Please be advised that we will be recording this presentation. Please mute your microphone. If you are speaking, if you wish to be heard, please use the raise hand function. You may also ask the presenters using the chat everyone function. Technical support can be reached via chat function. Browse over the search for AAPMR. Producer, please contact us with any technical issues you may have. Dr. Zelnick, you may begin. Hi, everybody. Welcome to our third annual community gathering and our second annual education session for the alternative pain medicine community. I'm Dr. Danielle Zelnick and I'm the community chair. So today we are honored to welcome our speakers who have worked together to provide team-based pain care at JFK Johnson Rehabilitation Institute. Our session director and first speaker, Dr. Sagar Parikh, is dual board certified in PM&R and pain medicine. He is both the director of the pain fellowship at Johnson Rehabilitation Institute as well as the director of the Center for Sports and Spine Medicine. Dr. Parikh has a passion for both interventional and integrative approaches to pain management. He takes a biopsychosocial approach to patient care and has interest in the inclusion of integrative treatments into standard of care. Our second speaker, Dr. Alyssa Kaplan, has prerecorded her presentation for us to premiere here today. Dr. Kaplan completed her PhD in psychology at Columbia University and her postdoctoral fellowship in rehabilitation neuropsychology at JFK University Medical Center, Johnson Rehabilitation Institute, where she continues to provide services. She has been treating rehabilitation patients, including chronic pain patients for 30 years. In recent years, she has been incorporating mind-body treatment, particularly mindfulness meditation into her work. Our third speaker, Dr. Jason Roth, is an integrative pain specialist, double boarded in PM&R and pain medicine and certified in medical acupuncture. He completed his pain fellowship at JFK Johnson Rehabilitation Institute. He is passionate about using a comprehensive approach to pain care and uses a full spectrum of treatments, from breathwork to neuromodulation. He currently practices at the Center for Interventional Pain and Spine in Delaware. So welcome, everybody. I will hand it off to Dr. Parikh at this time and we'll get started. Hello, thank you very much, Dr. Zelnick. Give me a moment to get my slides. So thank you very much for that introduction. I, myself, as well as my co-presenters, if I may speak for them, are very excited to be here to talk to you all about the multidimensionality of pain, especially talking about the cognitive, physiological, and behavioral aspects that plague our pain patients, especially those that are in chronic pain, something that each one of us, probably as well as many of you out there, have encountered in your career thus far. I've already been introduced, but I guess in the spirit of repetition and redundancy, I am Dr. Sagar Parikh. I'm Interventional Pain Physician by trade and the current director of the Pain Fellowship Program at the JFK Johnson Rehabilitation Institute, as well as director of the Center for Sports and Spine Medicine. And I have no financial disclosures. The only thing that I will disclose is that I am fully invested in the biopsychosocial model for the diagnosis and treatment of disease. This interdisciplinary model outlined by Dr. George Engel in the 70s looks at the interconnection between biology, psychology, and socio-environmental factors when treating patients. Practically speaking, it's a way of understanding a person's subjective experience as a contributor to not only their actual pain complaints, but also as a contributing factor to treatment outcomes. Outcomes are very important to us, of course. We want our patients to thrive and be well. So it's necessary that to move away from a model that just looks at nociception or just looking at anatomic pain generators, but accepting a more biopsychosocial holistic model for a diagnosis and care for our patients. Because after all, there is a multidimensionality to pain. So we need to understand that this multidimensionality we need to understand the multidimensionality nature of pain and be able to detect the multiple levels of influence. And so we can then also better understand our wide scope of our treatment options. So in this series of talks, we will, for example, discuss the role of mindfulness practices and even breath work and how it can be beneficial to someone that's afflicted with chronic pain. So I oftentimes ask myself, how prevalent is our understanding of these mind-body techniques in the current setting of our chronic pain treatments? And how many of us pain practitioners actually utilize them in our treatment paradigm? This is very much an ongoing survey assessment that we're conducting, looking at pain practitioners and their experience with pain psychology and mind-body techniques for chronic pain. And thus far from our survey data, it shows that though many pain physicians and most of the participants were in private practice, and ACGME trained, that many pain physicians are quite comfortable in their interventional and procedural pain training. There is a more mixed result when it comes to respect to knowing and learning about pain psychology, especially during their fellowship year. Also, the majority of our survey participants stated that they don't necessarily have access to a trained pain psychologist in order to implement them into their treatment paradigm. And also, even if they did, even the ones that did have access, there are still some reluctancy or some barriers to actual successful referral to a mind-body specialist or a pain psychologist. This of course could be due to various factors, including lack of education, lack of availability, lack of awareness of the benefits of it. And in some cases, perhaps even a difficulty for insurance coverage for services of this nature. So let's briefly dive into the different dimensions of pain and hopefully we can kind of get an understanding of why I think these types of treatments or alternative treatment options are important. Well, we all know the basic nomenclature of acute versus chronic pain, with chronic pain lasting more than six months and persisting longer than expected or long after tissue injury is presumed to have occurred. With chronic pain, it often, with chronic pain often comes this component of suffering. And when we talk about suffering, we're talking about issues such as loss of physical function and social isolation, family distress, a sense of inadequacy or even spiritual loss. Pain after all is an unpleasant sensory and emotional experience. And it's very much personal in nature. This is straight up from the IASP definition of pain. It's very personal in nature. And then some would say that a great portion of our pain experience as humans, especially how we relate and cope to pain is a learned concept. So how does that occur? Well, there's oftentimes, but not always, but oftentimes this initial physical injury or a noxious stimulus that activates the nociceptor in the peripheral part of the body and transduces and generates a signal, which then gets transmitted along a first order neuron, which then synapses at the spinal cord level to a second order neuron, which then ascends up to the thalamus to brain structures, at which point there is a series of cognitive communications that occur, after which there is a degree of modulation or even sensitization at the peripheral, around the nociceptor, at the spinal cord level, around the second order neuron, and even at the supraspinal level. Overall, with that modulation, we have our pain perception. So that's the perception that the patient feels after all of that has occurred. Diving into what's going on in the brain a little bit deeper. Well, the pain signal, as we said, travels through the medial thalamus. And as I mentioned before, it communicates with various cortical structures, such as the somatosensory cortex, the anterior cingulate cortex, the insula, the amygdala, the prefrontal cortex, hippocampus, a lot of limbic brain structures. So communicating with the neurocircuitry of the brain, and in many cases, evaluating and learning what that pain stimulus is all about and how we react to it. So it's all part of this neurocircuitry. In fact, we actually already have functional MRI evidence of this occurring. Various studies have already demonstrated activity in the brain in something called a default mode state or a resting state of a particular individual. fMRI, as you may or may not know, is a technique for measuring and mapping brain activity by detecting changes associated with blood flow. There is a correlation between cerebral blood flow and neuronal activation, which makes this type of analysis possible. So there are many labs right now that are comparing and contrasting the default mode or the resting state of a patient that let's say doesn't have pain to one that is afflicted with chronic pain or even depression. And they are finding many similarities. Well, first, they're finding many differences in patients that are not in pain versus those that have been afflicted with chronic pain. And they're finding many similarities with people who have depression and anxiety with the brain pattern and the brain activity of those that are in chronic pain. But of course, this isn't the first time that we've heard something like this, that we've heard about the cognitive processes that occur with respect to pain. Dr. Ronald Melzack, who some of you may already know from the Melzack and Wall Gate theory for pain, developed the concept of the pain neuromatrix, a multidimensional experience produced by a neurosignature pattern in our brains, a sequence of nerve impulses that then create, that are part of this pain neuromatrix and it actually influences how I, as a patient or any of our patients relate or even express their pain complaints. So busy slide, but the theory basically outlines that there are various inputs that feed into our brain or neurocircuitry. All of that influences our pain experience. We are already quite familiar with the sensory discriminative inputs like cutaneous injury or even visceral tissue damage or things of that sort. We're familiar with that model. But there are also motivational effective inputs, such as the activation of our hormonal system or reward centers, our sympathetic nervous system, even the activation of our stress responses. And even there are inputs coming from the cognitive evaluative aspect of this phenomenon. And these are mostly influences from our past experiences, our personality, our culture, what we've learned about pain. So all of this feeds into our brain circuitry. And the part of the nervous system where we have voluntary and actually involuntary connections occurring. And after it's sifted through that brain circuitry, it outputs out our total pain experience. So our actual pain and that pain experience is a combination of our actual pain perception, which could be mild, moderate, severe, five out of 10 pain, seven out of 10 pain, 10 out of 10 pain. It outputs out an action program. So our protective or coping behaviors like guarded movements or even decreased physical function or social isolation, that sort of thing. And also outputs out some sort of a stress regulation programs such as the release of cortisol, inflammatory mediators, that sort of thing. So all of that together is our pain experience. So why does characterizing a patient's pain experience really matter? Well, simply because no two people are alike. How the pain is perceived is determined not only by the amount of tissue injury, but also by these emotional and psychological factors. The best way to describe, this was best described by a Harvard physician, Dr. Henry Beecher, who observed that World War II soldiers who were injured in battle were better able to address or accept their pain and injury than civilians with similar injuries. There was almost a dissociation that was occurring. For a soldier, injury is perhaps a more accepted outcome as they are normally going into battle, going into war, or maybe even perhaps injury would give them a much needed reprieve from battle. So there's some association with that injury. For a civilian who's not expecting to be injured or relies on their physical health for their career, this could be felt as a major tragedy. So both of these are stressful events, but they are perceived differently or definitely from different degrees. So what is the stress? Well, stress, it can be defined as anything that threatens homeostasis, no matter how big or how small. Any challenging stressor, be it emotional or physical, will result in a response from our body to regain homeostasis or stability. The process of this is called allostasis, and the wear and tear that our bodies and brains go through to achieve this stability is called allostatic load. There's wear and tear because there is a utilization of resources to bring us back to stability. One can imagine how persistent stress can deplete these resources and put someone at a persistent allostatic load, which is not beneficial. A big portion of our stress response is controlled by our sympathetic nervous system, which causes a manner of responses that include an increase in heart rate, elevations in blood pressure, increased muscle tension, and so on. This is typically characterized as a fight-or-flight sympathetic response. Similar findings can be found in patients afflicted with chronic pain or those prone to catastrophizing about their pain. In addition to high pain scores, they are often hypertensive on exam or even coming in with multiple myofascial trigger points and tense muscles that all just compounds their whole pain experience and their overall suffering. And this same effect occurs with perceived stress. So past experiences and memories integrated into our limbic brain can have a direct impact on how we manage future stresses or future pains and ultimately affect our behavior. In fact, many alternative medicine therapies focus on this decrease of sympathetic drive, a decreasing of the symptoms of the fight or flight response and we try to increase more parasympathetic activity to promote relaxation and indirectly, hopefully promoting pain relief. Well, then what about the hormonal stress response? Well, this is dictated by the hypothalamic pituitary adrenal axis or the HPA axis, which there is a series of events that occur from the release of corticotropin releasing hormone CRH to the pituitary gland, which then releases ACTH which then acts on the adrenal medulla in the end releasing glucocorticoids such as cortisol stress hormone, as well as catecholamines. And catecholamines I kind of mentioned before that the catecholamines are related to the fight or flight response. But in addition to releasing these glucocorticoids as catecholamines, there is also an influence of those glucocorticoids on the brain structure like a feedback right on the brain structure. So some of the similar brain structures that we had outlined before when we talked about pain processing, influences, for example, on the hypothalamus, the hippocampus, the amygdala, the prefrontal cortex. These are all limbic brain structures. The glucocorticoid influence on them influences the way that we learn and form memory around certain stresses. There is evidence that already shows that glucocorticoid activity on those structures creates flashbulb memory events associated with strong emotion, almost like triggers to our neurocircuitry sometimes. And these triggers can become so embedded that they're involuntary. And that's what we think about when you think about learned responses to pain and how one individual can differ from another. Because no two stressors are alike. So how a stressor is perceived is determined by the qualities of that stressor as well as the memory that is attributed to it. So for example, if a stressor has an unpleasant valence, with a low to moderate arousal level, it can cause a feeling of dread and even enhanced pain. So when we talk about valence as a property, it's easy to understand valence because it has a binary result. It's either pleasant or unpleasant. Arousal is different. Arousal has multiple degrees of different levels, stemming from anything from calm to excitement. So for example, something with a high arousal, a stress that has a high arousal, such as the sight of a hungry tiger right in front of you, that will fling you into a quick fight or flight response because it's a high arousal stimulus. And even temporarily might even decrease your pain because your focus is now on survival. It has immediate fear and danger element to it. Something with a low to moderate arousal doesn't put you in that position of immediate danger. However, it does leave you feeling this dread or this prolonged future fear of some future pain. So I'll give you an example of that. On a personal level, I injured my ankle last year and went through a two to three month recovery process. And during which time, the stress and memory of the injury and the physical limitations that I felt, even though I was a physician and I knew exactly how I was gonna eventually end up, which I thought was gonna be fine. And although those limitations were temporary, it did leave me feeling this degree of suffering, which I think negatively impact my mood and my pain experience. And as I engaged in a lot of regret over the stupidity of my injury, as well as getting lost in a lot of future projections as to what being immobile would mean for my life. Of course, I'm fine now, but during those two to three months, I felt that heaviness, that suffering, that dread. And so it definitely felt different until I was able to come out of it. So pain and stress are both protective in nature. However, when they become chronic, they can lead to long-term maladaptive changes resulting in suffering and compromised wellbeing, which goes beyond the realm of simple tissue injury. You know, as I said before, the hippocampus, amygdala, and prefrontal cortex all play a critical role in fear learning and also fear extinction when it comes to a pain or stress. And these areas are heavily influenced by chronic pain and chronic stress. Chronic pain, the condition of chronic pain can be considered a condition where, in addition to all those central sensitization processes that we understand very well at the spinal level, there might even be a component where the brain actually fails to extinguish the fear and negative memory of that pain. And so it perpetuates on and on and actually leads to more maladaptive behavioral changes. I won't spend too much time on this slide, but it will only highlight that there is a correlation between chronic pain and the presence of depression and anxiety in our patients. And at times when these diagnoses are comorbid or occurring at the same time, there are each more difficult to treat individually. And it makes some intuitive sense that this would occur because we do see some overlap, even in functional MRI studies, but even in our patients, that we do see some overlap in the cognitive and behavioral elements of these different conditions. So there is some overlap. So what did we go over so far? And I apologize if that was quick. Chronic pain and stress have actual physiologic and cognitive impacts on our brains that can perpetuate our pain states in ways that a procedure or procedural interventions may not be able to treat. So the question is, how can we stop the vicious pain stress cycle that's going on between our HPA axis and our limbic systems? How can we separate ourselves from this cycle, remove ourselves from the trenches of this cycle? Is it possible to overcome, or is it possible to become a silent observer or a witness to what's happening in our brain circuitry to alter our pain experience? Can we actually look at our, can we somehow tap in and look into our pain neuromatrix and try to not allow certain triggers to go in certain ways? Can we gain control of our sympathetic nervous system to help promote a state of relaxation and hopefully pain relief? Well, one way to help our patients do this is proper detection of which patients do need these types of treatments. We've now, I think, done away with solely using a linear one-dimensional pain score, and I've now opted to try more multi-dimensional validated outcomes for a more complete view of a patient's pain experience. So for example, tools such as the Short-Form NPQ or the Pain Disability Index, or even the PROMIS-29 questionnaire, these questionnaires tease out our pain experience through multiple domains. So for example, the PROMIS-29 specifically looks at the domains of physical function, fatigue, pain interference, depression, anxiety, and sleep disturbance. Patients in chronic pain consistently score higher than the general population in the components of fatigue, depressive symptoms, anxiety, and sleep disturbance. And they consistently score more poorly when it comes to physical function. So hopefully a broader utilization of these tools will help clinicians identify those patients that need something more than just interventional or procedural care, identify those patients that need more alternative treatments options to help their pain, to be included in their pain regimen. And interestingly enough, we are conducting a quick survey on this as well, where we have a number of patients that have taken the PROMIS-29 questionnaire, and we noticed that those that are scoring on this questionnaire in ways that we expect, kind of poor with physical function and higher when it comes to depressive symptoms and sleep disturbances, et cetera. Also, a good portion of them also have concomitant mood disorders, and a good portion of them have chronic, have been in pain for years, while our patients that, let's say, don't have mood disorders and have more acute pain symptoms, like within first three months or even four months, they score differently on the PROMIS-29. So we're trying to use this measure as can we detect who needs what early on and help pain not become chronic and untreated as we continue on their care. So where do we go from here? Can mindfulness arm our patients with the necessary ability to overcome the suffering involved in this cyclic chronic pain phenomenon? Can breath work help us gain control of the sympathetically mediated responses that we have when we're in pain or even in stress? Can teaching our patients to mentally distance themselves from catastrophizing or from their pain that occurs when they're in pain chronically, and can teaching them to distance themselves give them some form of relief? Can we do better at teaching these concepts to the next generation of pain specialists and giving it the much needed emphasis that I think it deserves? So a little bit about my connection to the Himalayan Himalayan Himalayan Himalayan Himalayan for most of my life you know and that I attribute that to my grand my grandfather my my parents that have that have really adopted and really emphasize these concepts in so much so that I then pursue it for myself you even even taking a wonderful trip to the Himalayas decided to see if I can learn something more about how we can kind of control our minds and and control our own stress responses. Luckily, I landed at the Rehabilitation Institute of Chicago for my pain fellowship where I I was under the guidance of Dr. Steven Santos and then Dr. Ben Professor Gagnon and I really learned about the pre-neuromatrix for the first time while I was in fellowship something a concept that I had never heard of before and I think that was so influential to the point where I still talk about it to this day and still believe in it and then and serendipitously then when I'm joining JFK Johnson Rehabilitation Institute. I was happy to see that there were like-minded colleagues like Dr. Elisa Kaplan who you will be hearing from next as well as and being introduced to some very very open-minded and and brilliant fellows like Dr. Jason Roth who will be speaking last and so these concepts have sort of been following me and I really think that we can enhance our our treatment of pain if we if we accept them and and and utilize them more. So without further ado, I'd like to hand it over to the to Dr. Kaplan. We will be listening to a video of hers and I believe Myra will be helping us get that set up. So thank you very much for your time and I'll be looking forward to any kind of questions you may have or comments or even discussions after this is all done. Thank you. Welcome. Thank you so much for inviting me to present today. It's a privilege to be here and have the opportunity to speak about psychology's contribution to multidimensional treatment for chronic pain patients. Suffering spans physical, emotional, social, spiritual, existential, and financial domains. And as a whole person problem, it doesn't fit neatly within the current biomedical paradigms. There's a difference between pain and suffering, as physicians Epstein and Back point out in an essay that recommends that physicians develop a more encompassing approach to treating chronic pain patients than is typical in the age of specialized medicine. They are saying that chronic pain is bigger than a localized sensation of hurt. The complexity of chronic pain is what allows for, in fact calls for, a multidimensional, multidisciplinary approach to treating it. What a person thinks and feels about their pain shapes the way that they relate to their pain. There are many psychologically based factors that influence people's thoughts and feelings about pain. I've chosen four to talk about. Let's look at them one at a time. Context matters. I'll use a hypothetical example to illustrate how context plays a role in the psychology of pain. Let's imagine two women. I'll call them Lucy and Ethel. They develop equal, sudden, severe abdominal pain. Lucy wanted to get pregnant for the longest time. And eventually, she did get pregnant. And she's carried that pregnancy to term. And she understands that her sudden, severe abdominal pain is labor pain. And her attitude is, bring it on, because tomorrow, I'm going to hold my baby. Lucy is in pain, but she's not suffering. Ethel, on the other hand, has a twin sister who, unfortunately, was diagnosed last week with an abdominal tumor, a malignant tumor. And the reason why she went to the doctor in the first place was because of sudden, severe abdominal pain. And Ethel is terrified that, like her twin sister, she has a malignant abdominal tumor. In her terror, she is suffering in her pain. So context influences people's thoughts and feelings about their pain and whether or not they're suffering with their pain. Culture also shapes our thoughts, feelings, and behavior about pain and suffering. For example, some forms of Buddhism espouse that release from suffering can be achieved by transforming thoughts, feelings, and behaviors. Note that this Buddhist focus is on changing suffering, not pain. There's an assumption that pain is part of suffering. There's an assumption that pain is part of the human condition of having a body. The pain psychology treatment called mindfulness meditation is derived from this Buddhist philosophy that changing thoughts, feelings, and behaviors can reduce suffering. And sometimes, when the suffering diminishes, the perception of the pain diminishes too. This would be treating pain from the back door, taking an indirect route that begins with treating suffering. Now, I'll contrast this with dominant Western culture. Until about the 18th century, Christian cultures in Western Europe shared the Buddhist fatalistic view of pain. However, physiology research in the 18th century demystified pain. And the discovery of anesthetics and analgesics in the 19th century demonstrated that pain itself was subject to human intervention and treatment. This fomented a radical change in cultural values and expectations. In many Western societies, we now believe our pain conditions can and should be treated and controlled. We expect doctors and pharmacists to do that on demand. For the last century, most of the Western world has focused on treating pain, not suffering. I want to say that I titled this slide Mental Health for the sake of common parlance. However, I believe that distinguishing mental health from physical health is a false dichotomy. I believe that we are one integrated being, with the mind affecting the body and the body affecting the mind. Activation of the sympathetic nervous system when we are afraid is a clear example of the mind affecting the body. Now, moving on from medical philosophy, I will say that depression and anxiety are the most common psychological comorbidities in patients with chronic pain. Particularly relevant is that depression and anxiety can alter our attitudes. They literally change how we think. They are like putting on a pair of dark sunglasses, which suddenly make the world look dark. For example, some symptoms of depression are pessimism, poor motivation, and fatigue. It is extremely hard for someone with these symptoms to implement a physician's recommendations to participate in, say, physical therapy. Why bother doing something that requires effort and diligence if you don't believe things will ever get better? Likewise, symptoms of anxiety may include having a sense that doom is imminent, having difficulty controlling worry, and having the urge to avoid things that may trigger more anxiety. Those who fear that doing anything may make their pain worse will avoid implementing a physician's recommendations. These scenarios are frustrating for all parties involved. The good news is that depression and anxiety are treatable conditions. A history of childhood trauma is another relevant psychological factor, even when there is not depression or anxiety as an adult. There is a strong association between experiencing childhood trauma and experiencing chronic pain as an adult. The CDC Kaiser Permanente Adverse Childhood Experiences Study, also known as the ACES study, is one of the largest investigations of childhood abuse and neglect, and later life, poor health, and diminished well-being. The original ACES study was conducted by Kaiser Permanente from 1995 to 1997 with over 17,000 HMO members from Southern California. Participants received physical exams, completed confidential surveys regarding their childhood experiences, and answered questions about current health status and behaviors. Data collection is still ongoing now 25 years later. The findings show a dose-response relationship between number of ACES and negative health and well-being outcomes. In other words, as the number of ACES increases, so does the risk for later negative health outcomes. The things that many children endure are alarming. Female patients indicated that 27% of female patients experienced physical abuse as a child, 25% of female patients experienced sexual abuse as a child, and 13% emotional abuse. 30% of male patients experienced physical abuse as a child, 16% sexual abuse, and 8% emotional abuse. I find that alarming. Studies have found that childhood physical, sexual, or emotional abuse is associated with an increased risk for fibromyalgia, chronic pelvic pain, migraine, neck and back pain, and arthritis. It is beyond the scope of this lecture to delve into the mechanisms proposed that link adverse experiences in childhood to health problems that emerge decades later. However, I refer you to Dr. Bessel van der Kook, a psychiatrist who has spent almost 50 years researching post-traumatic stress disorder. He believes that trauma is stored in the body, not just the mind. And he has been studying trauma for over 50 years. Trauma is stored in the body, not just the mind. Hence the title of his seminal work, The Body Keeps the Score. The idea is that treating the original trauma with psychological interventions allows the body to stop keeping the score, allows the person to quiet the somatic expression of their psychological pain. The third mechanism that may be involved is epigenetics. As you have gathered by now, I diagnose and treat based on the assumption that the mind and body work together and reverberate off of each other. I want to turn now to describing one treatment intervention that I use. I teach mindfulness meditation. What is mindfulness? One definition is the awareness that arises from paying attention on purpose in the present moment non-judgmentally. Each phrase in that definition is an important component. It is a carefully crafted definition. Let's break it down. First, the goal is a particular kind of awareness. It's a dispassionate, curious, non-judgmental awareness. How does one get this particular kind of awareness? By paying attention on purpose in the present moment non-judgmentally. Paying attention on purpose. Mindfulness, as opposed to, say, a relaxation exercise, assumes highly focused, we could even say laser-focused attention. This in and of itself is not easy and requires steady practice to build cognitive stamina. And it's not attention to just anything. It's holding attention on the present moment experience. Now, what does that mean? Most of us allow our thoughts to be either future or past oriented. We may be planning for the future, like our endless to-do lists, or worrying about the future. We may be remembering and reviewing something in the past that we want to cherish or to fix. But it's rare for us to steadily hold our attention to our present moment experience. Right here, right now. Fortunately, there's a method to help us attach our attention to our present moment experience. We attach our attention to a sensation because our senses give us experiential information in live time. It might be the sensation of your feet on the floor or where your body makes contact with the chair or the sensation of your breath. The sensation of your inhalation and the sensation of your exhalation, each distinct and unique. Perhaps even smaller sensations, like the first faint hint of each in-breath and the first faint hint of each out-breath. We could even be noticing the tiny spaces between breaths, which are a little like rest notes in musical composition. The brief silences are important parts of music and important parts of our life energy. Now, holding your attention this way is not easy. On the surface, the sensation of breathing is not fascinating. So one's mind quickly starts to wander. As an aside, it turns out that your breath is truly fascinating because it's your life energy. Your life energy happening in the moment, moment by moment. It is our being. Mindfulness practice returns us to being a human being as opposed to a human doing. But I digress. Back to the definition. As I said, often when one tries to meditate, one's mind starts to wander. It is the nature of minds to wander. At some point, as one tries to meditate, one realizes that one's mind has wandered. And this is considered the moment of waking up. The expressions lost in thought and daydreaming are apt. From a mindfulness perspective, when one is lost in thought or daydreaming, one has lost what is real or is sleeping through what is real. Because in a sense, the only real thing is your present moment experience. The past is not exactly real because it's gone. And the future isn't real because it isn't here yet. What is real is whatever you're experiencing in this exact moment. At some point, while we're trying to meditate, we wake up to the fact that our mind has wandered. And we bring it back, hopefully non-judgmentally, to the present moment. Non-judgmentally is key. We are used to judging everything all the time. The room is too hot or cold. This presentation is boring or interesting. The chair is too hard. My back is getting sore. My spouse did something on purpose. I'm sure of it. On and on and on, wishing we could fix it all. So too, it is nearly automatic to judge our wandering mind or the practice of mindfulness, which may sound something like, I can't do this. Or mindfulness practices are idiotic as your mind wanders off the sensation of your breath for the nth time in a minute. The way that we try to be non-judgmental is to get a little emotional distance from ourself by seeing ourself as a dispassionate but curious witness of what's going on, which in the moment of waking up might sound like, oh, my mind has wandered again. It reverted to planning again. I can bring it back to the sensation of my breath. Curious and dispassionate. We can bring the same skill to emotional sensations that arise. Oh, I'm feeling anxiety in the pit of my stomach again. No judgment. I can bring my attention back to my breath. And the same skill can be used for physical pain. Oh, my mind has gone back to focusing on the throbbing in my knee. No judgment. No thoughts like, this pain is terrible because it means that I won't be able to fill in the blank, which brings us back to suffering from our thoughts about the pain. Instead, mindfulness teaches us to notice the throbbing in the knee and then gently bring our attention back to the breath. With a great deal of practice, we can learn that we can direct our attention to where we want it to be to keep it out of bad neighborhoods, like, I can't live with this pain for the rest of my life. That thought is a bad neighborhood filled with suffering. To summarize, there is a difference between pain and suffering. Our thoughts, feelings, and behaviors determine whether we have pain with or without suffering. Sometimes, reducing the suffering also reduces the pain. A person's thoughts and feelings are determined by many factors, including context, culture, current mental health status, and a history of childhood trauma. Mindfulness is a skill set that emerges from a philosophy about suffering. This skill set helps us gain control of our thoughts as opposed to our thoughts being in control of us. Having control of our thoughts helps us with emotional regulation. And mindfulness teaches that we can choose a dispassionate and curious response to whatever arises instead of being sucked into unpleasant major reactions. Dr. Viktor Frankl was an Austrian neurologist, psychiatrist, philosopher, author, and Holocaust survivor. He described this idea when he said, between stimulus and response lies a space. In that space lie our freedom and power to choose a response. In our response lies our growth and our happiness. Thank you again for the opportunity to speak to you today. All right, we should be good to go. Jay Roth, thanks for the introduction, Dr. Zelnick. Just again, in case you missed it, I'm a interventional pain doc in Delaware, Center for Interventional Pain and Spine, PM&R trained, pain medicine fellowship with a big interest in integrative medicine, obviously that's why we're here today. And I did my fellowship luckily at JFK with Dr. Parikh and Dr. Kaplan. And I miss them tremendously because it's unique to find in the pain world, people who understand the importance of this integrative approach, the mind-body medicine and not neglecting that when it comes to treating our patients. So happy to be here, thanks for being here, everybody. So I'll be focusing just on one aspect of mind-body medicine today, but it is perhaps the foundation of the mind-body connection, and that is breath. Specifically, we'll talk about some breathing techniques to try to reduce pain, and hopefully it'll be informative, but also practical and experiential as well. So before diving totally into breath, I just also wanna touch on just why talks like this are so important. This talk does fall under the title of alternative medicine, but I just wanna be clear that what we're really practicing is integrative medicine, which uses evidence to combine the best tools of everything that we have available to us, whether it be complementary alternative medicine or CAM or traditional Eastern medicine or conventional Western medicine. We wanna study and combine the best aspects of all of these to treat our patients more comprehensively, and as long as the benefits outweigh the risks, of course. So, and the reason why that's important as Dr. Parikh and Dr. Kaplan eloquently explained is that pain and disease in general is so complex. It's much more complex than just physical ailments, and so it requires complex treatments and treatment plans. So that's up to us to do. We can talk about medications and neuromodulation all day, and that's kind of how most pain conferences feel these days, but it's really no longer enough, I think, and it's actually proven detrimental to just try to mask these symptoms. What we need is to actually be able to get to the root cause. Ideally, our system would allow healthcare providers to take the time and effort to try to find the root cause of our patient's pain and help facilitate their journeys from painful suffering into healthier, more balanced, and fulfilled lives. So I just wanna encourage everyone to work toward integration going forward here. So here's how I integrate. I'm a pain doc, like I said. I prescribe a bunch of all kinds of medications and do all kinds of procedures up to neuromodulation and even some minor surgeries now, but I also practice acupuncture. I also prescribe a ton of physical therapy. I teach my patients home exercise programs and encourage yoga and meditation, and I also teach breathing exercises, and we'll go over how to do that quickly and hopefully efficiently. And this is not all inclusive by any means. I mean, underlying all of these things, I think, are nutrition, psychology, like Dr. Kaplan just went into, patient education and patient empowerment. But as you can see, breath is the simplest probably and most fundamental of all these treatments. So let's talk about it. So as long as there is breath in the body, there is life. And when breath departs, so too does life. So we should regulate the breath. Of course, we've seen this before in Dr. Kaplan, and actually Dr. Parikh, sorry, had excellent slides on this, but I just wanna make sure that we really focus in on that sensory and emotional experience and not ignore that because in the academic world, we focus so much on the pain pathway and transduction, transmission, modulation, perception, but I would argue that the emotional aspect of all of that is even more complex and less well understood at this point and certainly less well treated and focused on in our healthcare. So just wanna make sure we pay more attention to that. And as noted here, breathing can actually affect every aspect of the pain pathway. And we'll get into how that is. Another important distinction here, like Dr. Parikh went into, acute versus chronic pain are two very different things. Pain that persists longer than three to six months is considered chronic. And more importantly, it's no longer a warning symptom for an acute condition, excuse me. My throat's a little sore, so it's no longer serving a good purpose anymore. And it becomes the predominant clinical problem and it leads to sympathetic overdrive. The fight, flight, or freeze response is kind of always on. This increases people's cortisol levels and stress and leads to many different outcomes down the road, negative outcomes. So, and it also leads to our jobs, right? Trying to figure out what's going on, how can we treat and that costs a lot of money. There are estimates of $635 billion a year just in the US for treating chronic pain and all the losses that are involved in that. And it's so common, one in five people worldwide are in some form of chronic pain. And that's only increasing, so. So let's focus it on the topic here of breath. So breath is fundamental to health and we all understand that. I think it's human nature to understand that and it's been understood for millennia. And in fact, the word for breath has had greater connotation in many cultures, often meaning our life energy or our vital energy, such as Qi in Chinese culture, Prana, Ruach, Numa. These are all words for breath, but that also mean more than just breath. And using the breath for health and healing is tradition, right? It's used in for thousands of years in meditation and yoga and martial arts and prayer. And also childbirth and anger, even as kids, we're always taught, take a deep breath. And in acute pain, I think it's more well understood, taking a deep breath. But we're trying to just show that it's also useful in chronic pain as well. And unfortunately the importance of breath has been lost a bit in our technology-driven, fast-paced for-profit health system. Can't make much money telling someone to breathe slower. So that makes it even more important to try to include it somehow. And the pendulum hopefully is swinging. Over the last 20 years, there have been many more publications and research regarding breath and mindfulness in general. So the evidence comes from millennia of healers and now the evidence is being shown in modern research. So hopefully that will help show the importance of this even more. But basically we know that voluntarily modulating natural breathing patterns can improve mental and physical health. Many studies have shown various breathing exercises to decrease sympathetic tone, cortisol and stress levels, decrease blood pressure, glucose levels, and also help with anxiety, panic attacks and pain scores as well. So regarding evidence for pain, it's really just been in the last 10 or 15 years. Shillay in 2009 showed that sleep, sorry, slow deep breathing, decreased experimental heat pain and increased vagal cardiac activity. And this was significant when compared to distraction techniques. Zunhammer in 2013 showed that increased cardiac parasympathetic activity is associated with reduced pain perception. Bush in 2012 found that deep slow breathing and relaxation techniques significantly influenced autonomic and pain processing with decreased sympathetic activity. And in 2016, Zidane and Vago found that mindful breathing reduced self-reported pain scores. So, you know, probably the best part about these treatments is that they don't cause any harm, right? No matter how robust or non the evidence is, you're not comparing it to a harmful treatment option. So it's important to keep that in mind. And Vincent Minaschiello, I might've butchered that, said whether voluntary or involuntary, breathing is one form of non-pharmacological treatment or non-pharmacological medicine that can be practiced easily in any setting at any time. So let's talk about breath work. So breath work is any form of breathing exercise or breathing technique. It is an intentional change to your natural breathing pattern. There are many ways to modulate our breath. Here's a few of the more common categories. Pace and pattern breathing is probably the most common, taking slow deep breaths. You can also do muscle and body emphasis with breathing. So breathe, trying to use the diaphragm more or the nose more or something like that. Airway resistance. There's a lot of great techniques here. Purse lip, alternate nostril breaths, Ujjayi, which we'll talk about. Internal imagery linked to breath. So guided meditation along with breathing and coordination of breath with movement like yoga and Qigong. So I just wanna go into a few of these, just the ones that I think are maybe the most common or most useful for us as practitioners to try to pass along to our patients. So deep, slow breathing, simplest one probably. Basically, it's a type of pace or pattern breath, but you're just trying to slow your respiratory rate. So apparently the ideal respiratory rate, if you look at all different kinds of studies and also ancient rituals and prayers, there seems to be this agreement that about six cycles per minute is the ideal respiratory rate, really 5.5. So yeah, I think we're all breathing a little too fast probably. And this is actually, a ton of research behind this. Specific respiratory rate shown to do all of the changes that I kind of talked about with the sympathetic activity and blood pressure, but also has been shown to decrease hot flashes in menopausal women, decrease insomnia and improve heart rate variability. Another breathing technique, this one has been popularized by Dr. Andrew Weil, who's a pioneer of integrative medicine. The four, seven, eight breath, basically inhale for a count of four, hold for a seven count and exhale for an eight count. And I think the key point here is that the four and eight, it's an inhalation to exhalation ratio of one to two. You wanna increase the amount of your exhalation. You wanna basically make your exhales longer than your inhales. And that is the key to decreasing sympathetics, helping with relaxation. Another one that's kind of a little more popular now, super ventilation, which is super compared to hyperventilation, probably commonly known as the Wim Hof method. Wim Hof is a pioneer in breathing techniques. It's got a few other names here, but basically you actually intentionally increase your respiratory rate to one to four breaths per second. So what's that, 60, at least 60 a minute, which sounds crazy, but I think if you do that for about a minute, it's shown to essentially induce a respiratory alkalosis, which would lead to in some studies that they feel would lead to less effective transmission of pain signals. So that's how, here's how breathing can affect that pain pathway. But also in the short term can help with cold tolerance. That's how Wim Hof uses it. He kind of climbs mountains and does ice baths and pretty much naked, help with depression, fatigue, and in the longterm, potentially with cognition, pulmonary function testing. Now there's less evidence for this one in chronic pain, but I have a lot of patients who say their pain is worse in cold weather. I don't know if you all hear the same thing, but something to think about, you know, you can tell your patients to try to induce a respiratory alkalosis next time they're cold. So another breathing technique I want to talk about is Ujjayi breath, also called ocean breathing because it sounds like an ocean, and it's the primary breath of Ashtanga yoga. This is an altered airway resistance type of breathing pattern where you actually constrict your throat thereby hearing the breath louder, but it's actually a form of nasal breathing where you're not really blowing in and out of your nose. It's powered by the diaphragm and the throat. It's very calming and centering. It's my personal favorite, easy to do at any time. Just one breath makes you feel better and perfect for stressful situations like dealing with an angry patient or presenting at a conference, for instance. Nasal breathing, just a plug for nasal breathing in general and really a plug for a book that I've been listening to on audio books called Breath by James Nestor, who's a science journalist. This guy basically, you know, spent years exploring breath past and ongoing studies. And basically his central theme is that slow nasal breathing is best for various different reasons. I recommend the book. So let's make this experiential. Let's do a little practice. And hopefully if you get something out of this, you can, you know, help teach your patients as well and pass this along. So the breath I want to practice right now is actually a kind of a combination breath of the Ujjayi, which is the constricted throat breathing with deep, slow breathing, ideally, you know, exhale to inhale ratio of two to one. So let's all sit up if we can. Straight back, head up, shoulders back, or if you're lying down, that's fine. I guess we're all at home. So how you do this one is, I want you to imagine your palm as a mirror and as if you're going to fog up the mirror, okay? But instead of doing that, we're actually going to do that with our lips gently closed. So the air is actually coming out of your nose, but you don't really feel it coming out of your nose and you're not blowing out of your nose. It's coming from the diaphragm and the throat. So then you can inhale through your nose, either with a constricted throat or not. It should be that loud, audible breath. And then we want to try to aim for a two to one exhale to inhale ratio. So let's try to aim for six breaths in a minute, see if you can slow it down to that. So I'll give you a minute to try to try this and I'll lead you. All right, I'm feeling very relaxed. I don't know how you guys are feeling, hopefully feeling the same way. So now that you know it, I just want to encourage everybody to integrate these teachings more into your practice of rehab and pain. And, you know, the perfect patients to do this with are inpatients, acute pain consults, so easy to just lead them through a quick breathing technique. You know, patients with pain-related anxiety or panic attacks, hypertension, frequent flares of acute or chronic pain. And I think the best way to do this is one-on-one teaching in the office. That just took us, you know, what, a couple minutes to do. Once you do it more, you can get quicker with it. And, you know, I feel like it really strengthens your therapeutic relationship with your patient. I don't think patients are used to going into the doctor and having the doctor sit and basically meditate with them and do a one-minute breathing exercise with them. So not only are you teaching them a good technique, but you're getting them to, you know, basically trust you more. And, you know, then you can educate them more to try to guide them out of their pain. Obviously, handouts, YouTube videos, all that's good stuff too. But definitely keep practicing and see for yourself. And I think you'll find that you'll want to do it more. That's it. Thank you very much. Thank you, everybody. This was excellent. And I really appreciate you guys taking the time to come here today. And I'm feeling, I'm getting a little bit of feedback on my microphone. Okay, now it's gone. So I want to ask some questions for the panelists because we don't have any active questions in the question box right now, but I do encourage the participants to write your questions so we can get started. So I can give a question first to Dr. Parikh. You were talking about physicians as role models and you were explaining some of the experiences you had in the Himalayan mountains. How do you control your stress response? So it's funny. And I guess I'll get a little story about it. I'm a type of guy that I don't want to have any expectations for any experience. I want to see what unfolds as the experience comes. So when I went to that trip, which was back in 2019, actually, I know that people oftentimes when you hear tales, they flock to the forest, they flock to the mountains to gain some sort of balance. And how is sometimes not elucidated or not really explained. And I didn't want to, like I said, I didn't want to gain any other, I don't want to have any expectation going into it. I just thought, well, let's just see what happens if I can, if I just do this. And I found that, we've reached heights of close to 19,500 feet above sea level. So they're quite high. And as we were hiking, I realized that all you see is just terrain. You just see kind of empty terrain, mountainside, maybe some little vegetation, and you're just breathing as you're walking. Because if you're doing these hikes for eight hours, nine hours, 10 hours at a time, all you're doing is breathing. And before you know it, you're actually employing some of these techniques that Dr. Roth talked about, and even to some degree what Dr. Calvin talked about, which was, as I was walking, I just felt, okay, I just kept breathing, just kept walking forward. And at some point I realized that I was rhythmic breathing. And I realized that I was, even though this was a grueling hike, I was not stressed. I was energetic. My mind felt light. And I just felt great. And I just thought, like, isn't that something? Like, this is, no, I wasn't even trying to, let's say, rhythmic breathe or even empty my mind or sort of dissociate myself from my thoughts and just sort of keep going. But I did so just out of necessity because I was in the mountains. And it felt great. And that's when I came back and I thought, well, interesting, usually when you're doing some sort of really physical activity, your body's feeling stressed. You're feeling some wear and tear and you're feeling, there is a little bit of fatigue and tiredness that comes from that. And I felt none of that. And I think a lot of it has to do with, I think what Dr. Roth was saying is that when you think about our sympathetic response and you think about the firefight response when you're challenged, if it's a heart rate increase, a blood pressure increase, if it's a muscle tension or even increased respirations and breathing, the one thing that I think we can actually really control is breath. I can't will my heart rate to decrease. I can't will my blood pressure to get slower or to get to decrease, but I can control my breath. And I did so because as you're hiking, that's what you're doing. And so when I realized that by doing that, I just felt, I felt great. And so I think when the answer is, how do you gain control of your sympathetic nervous system? Utilize the one thing that I think we do have great control over, which is breath. And once you, that fight or flight response all kind of comes together. It's not just, oh, you just get heart rate or you just get rapid breathing or you just get this and that. I think if you can control one element of it, you can then influence your body to control the rest of it. So I think when it comes down to it, I think what I learned from that experience was how profound breath work could be. I think prior to that, I just accepted breath work as part of the meditative experience. But after really just utilizing it in that terrain, I realized how powerful it can really be. I hope that answers your question. Yes, and then I have a question for, I guess, both you and Dr. Roth. I know you have both worked in an interdisciplinary pain program with Dr. Kaplan, a pain psychologist. How does the referral process happen? Who is a suitable candidate for her services? Sure, I can answer that. Jason, I don't want to take your spot there. I was going to say pretty much every patient that I have is a good candidate. No, I mean, I think identifying patients whose chronic pain is affecting their lives in some sort of emotional way, which is, I think, almost everybody. That's probably going to be your target patient for that, especially if they're having issues coping. You know, Dr. Kaplan's great at teaching. And I'm sure pain psychology in general, that's what they do. They kind of teach adequate coping mechanisms. They use cognitive behavioral therapy. So anyone who you think could benefit from that, which to me is certainly the majority of chronic pain patients. Referral source, I'm actually working in Delaware at a private practice, and I'm actively trying to find good, any pain psychologist or any psychologist who's comfortable and able and willing to see chronic pain patients. And it's been a struggle. I've been there for a year and I haven't really found a good doctor to be able to refer to. You know, insurance obviously gets in the way and all of that. So anyone out there listening today, if you have a good pain psychologist in near Wilmington, Delaware, Philadelphia, yeah, I'm still searching. Yeah, I mean, I think, and just to piggyback off of what Dr. Roth has just said. So, you know, we were lucky to have Dr. Kaplan with us at JFK. When I joined, so I joined coming out of, I had worked somewhere previously before that, but I had come off the fellowship in Chicago at Northwestern RIC, which is now Shirley Ryan Billy Lab. And working, they have a chronic pain program that's quite, I think, really robust there. Dr. Stanos was, Stephen Stanos was there at this time. And we had a psychologist, Dr. Gagnon, who was there. And it was a good bootcamp. It was a nice multidisciplinary bootcamp. And the first I've ever seen, you know, just coming out, just being in training. And so it was lucky that when I joined, when I had come down to JFK, that we had Dr. Kaplan. Because at that point it was already, I realized how important this was. And mainly because I know that outcomes, outcomes wise, we want people to feel great. We do, we really do. And I noticed that even when we would provide them our interventions, even if they were able to now walk two miles when before they can only walk five minutes or whatever it was, you know, even if their physical ability improved, they would still indicate that their pain scores are very high. And it was, at first it was very bewildering, but then it came down to a point where it was like, everyone, they're suffering. There's something there that's causing them some suffering. And until we also cater to that, they're not going to feel that they're improving. And it's for us, for me, it was being able to identify that and then being able to refer them to somebody that can take care of them in that manner. And so even before using these questionnaires, like the Promise 29 questionnaire that I talked in my presentation, I would really employ a lot of these other questionnaires that even Dr. Melzack actually formulated, like the short form MPQ, which was talking about the descriptors for pain. So I would use these questionnaires to get a sense of not just the chronicity of how long they were in pain, but also how are they relating to how their pain is and getting that sense. Whenever I got a sniff of any kind of suffering or really heavy emotional and cognitive component to it, I would immediately refer them to a specialist. Great. I have a participant on the chat box, Jessica Mack. Hi, Jessica. Thank you for commenting on the presentations. She's having the same difficulty you're having, Dr. Roth, in getting a pain psychologist. She's looking for somebody in South Central Massachusetts, and she's also looking to start an interdisciplinary pain program. Any advice, both of you, for her? So I have... So Jessica, thank you for the question. As far as starting an interdisciplinary program, I think it's a great idea. It is a little bit of an uphill climb right now, only because, right, how does it get reimbursed and how does it get paid? That's the main question. I know that at the RIC or the Shirley Ryan Ability Lab, they had been doing this for years, and so they were able to prove to insurance companies that this package, this chronic pain, interdisciplinary, integrative pain package actually saves money and improves outcomes in the end. They were almost like... So I think in that sense, they were almost paid like it was an inpatient stay, but it does take time to do that. And I would say, if you're interested in creating one, maybe reaching out to some of these programs that have really full-fledged, fully fleshed out programs, and seeing if there can be some collaboration or a partnership to kind of create something. I do think we need more of these types of programs in the nation. We don't have enough. Yeah, I would just add, I mean, if we can somehow prove to insurance companies that, yeah, they would save money in the long run, that would be the best thing, but that's pretty hard to do. My practice is a pretty large multi-office pain practice in Delaware and Pennsylvania, and we do actually, over time, we have acquired some chiropractic providers, and that model is working out well. They used to refer to a chiro, then the chiro kind of rented space. Now they're on our staff. So I'm hoping to basically prove to my bosses that eventually we'll be able to do the same kind of thing with pain psychologist, a nutritionist, all of these other, maybe an acupuncturist, or if they'll let me do some acupuncture there. So that's another way to try to do it, Jessica, is to use your resources in the community and team up. You don't have to start from scratch, but just kind of join forces. But yeah, it's tough, and trying to get everything covered and make it profitable, or at least break even, because you need to do that to keep the lights on. That's the challenge. I personally, I know some integrative practices that have reached out to the community massage schools to get massage therapists or students to come by to clinics to provide the service, especially if you're dealing with a pain clinic in a low income area where there's not a lot of expendable income from the patient population. So that is one way, and a lot of integrative practices are now implementing group medical visits. So that's a whole other system, but you can get reimbursed for doing education. Some practices even do an acupuncture in the group medical visit, and then they see the patients individually for their appointments, and then they can reimburse for that. So those are two other suggestions. One thing I'll even say that, the one thing that the pandemic has done is telehealth is now very prevalent in the behavioral health world. And so now you don't necessarily need to have a pain psychologist that's even in your town or a couple of towns over, as long as I guess if they're practicing in Massachusetts, for example, maybe a telehealth service can be started or offered to patients. And I think, I mean, I do think in some ways having that one-on-one in-person contact is helpful, but I also think if there's no one around close by, telehealth has really opened up some doors, I think in behavioral health. Agreed, that's a good point. We'd like to open it up to the rest of the participants. I don't know if it, can we un-mic the participants if they want to chime in or introduce themselves or make any questions or comments before we wrap up? Okay, go ahead. So hi, everybody's un-miked, all the attendees. So if anyone wants to introduce themselves or chime in, we have a few minutes left. Hi, everyone. While you're gathering your thoughts and your questions, I do want to thank Dr. Roth there. Jason, I know he's been weathering a cold and so you got through that presentation well. Thank you, I've got my green tea. Very good. Well, thank you everybody for attending. Thank you, community members. This session is recorded, so it will be available later if you want to review it or if you came a few minutes late, so it'll still be here. And there's a part two, oh my gosh, there's a part two later in the month. Dr. Chugtai is going to do nutrition and pain and Dr. Katie McAbee, she's going to be doing more specific stuff with mindfulness. So if you liked the idea of mindfulness and you want a little bit more of an expanded outlook on that and more information, then you can tune in later this month for a part two. Thank you all. All right, bye everybody. Thank you, thanks everybody. Thank you.

multidimensionality of pain

mind-body techniques

pain management

context

culture

mental health

childhood trauma

multidimensional approach

mindfulness meditation

chronic pain

breathing techniques

interdisciplinary pain programs