Harness the Power of the Mind for total knee replacement
Bill Gallagher PT, CMT, CYT
Harness the Power of the Mind for Rehab (total knee replacement)
By Bill Gallagher, PT, CMT, CYT Last year I received an e-mail from my Aunt Kathy. She was interested in using guided imagery to harness the power of her mind to prepare for her second total knee replacement surgery. She knew from experience that she would have significant pain after the surgery and she hoped that imagery could help her deal with that discomfort. She also knew that the more she could relax her muscles, the easier it would be to regain range of motion. I e-mailed her the script that I developed during PT school and had a phone conversation with her to answer her questions and fine-tune the images. She believes that the imagery helped her use less pain medication, tolerate passive range of motion and get back to work faster than she did after the first surgery. Guided imagery can work with patients throughout the rehab continuum. Taking a ‘Virtual Vacation’ One of the most simple, accessible and effective mind-body relaxation techniques is to imagine that you are in a place where you could feel safe, comfortable, calm and connected. This special place can be an actual location (i.e., a day at your favorite beach) or completely imaginary (i.e., a white puffy cloud). This type of imagery is most effective if you imagine that you are in your body, rather than watching yourself on a TV in your mind’s eye. The image is enhanced by filling in all the sensory details including taste, touch, smell and sound. This technique is most powerful when the image used is developed by, or tailored for, the person using the technique. Using a canned image like a “day at the beach” will elicit relaxation in many people, but for others it may trigger thoughts of sharks and sunburn. Here are the key features of this technique:
� Think of a time and place, real or imaginary, where you remember or can imagine feeling comfortable, safe and at peace. � Fill in all the sensory details. � Imagine that you are in your body experiencing the image. � When thoughts distract the mind from this image, let them go and return to the image.
Mental practice uses imagery to facilitate skill acquisition and improve performance. Many elite performers including musicians, actors and athletes use this technique to harness the power of the mind. You and your patients can use it as well. Think of a skill that you would like to improve. Remember the last time you performed that task (or attempted to). Remember what you saw, heard, smelled and felt while you practiced. Imagine what it would be like to do it a bit better, with less effort, less help, more accuracy and more consistency. When you imagine performing a physical task, there is obviously brain activity, but really the whole neuromuscular system is active. This technique is particularly useful for working on skills that include performance anxiety or potential for injury. Say you are working with a client who sustained a hip fracture falling down a flight of stairs. Such a patient is likely to experience enough anxiety to impair performance on the stairs. If endurance is a limiting factor, the unnecessary tension elicited by this stress response could prevent the patient from negotiating the stairs at all. By giving such a patient the “homework” assignment to remember what their eyes saw, ears heard, nose smelled, and hands, feet and muscles felt while going down the stairs, you can help decrease unnecessary muscle tension and anxiety while improving the ability to attend to the critical features of that environment. This can all add up to a significant improvement in performance. The key features of this technique are:
� Pick a task to practice. � Remember the last time you practiced the task�include all five senses. � Imagine what it would be like to perform the task a bit better. Again, incorporate all five senses into the imagery. � When thoughts distract the mind from this image, let them go and return to the image.
The outcomes sought through guided imagery have included the destruction of cancer cells by the immune system, the release of adhesions between tissues impeding normal movement, reduction of chemotherapy-induced side effects and pain reduction. The procedure for using this type of imagery is: � Pick a healing process or a process that facilitates healing (e.g., wound healing, muscle strengthening, muscle stretching, muscle relaxation, joint stabilization, joint mobilization, neural plasticity, pain reduction, adhesion release, increased blood flow, immune response, bone fracture stabilization); � Develop an image of that healing process. It does not matter whether the image is biologically correct (like collagen fibers bridging the gap of a wound) or incorrect (like munchkins with tiny tools fixing the break in the skin). It is important that the image make sense to the client; � Imagine that healing process accelerating and succeeding; � When thoughts distract the mind from this image, let them go and return to the image.
Sample Script for Total Knee Replacement Preparation
- Body Scan for Relaxation. Gently close your eyes and focus on the natural rhythm of your breath. Allow your breaths to be long, deep and slow. Move your attention to your face. As you exhale let any tension there melt away. Let your face muscles hang limp on your skull. Bit by bit, go through rest of body. Focus on each part and allow it to be a bit softer, heavier and warmer with each exhalation.
- Continuous Passive Motion. Now it is time to imagine that the nurse or physical therapist is applying the knee bending machine. The “CPM” is made of metal and plastic covered with lamb’s wool. A hinge in the middle is placed under the knee. As the hinge bends your knee bends without you using your muscles at all. As the therapist increases the amount that the machine bends your knee you feel some stiffness that gradually decreases as the machine gently bends and straightens your knee, increasing the circulation and flushing away the inflammation and speeding healing in your knee. As you relax into the slow rhythm of the machine, your brain releases chemicals stronger than any drug that go directly to your knee and soothe the discomfort.
- Passive Range of Motion. Now it is time for the therapist to gently stretch your knee. You are sitting on your bed as the therapist slowly bends your knee. Breathe deeply. When you inhale, imagine that you are breathing into the muscles on the front of your thigh. As you exhale let some of the tightness in your knee go. You trust the therapist. Your therapist won’t harm your new knee. As the therapist bends the knee, adhesions between layers of muscle and connective tissue are released, freeing up the movement of your knee. With every exhalation feel the knee releasing.
- Mental Practice/”Virtual Vacation.” See yourself in a calming environment (e.g., walking, swimming, playing golf) with the new knee. The knee is strong and painless. Breathe deeply and slowly, inhaling confidence, exhaling fear.
While designing an experiment to evaluate the above script in PT school, one of my professors asked the question; What if it works? How will you know that it was not a placebo response? While I was tempted to answer, “that’s what the control group is for,” I knew this was a question that required more thought. I read everything I could find on the placebo response and decided that if the imagery worked, it had to be a placebo response. Or, at least, it had to share the same mechanism as a placebo response. In fact, placebo phenomenon can often be seen as dramatic examples of the imagination in action.
Bill Gallagher, a licensed Physical Therapist, Certified Massage Therapist, Certified Tai Chi Chuan/Qigong teacher and Certified Yoga Teacher has developed a uniquely integrative approach to help people suffering from pain and disability that is caused or perpetuated by pelvic floor dysfunction. By integrating the Physical Therapy traditions of the East (Tai Chi, Qigong, Yoga) with cutting edge therapies of the West, Bill helps his clients maximize function and minimize pain. Bill sees a broad spectrum of clients in his practice including people with severe disabilities and elite performers. In addition to traditional 1:1 sessions, Bill teaches specialized group programs that include pelvic floor training for people with pulmonary issues, brain injuries, chronic pain, and elders.
His work has been published in Topics in Geriatric Rehabilitation, Occupational Therapy Practice, Advance for Physical Therapists, Advance for Occupational Therapists and Tai Chi magazine. Bill is recognized as an authority on Integrative/Mind-Body/Complementary rehabilitation and teaches his visionary synthesis to practicing rehab clinicians and at several Physical Therapy doctoral programs. His jovial presentation style and mastery of his topics make him a sought after speaker in New York City and Nationwide.