Welcome back to the Healing Pain Podcast with Annette Willgens, PT, EdD
This marks about the halfway point in Our Radical Relief series. We are recovering three-time tested and science-backed approaches for the treatment of chronic pain, which include pain neuroscience education, mindfulness and acceptance and commitment therapy. This episode focuses on the evolution and the nurturing of mindfulness-based physical therapists. Starting to train and embed mindfulness, both as a process as well as a treatment approach for physical therapists. I’ll be speaking with Dr. Annette Willgens about mindfulness.
She is a Clinical Associate Professor in the Department of Health and Rehabilitation Sciences in the Program of Physical Therapy at Temple University. As Director of Admissions, her scholarly agenda includes physical therapy student success, resilience to stress and effective domain skills across the curriculum. That has published two papers on mindfulness for the student physical therapist and its impact on resiliency and usefulness in clinical practice.
In this episode, you’ll learn about the neuroscience supporting mindfulness, how mindfulness works and why training in mindfulness is important for both the student physical therapist, as well as a licensed physical therapist out in the field. This is a pivotal episode in Our Radical Relief series with regards to mindfulness, for physical therapists and other licensed health professionals. Let’s begin and let’s meet Dr. Annette Willgens.
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How To Nurture The Next Generation Of Mindfulness-Based Physical Therapists With Annette Willgens, PT, EdD
Annette, welcome to this episode. It’s great to have you here. Thanks for joining us.
It’s great to be here. Thanks for having me.
On the evolution of the show, we’ve talked a lot about the mind and the influence of the mind on the body and vice versa, how the mind can influence the body. People who follow this show are interested in mindfulness-based approaches as a physical therapist. I’m curious to hear how you first became interested in mindfulness.
I was a new faculty member. I had taken on a position as assistant faculty and the role of the Director of Clinical Education. I thought, how hard can this be? I play students, they’re happy. I watched them learn and grow. It wasn’t like that at all. My office became a revolving door of students with concerns about anxiety, depression, eating disorders, parents divorcing, ill parents, essentially students experiencing pain. At the same time, I learned that students would struggle in clinical education courses. Every year there was a couple of students that would be unsuccessful in the clinic. Although two students don’t seem like a lot, it would take over about 75% of my workload to manage those two students. It was hard to watch. These students were good people and coming to the end of grueling education and were profiling out.
My dissertation topic at the time became how do these bright capable students fail? My first publication indicated that they fall into two big categories, students with baseline anxiety, worry, emotionality, rumination, perhaps imposter syndrome. The other was this concept of they would turn off their emotions, turn off or hit the delete button for feelings, worries and thoughts that would arise. The remediation for these students was my role and I was lost. I have a colleague at the time had said to me, “What do you know about mindfulness?” I said, “Nothing.” I went and read everything I could possibly read and took courses and got certified as a teacher.
When I think back to when I was in PT school, which was in 1995, we knew there was a high amount of pressure and stress. Some of it placed on ourselves because many who are involved in physical therapy or get into your program are high achieving individuals and intelligent. Some of it’s stress based on the amount of that we’re required to learn to be effective as professionals. It’s interesting how lately there’s more in the physical therapy literature showing up about stress, anxiety, depression within PT students. I want to first thank you for your work as I go into the literature and look at some of that work with regard to student burnout. Your name is one that rises to the top, especially with regard to mindfulness. There are only a couple of mindfulness articles with regard to PT students. One particular that you wrote that I want to point people to is in the Journal of Physical Therapy Education 2016. It’s called Physical Therapists’ Perceptions of Mindfulness. Why did you decide to write that paper and why was it important?
This paper was a wonderful opportunity to connect with students. Students came to me and said they want to study mindfulness because I had been based on students struggling. I had begun infusing mindfulness practices into the curriculum. I would start the class with a pause or a moment of stillness and ask students to check-in. They liked that and wanted to do more. They had been through the first two clinical courses and said, “Why is this not out and about? Why do clinicians not know about this? More so, why do they minimize it if we bring it up?” They were curious. This was the combination of a student group that basically wanted to study it. They created a booklet and once a week would sit down with their clinical instructors and talk about different lessons that pertain to mindfulness. The first was definitions. What are the medical benefits? What are some of the research out there? Each week, they would talk about a specific topic and what unfolded was neat. A lot of the clinicians out there realized how much they plow through life. We all do it at varying points in our lives. I’m as guilty as anybody else. That’s how it all unfolded.
As I look at that paper, there were a couple of different themes that emerged from that paper. I’ll read them off so people can have an idea but the themes that emerged from that paper were one, the need to fix this. The second theme, which was to pause. As I pause, I noticed that this is hard. The third theme was that mindfulness works. The fourth theme was I need support. Can you tell us a little bit about each of those themes and what it told you about the outcomes from the study?
The first theme, the need to fix is a universal thing. We are fixers. We’re physical therapists. We help people and the need to fix when things are not necessarily fixable can be a difficult experience. When we’re not able to fix it, that’s where the stress comes from. It originates in that felt sense of needing to do something more than what we’re capable of doing. There’s this concept of emotional empathy as compared to cognitive empathy. I teach my students about that because I think that we get sabotaged by being led to believe that we can fix everything. We’re uncomfortable with discomfort. We’re not okay with being uncomfortable. If there’s anything that this practice has taught me is that that’s the most important thing that we do need to learn to tolerate.
The second was about pausing is hard and that’s that concept of, “I’m a physical therapist, I’m a doer, I’m a mover and a groover,” and it’s hard to stop. A lot of the participants in this study would share that they would go to bed at night. These skilled clinicians had a difficult time turning off the mind and the constant chatter of the brain and the rumination. Did I do enough? This work is hard. I believe it’s the hardest work we’ll ever do is to pause and feel. We’ve gotten good as a society at plowing past feeling and to remain in doing mode. That’s why that theme emerged. Mindfulness works were basically the small teachings that the students provided these clinicians did have a profound effect.
Some of the clinicians would say things like, “I turned off the television. I tasted my food for the first time in maybe years and I realized that I was full before I’d even finished my plate because I felt embodied and I felt connected.” Those things are fascinating. This stuff works. The biggest takeaway from the paper was that you don’t have to sit cross-legged for an hour every day to get the benefits of mindfulness. It can be like brushing your teeth. If you brush your teeth and feel the toothpaste on your teeth, if you walk and feel your feet hit the ground, if you notice the sensation of the air on your skin, as you’re walking your dogs, that’s mindfulness. That incrementally changes the brain in a dose-response relationship. That’s critical for all of us human beings.
We’re going to talk about some of the behind mindfulness but I want to go back to that first point for a moment where the theme was, “I need to fix this.” In this study, was that statement with regard to, “I need to fix my internal emotions, thoughts and sensations,” or was, “I need to fix my patient or the situation I’m in,” or is it a combination of all those?
It was a combination of all of those. Individuals would notice the need to fix patients and notice the need to fix their own responses to the patients. There was one quote that said, “We’re in high stress demanding job Working with people can be difficult. Any technique that could help us work better with patients, work better with students reduce stress, I’m all in.” I believe it’s that universal sense that we are inherently flawed. We are perfectionistic beings and that is not sustainable.
Especially for PT students, when there’s so much going and change in their life. PT curriculum has grown from the time I was in school, which is interesting. I’m curious from a professor’s perspective because if I were to go to many DPT websites, there’s a bit of a theme there that as professionals, we go to school, we achieve this degree and we have this ability to fix people. Now, a grade one ankle sprain. I’m confident I could “fix” that. As I’ve continued on in my career, we thought a lot of the work I’ve done with mindfulness and act, these themes have come up. I’m wondering how you communicate this. It’s communicated through mindfulness itself but do students raised their hand at some point and have an a-ha moment where they say, “I’m not sure this is what I thought I would be doing. This is not the way I thought I would be doing it,” as they come across information you’re sharing with them, which they’re probably not hearing in other classes and particularly other programs.
My experience has been that if I try to teach students about the complexity of patient care then I’m not teaching them from an inside out perspective and it doesn’t land with them. They check out and they’re like, “I’m going to go teach that grade two ankle sprain.” If I teach it from the perspective of, “This is stressful. This is a ruling program,” you will have moments of discomfort and failure potentially. That resonates with them because, by one example, there are three big-ticket items I teach students. One is that your thoughts are not necessarily real. That’s a great teaching that basically means we tend to judge everything. We like it. We don’t like it. It’s good, it’s bad or it’s neutral. We compare and we tend to check out of the present moment.
The present moment is not exciting. It’s not something that we want to hang out in a lot. We think about the future and the past. The students attached to that, “I got an A, that’s great,” I want that A. That’s the expectation. That’s striving. That becomes the focus of their attention. Not necessarily the learning but the A and similarly, when they attach to the bad, it’s that, “I got to see, am I meant for this?” That becomes the focus of their attention and the action arises from that felt sense. Without the attention and the awareness, the student gets enslaved or entangled with that emotionality and they move on with autopilot, which is that default center of the brain that says, “This is how I’m doing it. I’m not going to look any further than myself.”
The concept of real but not true teaches them well. There’s a real physiological and even biochemical response that the HPA axis, all the things we know about the sympathetic nervous system response. There’s a bear in the room, there’s not a bear at all. That’s always a big ah-ha moment for them. They realize that they can pause, reflect and discern their thoughts and feelings without action. That is a breakthrough moment for them. The fact that they themselves can restore their sympathetic nervous system to its proper function is important. It becomes a tool. The other thing I teach them is that feelings have names and there are temporary and universal.
For example, I start my class with, “Let me know how you’re doing. Put into the chatbox, number one, if you feel like you want to go back to bed or a number ten, if you are ready, taken on the day and bring it on.” They see the chatbox and they’re like, “I’m not alone. Look at all these other people that are 2s, 3s and 4s and changes the dynamic of the class.” It helps them feel like they are no different. Stress is a normal universal human experience. That’s huge too. When they tell me, “I’m feeling anger or sadness,” I’ve realized that students have increasingly few words to discern their experience. When they say, “I’m mad about this grade,” I asked them, “Are you mad? Are you angry? Is it more disappointment? Is it sadness or frustration?”
That is another a-ha moment for them. They are learning that it doesn’t have to be all in one bucket. There’s a great funny neuroscientist, Norman Farb, who basically says, “Why do we have to feel things? Why can’t we just think it through? Why can’t we be cognitive beings?” He’s written a paper on the concept of embodiment, interoception and the granularity of emotion. I teach my students all about that. When they learn that they don’t have to be enslaved and entangled with emotion, they say, “I see. I get it. If I feel it, I can make the emotion move through me much more quickly than if it stays in my brain space and I ruminate about it for three days.” It lends itself to self-confidence because if I can work it through myself and I don’t have to call mom and a friend and check in with them then I’m basically teaching my brain that I can manage things myself.
A piece about interoception is interesting to me, especially from the physical therapist’s perspective. There is so much mindfulness that focuses on thoughts but there’s a whole other aspect of mindfulness, which is mindfulness of the body and how interoception, which is the scientific-technical term influences our thoughts. Mindfulness itself has been defined by everyone from yogis to Buddhists to contemplative scholars to psychologists. What’s your definition of mindfulness that you’d like to share with your students so they start to understand, “This is what mindfulness is?”
There are some great definitions out there. I essentially teach them that mindfulness is about present moment awareness of what’s going on truthfully for them. The key ingredients are a healthy dose of gentleness and self-compassion and without judgment. That is the single most difficult thing that clinicians that all of us do is to try to look at ourselves with gentleness. We do it for everybody else. We’re compassionate to everybody else but it’s difficult to do it for oneself. It’s that concept of putting the oxygen mask on first in the plane as the plane is going down. We must do that for ourselves if we can give it away all day long for our patients.
How does mindfulness influence patient care? We’re starting to train mindfulness and student physical therapists and potentially even some of our educators. Maybe you weren’t trained in mindfulness, hopefully, are going back and starting to say, “Maybe this has a place everywhere in our curriculum, not just in one class.” How does it eventually influence patient care as we’re moving into affiliations and into clinical practice and further on in our career?
The biggest takeaways from the literature and are from great publications like Medical Teacher and some other physician journals. Those are patient satisfaction, fewer errors in clinical decision-making, higher quality of care, refraining from that default mode, increasing curiosity so that taking the step back, rather than jumping to conclusions. Patient adherence because when we teach this stuff, we get more buy-in from patients because it makes sense to them. It’s a big a-ha moment for them as well. There’s a direct connection to quality of life because of that. It keeps them coming back because they feel differently. They have a different relationship to whatever’s going on.
That’s important, especially with regard to chronic pain because oftentimes we look at the literature probably about 25% of people living with pain who engage in physical therapy or other types of therapies for pain never see their course of treatment through. What you’re saying can make a huge impact for practitioners but especially for the people that they’re treating.
I teach my students to talk to their patients directly and even draw pictures of the brain, the three levels of the brain. The reptilian brain, as opposed to the higher centers of the brain and how those work. Talk to them about the HPA axis, the Hypothalamic-Pituitary Adrenal axis and the influence of that on cortisol and stress because I believe that that is where all disease starts.
What is complex neuroscience? If you go into The Ledger and start to read about mindfulness and how it works, it’s complicated neuroscience. How do you begin to break that down into bite-sized chunks for either your student body or for patients and explain here’s how mindfulness works?
To be over-simplistic so forgive me in advance if you’re a neuroscientist, I talked to my students about the left prefrontal cortex, the happiness center of the brain and the right prefrontal cortex, which I called the caveman brain or the cavewoman’s brain. It is miserable. He or she is sitting on the side of the road, scanning for threats, there are direct connections to the caveman brain or that right prefrontal cortex to the amygdala, the fight-flight fear center of the brain. When we tap into sensation the body, the breath, we disconnect from that right prefrontal cortex and connect to the somatosensory cortex, which is activated and has been shown on functional MRI scans of the brain. That shows a dampening of beta waves and a functional shift to that left side of the brain and the happiness center with more direct connections to the executive functioning to our ability to make choices that, rather than be enslaved by emotion.
Interestingly, you can change the structure of your brain by pausing and meditating, even for up to eight minutes a day. I teach my students, download an app, do it right before bed and if you fall asleep, that’s great. If you don’t then you’ve done your 5 or 10 minutes of guided meditation. Sara Lazar out of the University of Massachusetts did a study in which she looked at people who have never meditated before and ask them to meditate about a half-hour a day. After only eight weeks, the participants had different brains, their insular cortex had more density.
The insular cortex is that part of the brain that provides us an accurate self-assessment. “What is happening? Am I doing what I need to be doing now?” The posterior cingulate, which is the area of the brain that has to do with mind wandering and self-focus became less dense. The hippocampus is denser. We know that has to do with learning and memory. The temporal parietal junction has to do with empathy, compassion perspective-taking is denser. The pons, which is the home of regulatory neurotransmitters is denser. The amygdala shrunk and this study after only eight weeks. I find that incredibly exciting. In terms of neuroscience, there’s always great studies out there.
It’s a big body of literature that’s continually growing. Where do you point people to as far as the most important research they should look at if they say, “I am looking at my mindfulness but I went into PubMed and I was overwhelmed. Can you shorten my learning curve a little bit?”
There are three important studies and then a fourth that I’ll mention that’s my favorite. The first is a study on epigenetics and aging. That’s from Frontiers in Psychology, there are a number of studies on epigenetics but this was 2020. We know that epigenetics is the science of aging gracefully. The study indicates that in terms of gene activity, we can’t change our DNA but we can change how the genome functions and how it adapts to the changing environmental context that we’re in. It is like the ability to turn down the noise on a dial. If you are turning down the noise on your stress response then you’re changing that genome for the better. That’s why Sabrina Venditti from Frontiers in Psychology in 2020.
In another amazing study, we know how prevalent diabetes is and how it is a public health concern. The Journal of Psychoneuroendocrinology, authors Michael Osborne and colleagues in 2019, he basically looked at amygdala activity, that fight-flight peer center of the brain and showed how it could predict future diabetes. It is not that groundbreaking. We know that stress causes disease but they proved it independent of adiposity. The higher the amygdala activity in the brain seen on functional MRI scans, the higher the stress response predicted new-onset diabetes, even if there was low adiposity. And of course, individuals in the study with low adiposity demonstrated low amygdala activity and did not go on to have diabetes. Those with high adiposity with low perceived stress, no diabetes. What the brain practices lives in the body. The third is the telomere study, which I tell everybody about as the protective caps on the tips of our chromosomes.
This was a meta-analysis, the highest level of evidence on meditation and telomere length. This came out in 2019 by Chute. He showed that these telomeres are shortened when we have a chronic disease and indicate early death and ill health. People who meditated in this study have thicker denser telomeres. There’s this dose-response relationship that exists. The more we meditate the better fit your telomeres have and the stronger the telomeres are. the most important study that I think I shared with a dozen people the day it came out, this is 2017, The Lancet, Ahmed Tawakol and colleagues were able to show proof of the mind-body connection, which is super cool.
They had an N of about 300 patients without cardiovascular disease or active cancer. They studied these people longitudinally. They looked at amygdala activity, bone marrow activity, arterial inflammation, C-reactive protein and perceived stress based on the illumination of the amygdala or perceived stress response. They could robustly predict who would go on to have cardiovascular disease. Predicting the increased hematopoiesis in the bone marrow connected to increased arterial inflammation in the aorta and all of these together could let them know who was going to go on to have cancer, stroke and arterial sclerosis.
Our thoughts have an impact on our physical bodies. That’s objectively measurable in studies. It is important for a physical therapist to key into more and while we’re talking about topics like this because it’s part of a bio-psycho-social approach to not only pain but many of the other chronic conditions that you mentioned, that we do treat as physical therapists, cardiovascular disease, chronic stress, all common in our clinical settings. A while back in this episode, I mentioned teaching not only mindfulness in your class but seeing it spill over into the other classes in your program. I noticed you perked up a little bit. It makes me wonder how has it been discussing the implementation of mindfulness with your professional colleagues and other professors. Not everyone takes to mindfulness right away. Sometimes it takes a little bit of time. People are extremely enthusiastic about it but I’m sure you interact with both colleagues in your DPT program as well as other colleagues around the country. Have you started to gently nudge this agenda along with your important work?
I send them these articles. I’ve started an individual study for students that want to go out to take a course and dive into this a little bit more, practice meditation and be accountable by handing them practice logs and things like that. Largely, the faculty are supportive. The problem is that there’s no room in a curriculum to add yet another thing. I do want us to believe that it’s the little moments that we can all practice moments of stillness and silence. We can teach students these things, especially those students that struggle in lab exams, lab practicals and clinical courses. Imposter syndrome is out there. If we can give them some of these tools and help them find an app that resonates with them that they can use regularly, that’s a large part of the battle.
I’ve been asking the expert speakers on the show a similar question, which I’d like to pose to you. As we learn more about the mind and as a physical therapist, we become more interested in the mind, depending on the circles and where we are, why is it a radical idea for physical therapists to use mind training and mindfulness and mental exercises in clinical practice?
The research is pointing to this robust mind-body connection and to treat one by itself is not doing our patients justice. When we essentially teach patients, students and when we ourselves learn that we have control over what we choose to think and the neural networks we strengthen with those thought patterns. We know that stress and negativity live in our bodies. I tell my students, it’s like cobwebs that live inside our bodies and muscles that campout, it creates disease. I always find it interesting as PTs, we love to move. We love to exercise. My students always say, “It’s time to go do my 5 or 10-mile run.” I say to them, “How do you feel after that run?”
They’re like, “I feel great.” “How about an hour later when those endorphins are gone?” “That’s when the stress comes back and then I have to go work out again.” The most important thing is that although the endorphin rush is great and we definitely need exercise, if we come back to our homes and we are back to rumination comparing ourselves on Facebook, checking out on Instagram then we’re practicing more rumination, fear and worry. To come from a place of steadiness and to learn to come from a place of not succumbing to fear and worry, I believe we need both.
That’s where I begged them, “Let’s all download this app and let’s do a meditation challenge this semester.” There’s a great study in 2017 by Edwards and Loprinzi. They did a review of randomized controlled trials, looking at exercise versus meditation on physical and psychological outcomes. Their end was about 300 participants. They found meditation was shown to be more effective than the exercise comparison arm when evaluating the psychosocial outcomes of anxiety, altruism and life changes.
Additionally, meditation was more effective at reducing chronic neck pain at rest and pain-related bothersomeness. Exercise, however, was more effective in producing physical health-related quality of life, HDL, LDL, LDL, fasting, blood glucose levels but interventions that were found to be comparable when evaluating the outcomes of well-being, alcohol consumption and perceived stress levels or definitely in combination for both of these modes of addressing the disease. Imagine if we taught our patients both, exercise and the influence of the mind.
Not one or the other but how do we bring this together for ourselves and for our patients? That’s an important point and one of the reasons why I wanted to chat with you. I mentioned earlier that paper in JPTE in 2016 Physical Therapists’ Perceptions of Mindfulness, there’s another paper that you did author, which I have to mention because you authored it with my former professor mentor and good friend, Kerstin Palombaro. Can you tell us what the title of that paper was so we give Kerstin a little shout out?
Kerstin is an amazing human being. She helped me pull this paper together. This was a study called A Mindfulness Workshop for Health Science Graduate Students: Preliminary Evidence for Lasting Impact on Clinical Performance. Essentially, we taught students a mindfulness class once a week. They got together. It was interdisciplinary PA students, nursing students, all sorts of backgrounds and disciplines. We said, “Go on clinical.” We then took a survey and found that up to nine months later, we had lasting improvements and the student’s ability to manage stress and function clinically as their best selves in terms of clinical decision-making, safety, relationships, patient satisfaction, scores and those sorts of things.
It’s been wonderful chatting with you. Thank you for sharing all of your research. I look forward to seeing and hopefully produce more of it with regard to mindfulness and PT education, as well as physical therapy in general. I think it’s an important work. How can we follow you and how can people follow your work?
I did participate in a wonderful textbook coming out called Lifestyle Medicine. It was an honor to have written a chapter in that book. I hope you pick it up when it comes out and take a look at that.
That book will be out 2021 but in the meantime, if you want to follow in that, I will help her out a little bit. You can find her on the website at the Health and Rehabilitation Sciences Program in Physical Therapy at Temple University. It’s a great place to reach out to her whether you’re a PT student and you’re seeing learning more about mindfulness or maybe you’re a PT professor and you’re thinking, “Maybe I need a little bit of mindfulness in my program.” You can find her there and reach out to her. I want to thank you enough for joining us. Make sure you share this episode with your friends, family and colleagues on Facebook, Twitter, LinkedIn or wherever anyone is talking about mindfulness pain and physical therapy. I want to thank you for joining me and we’ll see you next episode.
Important Links:
- Dr. Annette Willgens – LinkedIn
- Physical Therapists’ Perceptions of Mindfulness
- The Lancet
- A Mindfulness Workshop for Health Science Graduate Students: Preliminary Evidence for Lasting Impact on Clinical Performance
- Health and Rehabilitation Sciences
About Annette Willgens, PT, EdD
Dr. Annette Willgens is a clinical associate professor in the department of Health & Rehabilitation Sciences and Program in Physical Therapy at Temple University. She earned her Physical Therapy degree at Ithaca College, her Master of Education at New York University, and her Doctor of Education at Northcentral University. She is a pediatric practitioner of over 30 years and continues to practice clinically at Children’s Hospital of Philadelphia. As director of admissions, her scholarly agenda includes student success, resilience to stress, and affective domain skills across the curriculum.
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