Mind, body, and mobility: exploring yoga's role in rehab with Mitch Hunter

In this episode, Mitch explores the potential benefits of yoga for our patients. We delve into the symbiotic relationship between the breathing techniques employed in yoga and the transformation of our mindset regarding movement and positions that may exacerbate discomfort. Mitch also shares insights into the latest research on the connection between yoga and pain.

Mitch Hunter is a clinical educator, senior physiotherapist and lecturer at Griffith University. He additionally is a meditation teacher working with persistent pain, chronic health, and palliative care patents. Mitch can be found at: https://www.hunterhealing.com and @_mitchhunter. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is Michael Rizk (@thatphysioguy)


References to papers discussed: 

1. Bower, J. E., & Irwin, M. R. (2016). Mind–body therapies and control of inflammatory biology: A descriptive review. Brain, behavior, and immunity, 51, 1-11 https://www.sciencedirect.com/science/article/pii/S0889159115001658

2. Buric, I., Farias, M., Jong, J., Mee, C., & Brazil, I. A. (2017). What is the molecular signature of mind–body interventions? A systematic review of gene expression changes induced by meditation and related practices. Frontiers in Immunology, 8, 670 https://www.frontiersin.org/articles/10.3389/fimmu.2017.00670/full?fbclid=IwAR3UziUstPADj5tnIc46ctLJ4K_Uo8Kj6eMDxiWUyatIG3gHihoN7kypBH

3. Cherkin, D. C., & Herman, P. M. (2018). Cognitive and mind-body therapies for chronic low back pain and neck pain: effectiveness and value. JAMA internal medicine, 178(4), 556-557 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2673371

4. Villemure, C., Čeko, M., Cotton, V. A., & Bushnell, M. C. (2014). Insular cortex mediates increased pain tolerance in yoga practitioners. Cerebral cortex, 24(10), 2732-2740 https://academic.oup.com/cercor/article/24/10/2732/307000?login=true

5. Rivest-Gadbois, E., & Boudrias, M. H. (2019). What are the known effects of yoga on the brain in relation to motor performances, body awareness and pain? A narrative review. Complementary therapies in Medicine, 44, 129-142 https://www.sciencedirect.com/science/article/pii/S0965229918308288

6. Sterling, M., Smeets, R., Keijzers, G., Warren, J., & Kenardy, J. (2019). Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): a randomised controlled trial of a combined psychological/physical intervention. British Journal of Sports Medicine, 53(19), 1240-1247 https://bjsm.bmj.com/content/53/19/1240.abstract

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

Transcript

SPEAKER_01 0:00

I think a lot of the time if a patient has a situation where they can experience how their mind is able to change their pain, that is so fundamentally paradigm shifting for them that that can really break the chronic pain sort of pattern. It's one thing telling someone that your psychological perspective may be contributing to your pain, but it's a real different thing if you actually show them how it works and actually get them to be able to change that pain, even through deep breathing or reducing their stress associated with the injury and then seeing that physiological change in pain.

SPEAKER_02 0:40

Today, we explored the intersection of yoga and physio and how that can be helpful for our patients. We had Mitch Hunter on. Mitch is a clinical educator at Griffith University, is a senior physio, APA-titled musculoskeletal and sports physiotherapist, and he specializes in treating patients with rare, complex, and chronic conditions. Today, we covered how yoga can be more than just movement, but deep breathing. It can help to reduce stress, down-regulate some systems, and also bring some Welcome, Mitch. Thank you for joining us. Thanks for having me, Michael. We're talking about the use of yoga in physiotherapy and pain management, and off-air we were discussing what does stress inoculation techniques mean. So maybe start there, and then how does that relate to a patient and their experience?

SPEAKER_01 1:51

Yeah, for sure. So there was some research through Michelle Sterling in 2019 where she talks about the idea of stress inoculation techniques being used to help with people post-whiplash injuries. She was highlighting a few different techniques, kind of breathing techniques, sensory awareness techniques, meditation, and then different forms of exercise and stretching and so on. And basically, she found that there was more positive outcomes where people were able to engage with these therapies that were considering their mind and their body and the kind of relationship between the two and using these to try and mitigate and manage their stress response.

SPEAKER_02 2:28

What does that mean, positive outcomes?

SPEAKER_01 2:30

Well, the positive outcomes were that the patients had a shorter period of recovery and had improved recovery timeframes and improved outcomes afterwards as well. So I think they were managing disability index and things along those sorts of lines, like outcome measures. And they found that if people were able to engage with these, they were able to kind of self-manage things a lot better as well. So there were, I think the initial research only had one or two interventions and patients were able to take these techniques and kind of use them ongoing into their management. which is really great. And I think that kind of highlights this idea of these mind-body therapies. So that's what yoga basically is. It's kind of like a mind-body therapy, a therapy where you use your body in particular ways, but then also consider your perspective of your body while you're doing that. We talked about it before, how yoga is kind of looked upon as just being to do with stretching, but the stretching is kind of, it's actually one-eighth of the system, which is kind of funny. You know, there's all these other components that look at the person's perspective and tries to break down their relationship to their body through different postures.

SPEAKER_02 3:37

Tell us more about yoga. And I imagine there's different forms, different teachers. And if I think about it really biomechanically, I would imagine that's got to be good for anyone to move in that way. But tell me more specifically about what you just mentioned there is like the different awarenesses that you might go through when you're doing yoga.

SPEAKER_01 3:57

Yeah, I mean, I think that's like the first aspect of yoga. I remember when I started doing yoga, I was in a yoga class and I felt like the Tin Man. I felt like my body was going to explode. I could barely move, you know? Yeah. And so just the physical elements of going through and stretching out your body in a variety of ways is really beneficial because you can imagine your movement patterns have become very habitual and you get a certain amount of restriction within your body. And so yoga can help you to take you outside of those positions you're used to. But alongside that, The yoga practice, the physical postures are often combined with breathing regulation. So you do some kind of deep breathing techniques often to try and regulate your autonomic nervous system. And there's relatively good research around that using deep breathing in particular is able to reduce the sympathetic nervous system and increase parasympathetic nervous system activity. And so you can imagine you're doing these really hard postures, but then at the same time, you're regulating your nervous system to be in a more relaxed or calm state. And so what that does is that starts to change the psychological perspective of movement. So I might be in a position where I can feel a little tension in my stomach, I'm in a deep twist or something along those lines. And then my habitual process might be that I don't enjoy sensations through my stomach. It makes me feel queasy and it makes me feel a little bit of panic. You can imagine that by training yourself to be in that uncomfortable position, using the breathing technique to regulate the nervous system, then your thought processes associated with that area are going to start to change. And then as you start to kind of feel a bit more calm while you're feeling the sensation in your stomach, the sensation in your stomach actually changes. Because that sensation, a big part of that is your thought process to deal with it. It's just in the nature of sensation itself.

SPEAKER_02 5:37

Yeah. It's a kind of rewiring our thought about the movement. And then when we do the movement, we get different feedback. And then that feedback changes our thoughts. A bit of a positive feedback loop. Is that how you describe it?

SPEAKER_01 5:50

Yeah, I think so. It's kind of, you know, you're using the sequence of postures and techniques to explore different stresses on the body. And then while you're doing that, you're rewiring your perspective of them, which is that loop you were talking about. Yeah. And it's great because you can imagine, you know, if you've got these patients who have chronic pain in particular, chronic pain is, there's a number of different mechanisms to it, obviously, but one significant part is that The person's perspective of their body is outside the reality of what's going on. So you may think to yourself, my knee is really badly injured. It's very dangerous. I can't use it. But the reality is the knee is actually quite safe if it's just a pain condition. And so by developing kind of a meditative awareness, of a situation. So, you know, going through a posture where you're beaming your knee or something along those lines and keeping your mind calm while you're doing it, that's exploring those thought processes. And that starts to change them, as you can imagine.

SPEAKER_02 6:47

That's huge. So, take me to the clinic and even using that as an example, do you treat a lot of persistent pain patients? Is that something that you come across a lot?

SPEAKER_01 6:58

Yeah, that's an area where I kind of, I mean, I've ended up specializing in these days as working with these chronic pain patients, persistent pain and It was interesting because I found that a lot of the time I'd be having conversations with these patients about their perspective of their body and their movement and things along those lines. The tricky part about it was that people were very, very stuck in their thought processes associated with the area, the injury, the frustration, the fear, all these sorts of ideas. And so personally, I do a lot of meditation and yoga, and I found that if I was able to guide these patients through some sort of practice in that A meditative practice, autonomic regulation practice, so that they could be in more of a calm state of mind. Then when we weep back through and we kind of explore their perspective of those sensations again, the sensations would be different. And so I've been using these sorts of ideas with a lot of patients. And you can do it very much through physical postures like yoga postures, but you can also do it through a conversation, creating an awareness of the pain and then noticing, well, I'm feeling pain in this area, but I'm also feeling panic at the same time. And if a patient can highlight the difference between pain versus the panic, that on its own is very therapeutic. Then they start to recognize there might be other components that could be contributing to the pain as well.

SPEAKER_00 8:18

This podcast is sponsored by Cliniko.

SPEAKER_02 8:52

I'll just do a broad brush and say that the traditional physio appointment looks like an interview, some hands-on, maybe some movement. Are you branded in this way so people know they're coming to you and there'll probably be yoga involved? Or does it all just look like this is going to be a normal physio appointment and then you suggest doing yoga? How does that look?

SPEAKER_01 9:13

Yeah, it's a good point. I mean, you know, I work out of Griffith University. And so the majority of the time I'm having people coming to see me in a very academic type situation. And it's really nice because I kind of think of it as Trojan horses, to be honest. It's the idea that you're sneaking in a little idea. Yeah. And once the idea is in them and it unpacks, they're going to be changed regardless of what the phrasing is around it. If I sit to someone or, you know, we're looking to kind of if I use some sort of word like chakra or something like that in a physiotherapy setting, it's not really the language that we use. I might talk about psychological association with an area and that's more of the relationship that we're looking at. So I think a lot of it is, it would be a normal session that come in and it would seem like a very normal session. And then within that normal session, I might start talking to them about pain science. I might talk to them about nervous system regulation. I might talk to them about these different stress inoculation techniques that could create those sorts of changes and how they have a beneficial effect on the pain.

SPEAKER_02 10:13

Let's keep going with that scenario. So let's say there's someone who is listening to this podcast and they want to try some version of what you do on their patient in the day. Are you asking them, you know, would you be open to doing some yoga today or open to some stress relief technique or even some deep breathing and then retesting? How do you actually approach that?

SPEAKER_01 10:34

I think there's a lot of ways of introducing these ideas. I mean, it might be as simple as having, if you're a practitioner, looking at your patient and then while they're doing a particular movement, asking them about what's your perspective of what's going on. That could be a really nice starting point. Or yeah, introducing ideas of deep breathing to regulate the nervous system. And you can trial, I'm going to do some squats and feel panicked and then I'm going to do my deep breathing and see, does that change that panic sensation? So I very much try to integrate it in that same sort of model where it would be specific intervention based on my clinical reasoning on the patient's presentation. I would look at this patient seems to be presenting with some yellow flag factors that seem to be contributing to their pain. I've noticed they've talked about some hypervigilant behaviors and catastrophization and those sorts of ideas. And then I might say, well, with that justification, I'm going to trial some stress inoculation techniques alongside my normal therapy and then see, yeah, if I have that intervention, does that make a significant difference? So I think it has to fit within those same clinical reasoning paradigms. If we're stepping outside of that, then we're missing the scientific theory, which is such a valuable resource. I think yoga doesn't really sit outside of those sorts of ideas. It's very much along the same sort of paradigm of thought. You really want to make sure that if you're doing a yoga practice, you're actually seeing some sort of physical notable change that you're seeing in your practice. Same thing with your patients. You want to be able to test pre and post and see without too many confounding variables, is it actually helping?

SPEAKER_02 12:07

In the evidence or your experience, are you seeing this as a really nice short-term pain reliever and movement strategy? Or in your experience and evidence, is there something telling you that this actually helps long-term? And you mentioned outcomes earlier.

SPEAKER_01 12:26

Yeah, I mean, there's a good amount of research around how meditation can change cognitive processes, neurophysiology, even down to DNA changes and telomere lengths and all sorts of fun things. There's some good research around mind-body therapies. Again, within the use of mind-body therapies, we're seeing chronic low back pain, opioid-treated pain. And then there's even some research that shows that inflammatory-related diseases are reduced. potentially through genomic changes, through mind-body therapies. So, you know, there's pretty massive sort of implications there. With patients, there's some good research around how the pain threshold has changed through yoga practitioners. So there's a higher pain threshold. And then a number of things around, obviously, like many forms of exercise and significant cognitive changes. What I've seen with my patients, it's been really extraordinary, to be honest. I started integrating these techniques probably around about five or so years ago. And with the patients who were open to the ideas and were really able to take it on board, anecdotally, I've seen very significant changes. I think a lot of the time if a patient has a situation where they can experience how their mind is able to change their pain, that is so fundamentally paradigm shifting for them that that can really break the chronic pain sort of pattern. It's one thing telling someone that your psychological perspective may be contributing to your pain, But it's a real different thing if you actually show them how it works and actually get them to be able to change that pain, even through deep breathing or reducing their stress associated with the injury and then seeing that physiological change in pain.

SPEAKER_02 14:03

What might the young physio who's listening try as a first step? Would you recommend trialing a deep breathing or asking questions about their perception or taking home an app and saying, you know, This could be worth trying three times a week for 10 minutes.

SPEAKER_01 14:20

That's a great starting point when you just mentioned. The biggest thing I would say would be I would love to see the physio trial these things for themselves first. So I'd love to see the physio to go through and do a 10-week meditation block through a guided app or to go through inducing breathing practices or to... start to look at some stretching in a relaxing sort of way. And then once they have a little bit more of an understanding about it, try it out. See if patients are open to the idea, present it in a way that's scientifically valid and in the kind of language that we would typically use. And then just be clear about assessing the outcomes of your results.

SPEAKER_02 14:57

Mitch, we'll have to leave it there, but thank you so much for the insights and thank you so much for your time.

SPEAKER_01 15:02

Great. Thanks for having me, Michael.

UNKNOWN 15:04

Thank you.