Injuries happen.

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Every month, it seems like there is a new fad for injuries.  One month inflammation is the devil, then its icing. This year, cupping is all they hype, but what happened to K-tape? And whats up with blood-restriction training?!  In order to be an educated consumer, you must arm yourself with the facts behind what happens when you get hurt. Understanding the healing cycle will help you know what you can do to help your body rebound.  Here are some answers to some common questions people have about getting hurt.

How do Injuries happen?

Most of the time, we can point our fingers at stress and a bit of bad luck.  Stress is directly proportionate to strain. The more strain we put on our body, the higher the chance we have for injury. Stress on the body comes in all different forms. Some examples of stress includes:  physical, postural, emotional and breathing patterns. Stress puts strain on the body and strain increases stress. Its a vicious cycle, but it can be broken.  Posture can be fixed, emotions can be lifted, and breathing patterns can be changed.  Although bad luck happens, your tissues can recover and heal in a way that can minimize future strain.

What happens when an injury occurs?

Depending on what source you use, there are 3-4 stages in healing.  For our purposes today, I am going to use the 3 stage model.

  1. Inflammation
  2. Repair
  3. Remodeling
Inflammation Stage (Acute):

This stage is the shortest of the three, typically lasting just a few days up to a couple of weeks.  This is the time that your body attempts to clean up the mess.  Your injury might get red or black & blue, swell up and be painful.  The mechanism behind this stage is an influx of blood to the area. This is because more white blood cells (Neutrophils & Macrophages) need to enter the area to clean up damaged tissue.

Inflammation gets a bad rep.  Thats too bad because it is necessary for healing.  Inflammation becomes a problem when it lasts longer than it should.

When does inflammation become a problem?  As a rule of thumb, its more than two weeks.

Repair (Sub-acute):

This is when the good stuff starts to happen.  Your pain begins to decrease, while your body begins to rebuild the damaged tissues.  Your body replaces the injured tissues with scar tissue made up of collagen.  This tissue is not as strong as the original tissue and is prone to re-injury if too much stress is applied too early. This stage may lasts up to six to eight weeks.

Remodeling (Chronic):

This final stage is the longest, which can last anywhere from 3 weeks to 12 months following the injury. Tissues that have a good blood supply (i.e. bones & muscles) will heal the fastest.  Tissues with poor blood supply (tendons, ligaments, joint capsules), will take the longest. This stage is when the new tissue is “remodeled” by good physiological stresses.  This helps to align the collagen fibers in a way that maximizes their strength.  The damaged tissues may never be as strong as it once were, but if it heals correctly- it can be pretty darn close.

How do I know what stage my injury is in?

Understanding what stage of healing your body is in will be the best guide for determining what to do.  We use pain to determine what stage we’re in.

  • Inflammation: it hurts before resistance is applied to the tissue.
  • Repair: it hurts when resistance is applied to the tissue
  • Remodeling: it hurts after resistance is applied to the tissue.

So what does that mean?  Lets use an ankle sprain as an example.  When you first twist an ankle, it hurts just putting your toe on the ground.  That’s pain before resistance, therefore you are in the Inflammation/Acute Stage. A few days later, you are able to walk on it but it hurts when you do so. Thats the Repair/Sub-acute Stage.  Eventually, you are able to walk longer distances, but hurts at night.  Thats the Remodeling/Chronic Stage.

Why do injuries re-occur?

Injuries re-occur because the healing tissues aren’t as strong as they were pre-injury.  The tissues are most vulnerable in the remodeling period. Since we use pain as our indicator for determining what healing stage we are in, pain killers may inhibits our ability to tell where we are at.   I am not advocating that we stop taking pain killers. I just want to highlight the fact that we are not able to listen to our body if we are blocking what it is trying to tell us.  Athletes have a tendency to go too hard too fast. We block the pain and then go back out there in hopes of  performing at the same level that we were at before.  If we do this during the Repair Stage, we are likely to re-injure the tissue.  This is how injuries become chronic.

How do injuries become chronic?

Injuries may become chronic at any of the healing stages and are also be prone to going hay-wire.  For example, chronic inflammation.  This becomes an issue because it interferes with the Repair and Remodeling stage, preventing healing and may actually further damage healthy tissues.  This is due to the non-discriminate action of Neutrophils. Injuries may also cause trouble in other areas of the body.  One of the underlying reasons for this is because other areas of the body now have to “compensate” for the weakened tissues or for a lack motion available. Scar tissue may also cause issues.  Scar tissue can proliferate beyond the boundaries of the injury.  This causes tissues that once slid past each other to get stuck.

You will be able to find more information on this blog site which will help you to address the injuries in your body and the deficits that may follow.  Stay tuned.

Diastasis Recti

What is it?

Diastasis recti (DR) is a common musculoskeletal condition found during and after pregnancy. This condition is a widening of distance between the rectus abdomis muscles along the linea alba.  The recti abdominis are the two muscles that make up your six pack.  The linea alba is a band of connective tissue that connect the two 3-packs along midline.  Women at menopausal age and men may also develop this condition.  If it is left untreated, it may result in a hernia.

DiastasisRectusAbd-LG
Photo credit

DR commonly occurs during the third trimester of pregnancy, but typically resolves the largest distance within 1-8 days following delivery.  DR has been reported to be experienced by 66-100% of women during their third trimester and up to 53% postpartum.1,2 In 1987, Boissonnault and Blaschak2 published the first research articles published on DR.  They found that DR may compromise the function of the abdominal wall including:

  1. postural stability
  2. respiration
  3. delivery of a fetus
  4. trunk range of motion (flexion, rotation and side bending).2

Several research articles agree that these deficits may result in low back pain, lumbo-pelvic instability, non-optimal loading strategies and cosmetics defects.1,2,4,9 In a study completed in 2007 by Spitznagle8 on the uro-gynecological population, 66% of women with DRA also had at least one support-related pelvic floor dysfunction; such as stress urinary incontinence, fecal incontinence and/or pelvic organ prolapse.  Although DR is commonly found during pregnancy, it is clinically significant if it is painful or persistent following the birth.

Why did this happen?

Researchers agree that the increased distance between the rectus abdominis muscles is thought to be due to stretching and thinning of the linea alba.7,9   Boissonnault and Blaschak1 report that it may be due to the hormonal softening of connective tissue that is experienced during pregnancy and post-partum, the increase in inter-abdominal pressure and/or the displacement of organs from the growing fetus.  Prenatal risk factors have been identified by Spitznagle et al8 as including:

  • a woman’s age
  • pregnancy body mass index (BMI)
  • weight gain during pregnancy
  • BMI at six months postpartum
  • hypermobility score
  • baby weight at birth
  • abdominal circumference in late pregnancy
  • and level of exercise training.

Although, a study by Fernandes da Mota et al4 in 2015 found these risk factors to not be significant in predicting DR.

Do I have it?

It has been accepted that a widening greater than 22-23mm (2 finger widths) as identified by ultrasound measurements to be clinical significant.4  The “finger width” palpation method has been shown to be a good screening tool for clinicians as determined by a systematic review completed by Van de Water, et al.9 Here are some steps in measuring DA:

  1. Lie on your back with her knees bent and feet flat on the floor
  2. Engage your abs by lifting your head off the floor.
  3. Use your fingers to palpate the space inbetween your abdominal muscles.
  4. Determine the width of the distance by estimating how many finger widths it is

Depending on the width of your fingers, more than 2 fingers would be clinically significant.  Don’t freak out unless its been longer than 6 months post-partum.  It should resolve on its own, assuming you have good posture & proper biomechanics.

What can I do about it?

There is no consensus on the best way to treat DRA, but current treatment options include:

  • surgical interventions
  • abdominal exercises
  • postural and back care education
  • external support
  • aerobic exercises

It is important to treat DR.  This has been illustrated by research completed by Lee, et al5 in which they found that injury to the myofascial of the lumbo-pelvic region, may play a significant role in decrease function, incontinence and abnormal respiration, by creating non-optimal loading strategies in the core region. Non-optimal loading strategies develop during pregnancy and perpetuate DR.  Lee et al5 states that restoring optimal loading strategies of this area, may help to decrease the impairments cause by a compromised fascial system of the core following pregnancy.  Good posture and biomechanics is an area that many physical therapist specialize in.  Finding the right practitioner for you is key in treating your DR.

It is important to treat DR even if it is non-symptomatic.

The goal of treatment will be to restore normal movement patterns of the body and prevent future injury.  This will allow your body to restore it’s function and shape.  DR is not a permanent condition, but is a sign of an underlying imbalance in your body.  Even if it is not causing pain, it will be beneficial to treat it if it doesn’t go away on its own.

If you have signs and symptoms of DR, please contact your local physical therapist.  They will be able to provide you with the tools necessary to treat the imbalances found in your body that may be perpetuating the DR condition.  Individualized treatment will include: postural education, manual therapy, neuromuscular re-education, refinement of your motor control, and a home exercise program.  Physical therapist have the knowledge and skills necessary to treat your DR with conservative management, avoiding surgery and preventing future injuries.  A PT should be able to recognize the postural & biomechanical imbalances on the first visit, and be able to make a significant change within a few visits.

Bibliography
  1. Benjamin DR, van de Water ATM, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014;100(1):1-8. doi:10.1016/j.physio.2013.08.005.
  2. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther. 1988;68:1082-1086.
  3. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Man Ther. 2008;13(2):112-121. doi:10.1016/j.math.2006.10.001.
  4. Fernandes da Mota PG, Pascoal AGBA, Carita AIAD, Bo K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther. 2015;20(1):200-205. doi:10.1016/j.math.2014.09.002.
  5. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: The role of fascia following pregnancy and delivery. J Bodyw Mov Ther. 2008;12(4):333-348. doi:10.1016/j.jbmt.2008.05.003.
  6. Moseley GL, Hodges PW. Reduced variability of postural strategy prevents normalization of motor changes induced by back pain: a risk factor for chronic trouble? Behav Neurosci. 2006;120(2):474-476. doi:10.1037/0735-7044.120.2.474.
  7. Rath AM, Attali P, Dumas JL, Goldlust D, Zhang J, Chevrel JP. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surg Radiol Anat. 1996;18(4):281-288.
  8. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):321-328. doi:10.1007/s00192-006-0143-5.
  9. Van de Water ATM, Benjamin DR. Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): A systematic review of their measurement properties and meta-analytic reliability generalization. Man Ther. 2016;21:41-53. doi:10.1016/j.math.2015.09.013.

Yoga & Mechanical Diagnosis and Treatment (MDT)

Robin McKenzie, a physical therapist from New Zealand, revolutionized the treatment for LBP in the 1950s. McKenzie discovered symptom centralization by using repeated movements or sustained postured.  Mechanical Diagnosis and Treatment (MDT) is a tool for assessment, treatment and prevention of musculoskeletal disorders.  McKenzie is an advocate for independent management of a person’s own back pain.  He said,

“I believe the treatment dependency is undesirable and should be avoided where possible. Therefore, in addition to whatever treatment is necessary for present symptoms, the patient should be taught to become self-reliant and independent of the therapist in the management of future low back pain” RA McKenzie, 19811

McKenzie advocates patient education to prevent the recurrence of low back pain. It can be safe to assume that he would support the daily yoga practice as long as it is individualized to the student’s needs. MDT consists of three categories for diagnosing back pain: Postural, Dysfunction and Derangement. A specific style yoga may be the key to a person’s self-management of their back condition.  By understanding the treatment strategies of physical therapists, yoga can be applied appropriately.

Postural Syndrome

Postural Syndrome is when normal tissues are placed on end range stretch for prolonged periods of time. It is insidious in nature and can be hard to reproduce.  The yoga student with a postural syndrome will have pain or symptoms that increase throughout the day. They may have a job where they sit for long periods of time or have a medical condition that causes abnormal posture.  Postural Syndrome is from sustained poor posture.

Postural education and exercises can address any muscle strength imbalances which underlie postural dysfunctions. Postures that open up the chest and strengthen antigravity muscles will help address these deficits.  Specific yoga classes that focus on posture, such as Iyengar yoga, are appropriate.  A study completed in 2009 compared 24 weeks of Iyengar Yoga to conventional interventions for LBP. The yoga group had greater improvements in functional disability, pain, depression and a reduction in pain medication.2 A yoga teacher who understands muscle imbalance and compensatory movement patterns will help a student overcome their postural syndrome.

Dysfunction

Abnormal or dysfunctional tissues often cause low back pain.  Dysfunctional tissues cause pain when placed on end range stretch or placed under mechanical deformation (palpation). A physical therapist uses repeated movements to determine if their client has dysfunctional tissues. Symptoms will either decrease or stay the same with repeated motion into the painful direction. Muscle guarding and spasms, facet joint restrictions or adhesions in the fascia can cause dysfunction of the back. These restrictions may result from previous trauma, inflammatory or degenerative processes.3  Research agrees that compensatory strategies may develop as a result of habits formed due to previous injury4,5.  This may cause habituated abnormal movement patterns that perpetuate the dysfunctional tissues.

The repeated motion that is used to diagnose dysfunction in the clinic is also used to treat.  This can easily be applied to a yoga class, but difficulty arises when there is a mixed class of dysfunctions.  Someone may have a flexion dysfunction due to quadratus lumborum (back) spasm.  They need a gentle class consisting of forward folds and twists.  Those with tight iliopsoas (hip flexor) will enjoy erected postures, gentle extension and lunges. Most yoga asanas can be placed into a direction specific exercise group and can be used to treat specific dysfunctions (Specific Exercise PDF). Back Care, restorative and a beginner yoga class will help a majority of people with dysfunction. Themed classes, such as psoas release or stiff back classes, might help to separate people into groups based off of their dysfunction.  Class should consist of hands on assists that are massage-like and repetitive movements that flow with the breath.

Derangement

Derangements are often thought to be discogenic in nature.  Discogenic in nature implies that a nerve root is being pinched, either due to decreased vertebral disc height or a bulge or herniation.  A crucial symptom for diagnosing a derangement is the migration of pain in response to repeated motions.  Centralization occurs when a movement or position relieves the pain or causes it to move towards the spin.  If the pain centralizes with a forward fold, that means it migrates proximally.  If it peripheralizes, the pain migrates distally from the spine, down the leg or to the foot.  Directional Preference is similar to centralization, but more specific to a position in which one finds relief from pain.  Centralization with movement indicates a better prognosis than directional preference alone.6 Despite this finding, directional preference is used for exercise prescription. A study found matching directional preference with specific exercise decreased pain and medication use.7  For treatment of derangement, it first must be reduced.  This is done using either specific movements, manipulation or mobilizations by a trained professional.  Next, the patient needs to perform exercises to increase the stability of the spine and normalize posture.

Individualized yoga classes will help a person with a derangement recover faster and manage their symptoms better, although direct communication with a physical therapist is recommended.  Understanding their directional preference and what movements cause the symptoms to centralize will help the teacher tailor the practice to meet their needs.  Often, a person can go from a derangement to dysfunction.  In order to prevent this, yoga as therapy must be applied appropriately.

It is a challenge for a yoga teacher to meet the needs of every student. A partnership between the teacher and a physical therapist may help alleviate the burden.  If a studio offers back care classes, they must accept the responsibility of providing the best care possible.  An understanding of the student’s symptom behavior is necessary to determine the best class for them.  A thorough intake form may be helpful in screening a student for a serious condition and to understand the nature of the student’s symptoms (Intake Form).  Keeping classes small and offering them in a series may help reduce the unnecessary risk of exacerbating symptoms. It is possible for physical therapy and yoga to partner in providing long term care for low back patients using the principles of MDT. Understanding MDT and the terms will improve communication between yoga teachers and physical therapists.

References

  1. Moore, Jeff, DPT. Incorporating Repetitive Movement. (Power Point Presentation) Masterminds Mentorship Group. 4 November 2015.
  2. Williams, K., Abildso, C., Steinberg, L., Doyle, E., Epstein, B., Smith, D., … Cooper, L. (2009). Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine, 34(19), 2066–76. http://doi.org/10.1097/BRS.0b013e3181b315cc
  3. McKenzie and May, The Lumbar Spine, Mechanical Diagnosis and Therapy, Vol I & II, Spinal Publications Limited, P.O. Box 2, Waikanae, New Zealand, 2003.
  4. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: The role of fascia following pregnancy and delivery. J Body Move Ther. 2008;12(4):333-348. doi:10.1016/j.jbmt.2008.05.003.
  5. Moseley GL, Hodges PW. Reduced variability of postural strategy prevents normalization of motor changes induced by back pain: a risk factor for chronic trouble? Behav Neurosci. 2006;120(2):474-476. doi:10.1037/0735-7044.120.2.474.
  6. Werneke MW, Hart DL, Cutrone G, et al. Association between directional preference and centralization in patients with low back pain. J Orthop Sports Phys Ther. 2011;41(1):22-31. doi:10.2519/jospt.2011.3415.
  7. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004;29(23):2593-2602. doi:00007632-200412010-00002

Yoga for Chronic Low Back Pain

Chronic Low Back Pain (cLBP) is a subset of back pain which may be alleviated with the practice of yoga. A study found that 85-95% of patients with LBP are diagnosed as having “nonspecific low back pain”.1 This means that the doctor doesn’t know the specific patho-anatomical cause of the pain.  A majority of patients with chronic pain fall outside the typical healing time frame.  This is one of the reasons chronic conditions have stumped the medical community for so long.   There has been a recent increase in research that looks at the central nervous system’s role in cLBP. It is widely accepted that a person’s history and beliefs about pain can influence the outcome of treatment. Recently discovered insights on central sensitization and neuroplasticity have allowed for the development of more effective treatments.

A physician may refer their patient for an MRI or radiograph to diagnose the cause of cLBP. These can be useful in identifying serious conditions, such as vertebral fractures or a spinal cord impingement.  Most often, imaging causes unnecessary stress over normal changes that occur in the spine.  A recent study found that disc degeneration was present in close to 90% of individuals 60 years of age or older.  More than 50% of asymptomatic people ages 30-39 also had degenerative change of their spine.2  Degenerative changes, such as disc degeneration disease, are part of the normal aging process and cause unnecessary anxiety when used as a diagnosis.  This counter-acts the healing process by activating the autonomic nervous system.  There are many structures in the back that can cause pain that may or may not be related to what the imagining shows. A patient’s belief about the cause of the pain and diminished sense of body awareness can play a role in managing chronic pain.

Traditional and non-traditional interventions for chronic low back care have fallen short.  A recent study found that interventions, such as manual therapy, exercise, acupuncture, and spinal injections, are not superior to one another and all have limited long-term impacts on the disorder.3  This might be due to interventions failing to address cLBP within a multidimensional framework. A multi-disciplinary approach to cLBP is one solution. Physical therapists and yoga teachers have complementary skills that can be utilized to help counteract chronic pain.

Cognitive Behavior Therapy (CBT) addresses the biopsychosocial issues that often go with chronic pain.  Biopsychosocial issues include:

  • Cognitive Factors: negative beliefs, fear avoidance behaviors, anxiety, depression, poor coping skills
  • Physical Factors: pain provocative postures and movement patterns
  • Lifestyle factors: sedentary behavior, sleep deficits11

Yoga interventions found in Mindful-based Stress Reduction (MBSR) address the same factors as CBT.  MBSR is a “mind-body approach that focuses on increasing awareness and acceptance of moment to moment experiences, including physical discomfort and difficult emotions.”4  MBSR uses meditation, pranayama, yoga and patient education to help a person cope (MBSR Protocol).  A recent study compared this approach to CBT and normal medical treatment and found MBSR had similar results as CBT.  Both had significant improvement when compared to standard medical treatment.5  There are many similarities between the two approaches.  Both have elements of body awareness, addressing movement and cognitive deficits, imagery and coping skills.  However, both practices come from different schools of thought, which becomes clear after looking at the comparative chart (Comparison Chart). Those who come to a yoga back care class will likely respond well to the MBSR approach described in this study.

 

The brain is an amazing structure of the body due to its ability to adapt to stresses placed on the body. Neuroplasticity is “the ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections.”6 There are structural and functional changes in the brains of people with chronic musculoskeletal pain. These changes contribute to the development and maintenance of the chronic pain state.7 An example of these changes is central sensitization.  This is an adaption of the nervous system to noxious stimuli: stimuli that are non-painful, but are perceived to be painful.  Studies show that a person who experiences cLBP undergoes anatomical changes to the brain, including decreased cortical thickness, hippocampus (memory center) and medial prefrontal cortex (learning and memory) and increased amygdala (fear center) size.8 Changes to the cerebral cortex can cause changes to the homunculus, the “sensory map” in the brain (Noi Group).  This map of the body can change when a person experiences chronic pain.  The mind “smudges out” that body part and creates a distorted body image.  The Noi Group has developed a method called “Graded Motor Imagery.”16 This uses Left/Right Discrimination, Motor Imagery and Mirror Therapy to re-introduce the area of the body back to the brain.  Both these intervention uses neuroplasticity as a catalyst to induce change in the brain caused by chronic pain conditions.

The medical community has realized the importance of the brain’s neuroplastic ability in treating chronic pain.  Recent studies have shown that meditation used in MBSR has the ability induce neuroplasticity.  A recent study took people who had never meditated before and put them through the eight week MBSR program.  This study found that five regions of the brain experienced a change in volume after 8 weeks.  Four areas thickened: posterior cingulate (mind wandering and self-relevance), the left hippocampus (learning, cognition, memory and emotional regulation), the temporoparietal junction (perspective taking, empathy and compassion), and the pons (regulatory neurotransmitters production). One area, the amygdala, got smaller, which is the center that stores negative memories and feelings.9   This is a groundbreaking discovery for MBSR in management of chronic pain.  Yoga for chronic pain has a place at yoga studios.  Studios can offer a series that is completed over eight weeks and follows the MBSR protocol (Appendix 3).  Yoga as Therapy has research behind it to legitimize its use for treatment in the clinic, especially for chronic pain.

Bibliography

  1. Apeldoorn AT, van Helvoirt H, Meihuizen H, et al. The Influence of Centralization and Directional Preference on Spinal Control in Patients With Nonspecific Low Back Pain. J Orthop Sport Phys Ther. 2016;46(4):258-269. doi:10.2519/jospt.2016.6158.
  2. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. a, … Jarvik, J. G. (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Spine, 36(4), 811–6. http://doi.org/10.3174/ajnr.A4173
  3. Fersum,Vibe K, et al. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain (United Kingdom). 2013;17(6):916-928. doi:10.1002/j.1532-2149.2012.00252.x.
  4. Cherkin, D. C., et al. (2016). Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. Jama, 315(12), 1240. http://doi.org/10.1001/jama.2016.2323
  5. Cramer, S. C., et al. (2011). Harnessing neuroplasticity for clinical applications. Brain, 134(6), 1591–1609. http://doi.org/10.1093/brain/awr039
  6. Wand, B.M., et al. (2011). Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice. ManualTherapy, 16: 15-20
  7. Lucas, PH. Practical Application of Yoga-based Techniques in the Treatment of Chronic Pain. Power Point Presentation. CSM 2014 (Las Vegas, NV).
  8. Butler, David and Moseley, Lorimer. (2014). Explain Pain. Noigroup Publications, Adelaide, Austrailia. Pg. 76
  9. Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893-1897. doi:10.1097/01.wnr.0000186598.66243.19.