies indicate that MBSR can alter the function of the brain that is responsible for affect regulation and the areas that govern how we react to stressful impulses, and this in turn may normalize body functions such as breathing, heart rate, and immune function.[29,30] Mindfulness practice reduces reactivity to distressing thoughts and feelings that comorbid and strengthen pain perception.[31] Also mindfulness may lessen psychophysiological activation related to stress and mood dysfunction by strengthening positive reappraisal and emotion regulation skills.[32]


The strength of this study is the use of a new effective psychotherapy in reducing the stress on a complaint that is less studied, but it is a common medical problem. The implications of our study are using a simple psychotherapy that does not make too much cognitive demand and is readily usable as a coping skill for the patient with tension headache. Therefore, the health-care professionals related to this complaint and the patient will be able to use this treatment. Also, MBSR will change the patient’s lifestyle who would be exacerbated by his/her problem. The main limitation of this study was the lack of comparison between MBSR and the gold standard psychotherapies such as cognitive behavior therapy (CBT). It is suggested that future studies need to compare the efficacy of MBSR and other traditional and newer cognitive behavioral therapies in patients with tension headache.




Our study supports the hypothesis that patients suffering from tension headache can enhance their general mental health by participating in the MBSR program. In summary, the results of the present study suggest that MBSR can reduce pain-related anxiety and interference in daily activities in the short term. The unique features of mindfulness exercises are easy training and no need to complex cognitive abilities.


Financial support and sponsorship: Nil.


Conflicts of interest: There are no conflicts of interest.


Author’s Contribution


AO contributed in the conception of the work, conducting the study, and agreed for all aspects of the work. FZ contributed in the conception of the work, revising the draft, approval of the final version of the manuscript and agreed for all aspects of the work.




Authors are grateful to the staff of Shahid Beheshti Hospital and participants. Authors also express their gratitude to Kabat-Zinn from the Center for Mindfulness (CFM) at the University of Massachusetts who graciously provided electronic copies of the MBSR guidelines.


In conclusion,�while short-term stress is helpful, long-term stress can eventually lead to a variety of health issues, including anxiety and depression as well as neck and back pain, headache and disc herniation. Fortunately, mindfulness interventions, such as chiropractic care and mindfulness-based stress reduction (MBSR) are safe and effective stress management alternative treatment options. Finally, the article above demonstrated evidence-based results that MBSR could reduce stress and improve general mental health in patients with tension headache. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .


Curated by Dr. Alex Jimenez




Additional Topics: Back Pain


According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.


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EXTRA IMPORTANT TOPIC: Managing Workplace Stress



MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor


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Cognitive-Behavioral Therapy for Auto Accident Injuries in El Paso, TX

Cognitive-Behavioral Therapy for Auto Accident Injuries in El Paso, TX

Being involved in an automobile accident is an undesirable situation which can result in a variety of physical trauma or injury as well as lead to the development of a number of aggravating conditions. Auto accident injuries, such as whiplash, can be characterized by painful symptoms, including chronic neck pain, however, recent research studies have found that emotional distress resulting from an auto collision could manifest into physical symptoms. Stress, anxiety, depression and post traumatic stress disorder, or PTSD, are common psychological issues which may occur as a result of an automobile accident.


The researchers of the research studies also determined that cognitive-behavioral therapy may be an effective treatment for emotional distress and psychological issues which may have developed as a result of the auto accident injuries. Additionally, auto accident injuries may also cause stress, anxiety, depression and even PTSD if left untreated for an extended amount of time. The purpose of the article below is to demonstrate the effects of cognitive-behavioral therapy, together with alternative treatment options like chiropractic care and physical therapy. for auto accident injuries, such as whiplash.


Neck Exercises, Physical and Cognitive Behavioural-Graded Activity as a Treatment for Adult Whiplash Patients with Chronic Neck Pain: Design of a Randomised Controlled Trial






Many patients suffer from chronic neck pain following a whiplash injury. A combination of cognitive, behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders. The objective is to present the design of a randomised controlled trial (RCT) aimed at evaluating the effectiveness of a combined individual physical and cognitive behavioural-graded activity program on self-reported general physical function, in addition to neck function, pain, disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline.




The design is a two-centre, RCT-study with a parallel group design. Included are whiplash patients with chronic neck pain for more than 6 months, recruited from physiotherapy clinics and an out-patient hospital department in Denmark. Patients will be randomised to either a pain management (control) group or a combined pain management and training (intervention)group. The control group will receive four educational sessions on pain management, whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months, including guidance in specific neck exercises and an aerobic training programme. Patients and physiotherapists are aware of the allocation and the treatment, while outcome assessors and data analysts are blinded. The primary outcome measures will be Medical Outcomes Study Short Form 36 (SF36), Physical Component Summary (PCS). Secondary outcomes will be Global Perceived Effect (-5 to +5), Neck Disability Index (0-50), Patient Specific Functioning Scale (0-10), numeric rating scale for pain bothersomeness (0-10), SF-36 Mental Component Summary (MCS), TAMPA scale of Kinesiophobia (17-68), Impact of Event Scale (0-45), EuroQol (0-1), craniocervical flexion test (22 mmHg – 30 mmHg), joint position error test and cervical range of movement. The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a standard deviation of 10.




The perspectives of this study are discussed, in addition to the strengths and weaknesses.


Trial registration


The study is registered in identifier NCT01431261.




The Danish National Board of Health estimates that 5-6,000 subjects per year in Denmark are involved in a traffic accident evoking whiplash-induced neck pain. About 43% of those will still have physical impairment and symptoms 6 months after the accident [1]. For Swedish society, including Swedish insurance companies, the economic burden is approximately 320 million Euros [2], and this burden is likely to be comparable to that of Denmark. Most studies suggest that patients with Whiplash-Associated Disorders (WAD) report chronic neck symptoms one year after the injury [3]. The main problems in whiplash patients with chronic neck pain are cervical dysfunction and abnormal sensory processing, reduced neck mobility and stability, impaired cervicocephalic kinaesthetic sense, in addition to local and possibly generalised pain [4,5]. Cervical dysfunction is characterised by reduced function of the deep stabilising muscles of the neck.


Besides chronic neck pain, patients with WAD may suffer from physical inactivity as a consequence of prolonged pain [6,7]. This influences physical function and general health and can result in a poor quality of life. In addition, WAD patients may develop chronic pain followed by sensitisation of the nervous system [8,9], a lowering of the threshold for different sensory inputs (pressure, cold, warm, vibration and electrical impulses) [10]. This can be caused by an impaired central pain inhibition [11] – a cortical reorganisation [12]. Besides central sensitisation, the group with WAD may have poorer coping strategies and cognitive functions, compared with patients with chronic neck pain in general [13-15].


Studies have shown that physical training, including specific exercises targeting the deep postural muscles of the cervical spine, is effective in reducing neck pain [16-18] for patients with chronic neck pain, albeit there is a variability in the response to training with not every patient showing a major change. Physical behavioural-graded activity is a treatment approach with a focus on increasing general physical fitness, reducing fear of movement and increasing psychological function [19,20]. There is insufficient evidence for the long-term effect of treatment of physical and cognitive behavioural-graded activity, especially in chronic neck pain patients. Educational sessions, where the focus is on understanding complex chronic pain mechanisms and development of appropriate pain coping and/or cognitive behavioural strategies, have shown reduced general pain [6,21-26]. A review indicated that interventions with a combination of cognitive, behavioural therapy with physiotherapy including neck exercises is effective in the management of WAD patients with chronic neck pain [27], as also recommended by the Dutch clinical guidelines for WAD [28]. However, the conclusions regarding the guidelines are largely based on studies performed on patients with either acute or sub-acute WAD [29]. A more strict conclusion was drawn for WAD patients with chronic pain in the Bone and Joint Decade 2000-2010 Task Force, stating, that ‘because of conflicting evidence and few high-quality studies, no firm conclusions could be drawn about the most effective non-invasive interventions for patients with chronic WAD” [29,30]. The concept of combined treatment for WAD patients with chronic pain has been used in a former randomised controlled trial [31]. The results indicated that a combination of non-specific aerobic exercises and advice containing standardised pain education and reassurance and encouragement to resume light activity, produced better outcomes than advice alone for patients with WAD 3 months after the accident. The patients showed improvements in pain intensity, pain bothersomeness and functions in daily activities in the group receiving exercise and advice, compared with advice alone. However, the improvements were small and only apparent in the short term.


This project is formulated on the expectation that rehabilitation of WAD patients with chronic neck pain must target cervical dysfunctions, training of physical function and the understanding and management of chronic pain in a combined therapy approach. Each single intervention is based upon former studies that have shown effectiveness [6,18,20,32]. This study is the first to also include the long-term effect of the combined approach in patients with chronic neck pain after whiplash trauma. As illustrated in Figure ?Figure1,1, the conceptual model in this study is based upon the hypothesis that training (including both individually-guided specific neck exercises and graded aerobic training) and education in pain management (based on a cognitive behavioural approach) is better for increasing the patients’ physical quality of life, compared with education in pain management alone. Increasing the physical quality of life includes increasing the general physical function and level of physical activity, decreasing fear of movement, reducing post-traumatic stress symptoms, reducing neck pain and increasing neck function. The effect is anticipated to be found immediately after the treatment (i.e. 4 months; short-term effect) as well as after one year (long-term effect).


Figure 1 Hypothesis of the Intervention Effect

Figure 1: Hypothesis of the intervention effect for patients with chronic neck pain after a whiplash accident.


Using a randomised controlled trial (RCT) design, the aim of this study is to evaluate the effectiveness of: graded physical training, including specific neck exercises and general aerobic training, combined with education in pain management (based on a cognitive behavioural approach) versus education in pain management (based on a cognitive behavioural approach), measured on physical quality of life’, physical function, neck pain and neck functions, fear of movement, post-traumatic symptoms and mental quality of life, in patients with chronic neck pain after whiplash injury.




Trial Design


The study is conducted in Denmark as an RCT with a parallel group design. It will be a two-centre study, stratified by recruitment location. Patients will be randomised to either the Pain Management group (control) or the Pain Management and Training group (intervention). As illustrated in Figure ?Figure2,2, the study is designed to include a secondary data assessment 12 months after baseline; the primary outcome assessment will be performed immediately after the intervention program 4 months after baseline. The study utilises an allocation concealment process, ensuring that the group to which the patient is allocated is not known before the patient is entered into the study. The outcome assessors and data analysts will be kept blinded to the allocation to intervention or control group.


Figure 2 Flowchart of the Patients in the Study

Figure 2: Flowchart of the patients in the study.




The participants will be recruited from physiotherapy clinics in Denmark and from The Spine Centre of Southern Denmark, Hospital Lilleb�lt via an announcement at the clinics and the Hospital. Using physiotherapy clinics spread across Denmark, the patients will receive the intervention locally. The physiotherapy clinics in Denmark receive patients via referral from their general practitioners. The Spine Centre, a unit specialising in treating patients with musculoskeletal dysfunctions and only treating out-patients, receives patients referred from general practitioners and/or chiropractors.


Study Population


Two hundred adults with a minimum age of 18 years, receiving physiotherapy treatment or having been referred for physiotherapy treatment will be recruited. For patients to be eligible, they must have: chronic neck pain for at least 6 months following a whiplash injury, reduced physical neck function (Neck Disability Index score, NDI, of a minimum of 10), pain primarily in the neck region, finished any medical /radiological examinations, the ability to read and understand Danish and the ability to participate in the exercise program. The exclusion criteria include: neuropathies/ radiculopathies (clinically tested by: positive Spurling, cervical traction and plexus brachialis tests) [33], neurological deficits (tested as in normal clinical practice through a process of examining for unknown pathology), engagement in experimental medical treatment, being in an unstable social and/or working situation, pregnancy, known fractures, depression according to the Beck Depression Index (score > 29) [18,34,35], or other known coexisting medical conditions which could severely restrict participation in the exercise program. The participants will be asked not to seek other physiotherapy or cognitive treatment during the study period.






The Pain Management (control) group will receive education in pain management strategies. There will be 4 sessions of 11/2 hours, covering topics regarding pain mechanisms, acceptance of pain, coping strategies, and goal-setting, based upon pain management and cognitive therapy concepts [21,26,36].




The Pain Management plus Training (intervention) group will receive the same education in pain management as those in the control group plus 8 treatment sessions (instruction in neck exercises and aerobic training) with the same period of 4 months length. If the treating physiotherapist estimates additional treatments are needed, the treatment can be extended with 2 more sessions. Neck training: The treatment of neck-specific exercises will be progressed through different phases, which are defined by set levels of neck function. At the first treatment session, patients are tested for cervical neuromuscular function to identify the specific level at which to start neck training. A specific individually tailored exercise program will be used to target the neck flexor and extensor muscles. The ability to activate the deep cervical neck flexor muscles of the upper cervical region to increase their strength, endurance and stability function is trained progressively via the craniocervical training method using a biopressure feedback transducer [18,37]. Exercises for neck-eye coordination, neck joint positioning, balance and endurance training of the neck muscles will be included as well, since it has been shown to reduce pain and improve sensorimotor control in patients with insidious neck pain [17,38]. Aerobic training: The large trunk and leg muscles will be trained with a gradually increasing physical training program. Patients will be allowed to select activities such as walking, cycling, stick walking, swimming, and jogging. The baseline for training duration is set by exercising 3 times at a comfortable level, that does not exacerbate pain and aims at a rated perceived exertion (RPE) level of between 11 and 14 on a Borg scale [39]. The initial duration of training is set 20% below the average time of the three trials. Training sessions are carried out every second day with a prerequisite that pain is not worsened, and that RPE is between 9 and 14. A training diary is used. If patients do not experience a relapse, and report an average RPE value of 14 or less, the exercise duration for the following period (1 or 2 weeks) is increased by 2-5 minutes, up to a maximum of 30 minutes. If the RPE level is 15 or higher, the exercise duration will be reduced to an average RPE score of 11 to 14 every fortnight [20,40]. By using these pacing principles, the training will be graded individually by the patient, with a focus on perceived exertion – with the aim of increasing the patient’ s general physical activity level and fitness.


Patients’ compliance will be administered by registration of their participation in the control and intervention group. The patients in the control group will be considered to have completed the pain management if they have attended 3 out of 4 sessions. The patiesnts in the intervention group will be considered to have completed if the patient has attended a minimum of 3 out of 4 pain management sessions and a minimum of 5 out of 8 trainings sessions. Each patient’s home training with neck exercises and aerobic training will be registered by him/her in a logbook. Compliance with 75% of the planned home training will be considered as having completed the intervention.




The participating physiotherapists will be recruited via an announcement in the Danish Physiotherapy Journal. The inclusion criteria consist of: being a qualified physiotherapist, working at a clinic and having at least two years of working experience as a physiotherapist, having attended a course in the described intervention and passed the related exam.


Outcome Measures


At baseline the participants’ information on age, gender, height and weight, type of accident, medication, development of symptoms over the last two months (status quo, improving, worsening), expectation of treatment, employment and educational status will be registered. As a primary outcome measure, Medical Outcomes Study Short Form 36 (SF36) – Physical Component Summary (PCS) will be used [41,42]. The PCS scales are scored using norm-based methods [43,44] with a mean score of 50 with a standard deviation of 10. The primary outcome with respect to having an effect, will be calculated as a change from baseline [45]. Secondary outcomes contain data on both clinical tests and patient-reported outcomes. Table ?Table11 presents clinical tests for measuring the intervention effect on neuromuscular control of the cervical muscles, cervical function and mechanical allodynia. Table ?Table22 presents the patient-related outcomes from questionnaires used to test for perceived effect of the treatment, neck pain and function, pain bothersomeness, fear of movement, post-traumatic stress and quality of life and potential treatment modifiers.


Table 1 Clinical Outcomes Used for Measurement of Treatment Effect

Table 1: Clinical outcomes used for measurement of treatment effect on muscle strategy, function and treatment modifiers.


Table 2 Patient Reported Outcomes Used for Measured of Treatment Effect

Table 2: Patient reported outcomes used for measured of treatment effect on pain and function.


Patients will be tested at baseline, 4 and 12 months after baseline, except for GPE, which will only be measured 4 and 12 months after baseline.


Power and Sample Size Estimation


The power and sample size calculation is based on the primary outcome, being SF36-PCS 4 months after baseline. For a two-sample pooled t-test of a normal mean difference with a two-sided significance level of 0.05, assuming a common SD of 10, a sample size of 86 per group is required to obtain a power of at least 90% to detect a group mean difference of 5 PCS points [45]; the actual power is 90.3%, and the fractional sample size that achieves a power of exactly 90% is 85.03 per group. In order to adjust for an estimated 15% withdrawal during the study period of 4 months, we will include 100 patients in each group. For sensitivity, three scenarios were applied: firstly, anticipating that all 2 � 100 patients complete the trial, we will have sufficient power (> 80%) to detect a group mean difference as low as 4 PCS points; secondly, we will be able to detect a statistically significant group mean difference of 5 PCS points with sufficient power (> 80%) even with a pooled SD of 12 PCS points. Thirdly and finally, if we aim for a group mean difference of 5 PCS points, with a pooled SD of 10, we will have sufficient power (> 80%) with only 64 patients in each group. However, for logistical reasons, new patients will no longer be included in the study 24 months after the first patient has been included.


Randomisation, Allocation and Blinding Procedures


After the baseline assessment, the participants are randomly assigned to either the control group or the intervention group. The randomisation sequence is created using SAS (SAS 9.2 TS level 1 M0) statistical software and is stratified by centre with a 1:1 allocation using random block sizes of 2, 4, and 6. The allocation sequence will be concealed from the researcher enrolling and assessing participants in sequentially numbered, opaque, sealed and stapled envelopes. Aluminium foil inside the envelope will be used to render the envelope impermeable to intense light. After revealing the content of the envelope, both patients and physiotherapists are aware of the allocation and the corresponding treatment. Outcome assessors and data analysts are however kept blinded. Prior to the outcome assessments, the patients will be asked by the research assistant not to mention the treatment to which they have been allocated.


Statistical Analysis


All the primary data analyses will be carried out according to a pre-established analysis plan; all analyses will be done applying SAS software (v. 9.2 Service Pack 4; SAS Institute Inc., Cary, NC, USA). All descriptive statistics and tests are reported in accordance with the recommendations of the ‘Enhancing the QUAlity and Transparency Of health Research’ (EQUATOR) network; i.e., various forms of the CONSORT statement [46]. Data will be analysed using a two-factor Analysis of Covariance (ANCOVA), with a factor for Group and a factor for Gender, using the baseline value as covariate to reduce the random variation, and increase the statistical power. Unless stated otherwise, results will be expressed as the difference between the group means with 95% confidence intervals (CIs) and associated p-values, based on a General Linear Model (GLM) procedure. All the analyses will be performed using the Statistical Package for Social Sciences (version 19.0.0, IBM, USA) as well as the SAS system (v. 9.2; SAS Institute Inc., Cary, NC, USA). A two-way analysis of variance (ANOVA) with repeated measures (Mixed model) will be performed to test the difference over time between the intervention and the control groups; interaction: Group � Time. An alpha-level of 0.05 will be considered as being statistically significant (p < 0.05, two- sided). The data analysts will be blinded to the allocated interventions for primary analyses.


The baseline scores for the primary and secondary outcomes will be used to compare the control and intervention groups. The statistical analyses will be performed on the basis of the intention-to-treat principle, i.e. patients will be analysed in the treatment group to which they were randomly allocated. In the primary analyses, missing data will be replaced with the feasible and transparent ‘Baseline Observation Carried Forward’ (BOCF) technique, and for sensitivity also a multiple imputation technique will apply.


Secondarily, to relate the results to compliance, a ‘per protocol’ analysis will be used as well. The ‘per protocol’ population he patients who have ‘completed’ the intervention to which they were allocated, according to the principles described in the intervention section above.


Ethical Considerations


The Regional Scientific Ethical Committee of Southern Denmark approved the study (S-20100069). The study conformed to The Declaration of Helsinki 2008 [47] by fulfilling all general ethical recommendations.


All subjects will receive information about the purpose and content of the project and give their oral and written consent to participate, with the possibility to drop out of the project at any time.


Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Managing stress, anxiety, depression and symptoms of post traumatic stress disorder, or PTSD, after being involved in an automobile accident can be difficult, especially if the incident caused physical trauma and injuries or aggravated a previously existing condition. In many cases, the emotional distress and the psychological issues caused by the incident may be the source of the painful symptoms. In El Paso, TX, many veterans with PTSD visit my clinic after manifesting worsening symptoms from a previous auto accident injury. Chiropractic care can provide patients the proper stress management environment they need to improve their physical and emotional symptoms. Chiropractic care can also treat a variety of auto accident injuries, including whiplash, head and neck injuries, herniated disc and back injuries.




This study will contribute to a better understanding of treating patients with chronic neck pain following a whiplash accident. The knowledge from this study can be implemented into clinical practice, as the study is based on a multimodal approach, mirroring the approach, which in spite of the current lack of evidence, is often used in a clinical physiotherapy setting. The study may also be included in systematic reviews thereby contributing to updating the knowledge about this population and to enhancing evidence-based treatment.


Publishing the design of a study before the study is performed and the results obtained has several advantages. It allows the design to be finalised without its being influenced by the outcomes. This can assist in preventing bias as deviations from the original design can be identified. Other research projects will have the opportunity to follow a similar approach with respect to population, interventions, controls and outcome measurements. The challenges of this study are related to standardising the interventions, treating a non-homogeneous population, defining and standardising relevant outcome measures on a population with long-lasting symptoms and having a population from two different clinical settings. Standardisation of the interventions is obtained by teaching the involved physiotherapists in an instructional course. Population homogeneity will be handled by strict inclusion and exclusion criteria and by monitoring the baseline characteristics of the patients, and differences between groups based on other influences than the intervention/control will be possible to analyse statistically. This research design is composed as an ‘add-on’ design: both groups receive pain education; the intervention group receives additional physical training, including specific neck exercises and general training. Today there is insufficient evidence for the effect of treatment for patients with chronic neck pain following a whiplash accident. All participating patients will be referred for a treatment (control or intervention), as we consider it unethical not to offer some form of treatment, i.e. randomising the control group to a waiting list. The add-on design is chosen as a pragmatic workable solution in such a situation [48].


For whiplash patients with chronic pain, the most responsive disability measures (for the individual patient, not for the group as a whole) are considered to be the Patient Specific Functional Scale and the numerical rating scale of pain bothersomeness [49]. By using these and NDI (the most often used neck disability measure) as secondary outcome measures, it is anticipated that patient-relevant changes in pain and disability can be evaluated. The population will be recruited from and treated at two different clinical settings: the out-patient clinic of The Spine Centre, Hospital Lilleb�lt and several private physiotherapy clinics. To avoid any influence of the different settings on the outcome measures, the population will be block randomised related to the settings, securing equal distribution of participants from each setting to the two intervention groups.


Competing Interests


The authors declare that they have no competing interests.


Authors’ Contributions


IRH drafted the manuscript. IRH, BJK and KS participated in the design of the study. All contributed to the design. RC, IRH; BJK and KS participated in the power and sample size calculation and in describing the statistical analysis as well as the allocation and randomization procedure. All authors read and approved the final manuscript. Suzanne Capell provided writing assistance and linguistic corrections.


Pre-Publication History


The pre-publication history for this paper can be accessed here:




This study has received funding from the Research Fund for the Region of Southern Denmark, the Danish Rheumatism Association, the Research Foundation of the Danish Association of Physiotherapy, the Fund for Physiotherapy in Private Practice, and the Danish Society of Polio and Accident Victims (PTU). The Musculoskeletal Statistics Unit at the Parker Institute is supported by grants from the Oak Foundation. Suzanne Capell provided writing assistance and linguistic correction.


The trial is registered in identifier NCT01431261.


A Randomized Controlled Trial of Cognitive-Behavioral Therapy for the Treatment of PTSD in the context of Chronic Whiplash






Whiplash-associated disorders (WAD) are common and involve both physical and psychological impairments. Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes. Trauma-focused cognitive-behavioral therapy (TF-CBT) has shown moderate effectiveness in chronic pain samples. However, to date, there have been no clinical trials within WAD. Thus, this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder (PTSD).




Twenty-six participants were randomly assigned to either TF-CBT or a waitlist control, and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview, self-report questionnaires, and measures of physiological arousal and sensory pain thresholds.




Clinically significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at postassessment, with further gains noted at the follow-up. The treatment of PTSD was also associated with clinically significant improvements in neck disability, physical, emotional, and social functioning and physiological reactivity to trauma cues, whereas limited changes were found in sensory pain thresholds.




This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD. The finding that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD. Clinical implications of the findings and future research directions are discussed.


In conclusion, being involved in an automobile accident is an undesirable situation which can result in a variety of physical trauma or injury as well as lead to the development of a number of aggravating conditions. However, stress, anxiety, depression and post traumatic stress disorder, or PTSD, are common psychological issues which may occur as a result of an automobile accident. According to research studies, physical symptoms and emotional distress may be closely connected and treating both physical and emotional injuries could help patients achieve overall health and wellness. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .


Curated by Dr. Alex Jimenez



Additional Topics: Back Pain


According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.


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EXTRA IMPORTANT TOPIC: Managing Workplace Stress



MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor



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