Mind-Body Techniques in Wound Healing
I n the realm of wound care, healing may stagnate despite the healthcare provider's best efforts. The behavioral tendencies or attitudes of the patient may contribute to the chronic nature of wound healing. Perhaps the patient has disassociated from the wound - showing up for the appointment is enough, and the healing part is up to the healthcare provider. In another scenario, the patient may feel powerless to make the recommended changes: The sheer pain and stress of having a wound does not allow the patient to make a behavioral change such as smoking cessation. Another subset of patients seems to have lost all goals and hopes to ever heal. Depression is evident in their speech and body language. Finally, some patients simply have more invested in staying wounded. For this type of patient, the wound may provide an excuse not to return to work. The patient also may fear the loss of attention if he or she actually were to heal.
In contrast, a common group of behavioral attitudes exist in the patient who does heal. Attainable goals expressed include returning to work, attending a daughter's wedding, or taking a planned vacation. The healed patient may have been more receptive to learning and compliant with treatment. Often, this type of patient does not express fear of the physical wound. Instead, the patient is curious, willing to look at the wound, and above all, eager to participate in the healing process.
When considering those who heal and those who do not, no disparity in the treatment options offered to both groups is readily evident. However, a common thought pattern emerges in those whose healing has stagnated. The mind and spirit, and overall willingness to heal, play a significant role in the body's ability to heal physically. The challenge for the healthcare provider is to understand the deeper wounds that are intimately related to the physical wound. The purpose of this article is to review the literature regarding wound healing and mind-body health, as well as to provide the clinician with a model of mind-body techniques that can facilitate healing in the chronic wound patient.
Curing versus Healing
Clinical goals often are structured toward curing through the removal of symptoms.1 Evidence-based research strives for positive and measurable outcomes. However, when providers shift the emphasis from treating the wound to treating the human being in which the wound exists, a deeper opportunity for healing may be achieved.2 Only then can healthcare providers truly serve as co-facilitators of healing, rather than merely attempting to cure the superficial symptoms. This stated, healing is accomplished by the individual who is sick.1 Healthcare providers bring the gifts of love and kindness to their patients through their skills and compassion. Mother Theresa of Calcutta once said, "It is not how much we do, but how much love we put in the doing." A healthy caregiver-patient relationship will enable the innate doctor within to go to work.2 However, a critical role in the healing process is the patient's participation and desire to heal. Herein lies the challenge for even the most resourceful clinician.
The Mind-Body-Spirit Relationship
Conventional medicine has a long history of breaking down physical and mental function into a mechanistic model. The emergence of a new paradigm, holistic medicine as a complement to conventional medicine, has lead to the acknowledgment of a so-called "ghost in the machine"1 - the role of human spirit or consciousness in the healing process. The placebo effect is an example of this theory. Without tangible explanation, the placebo transcends patient confidence in the caregiver and treatment into biochemical changes.2 Growing research in the field of psychoneuroimmunology suggests that the neuropeptide network is not linear in transmission, but rather numerous, spontaneous interconnections between ganglia, organs, immune system and skin.3 Thus, research is beginning to reveal communications between the nervous, endocrine, and immune systems.4 Although the immune system is still considered central, virtually all biological systems are considered part of the healing process, including the mind and emotion.3 The emergence of psychoneuroimmunology has been able to significantly demonstrate biochemical changes in the body that can be traced to emotion and/or repressed memories locked in the mind-body network.5 Often, this repression becomes the long-term coping strategy of the individual3; therefore, the manner in which human beings handle stress and form coping behaviors has a significant impact on their overall health. Likewise, it is inferred that the degree of stress on the immune system can be correlated to the quality of wound repair.5
Research by Marucha et al6 involving dental students demonstrated that examination stress resulted in a 40% slower healing rate of punch biopsies taken from the hard palate. Perhaps most interesting is that examinations for students at this level are relatively mild and predictable stressors to which they have become well accustomed. Despite this fact, examination stress was found to have statistically significant consequences for healing.6 Another study found that anxiety and depression have a distinct relationship to delayed wound healing.7 In addition to the possible psychoneuroimmunology explanation, the authors point out that indirect factors such as self neglect, disturbed sleep, and poor appetite also may be contributing to the delayed healing findings.
Various authors and researchers have explored the connection between physical ailments and a lack of self worth.8,9 These symptoms often are compounded by feeling overwhelmed and helpless in the face of illness.9 The loss of personal control and lack of self worth are described as paramount emotions linked with delayed wound repair.8-10
An ever-increasing body of knowledge points to the effect of stress on the body. More often than not, physical symptoms are not the first signs of an illness, but rather the last. Emotions and faith are being explored in their direct relation to healing. Stress stimulates the sympathetic nervous system; thus, inducing vasoconstriction, decreased tissue profusion, the release of glucose from the liver, and hormonal changes in the levels of cortisol.11-13 The secretion of cortisol, a glucocorticoid, will promote further constriction of arteries, inhibit inflammation, decrease the release of lymphocytes, and suppress the proliferation of fibroblasts.13 Although a study by Braden13 was not able to draw a causal relationship between cortisol and pressure ulcer formation, stress-induced negative thinking is believed to contribute to a diminished wound repair.
Kiekolt-Glaser et al5 describe slower wound healing rates of punch biopsies in caregivers that are stressed. They theorize that healing may be influenced by how one perceives stress and if adaptive coping strategies are utilized. Patients may be able to promote wound healing by decreasing their stress through positive thinking. Positive emotions such as hope, love, and forgiveness can lead to decreased activation of the sympathetic nervous system.14 Studies have shown promising outcomes in wound repair when sleep, relaxation, and guided imagery are used.14-16 Holden-Lund14 found that lessening anxiety through guided imagery audiotapes significantly decreased erythema, a typical index of inflammation. The tapes lead the listener through the progressive phases of normal wound healing via a "mental journey through their body to the healing area."14 A study by Surwit et al16 demonstrated improved glycemic control using stress management techniques, such as progressive muscle relaxation. These techniques were found to be more effective after 12 months than standard diabetic education. Even without formal practice at 1 year post initiation, patients appeared to have incorporated stress reduction techniques into their lifestyle, resulting in a continued reduction in blood glucose levels.16 These findings are supported and further investigated by those who believe the body is a mirror of one's inner thoughts and beliefs. These concepts, however, do not exclude the role of genetics and environment in the wound healing process.
In her book, Why People Don't Heal and How They Can, Myss17 examines woundology as a social phenomenon. Wounds, whether physical or emotional, possess a manipulative value. They seduce the individual into a life with minimal expectation and freedom from failure. As mentioned earlier, a tempting desire to stay actively wounded and in need is evident. The wound proliferates the assistance of friends and family.
Myss identifies five common themes or myths held by those wounded and exhibiting a slowness or reluctance to heal.17
* "My life is defined by my wound."17 An exorbitant amount of the individual's energy is focused on the wound and staying wounded. Positive thinking and restorative healing are hastened. This theme is often related to the suppression of feelings such as anger, guilt, and powerlessness.
* "Being healthy means being alone."17 The underlying belief that one cannot stand up for oneself creates a tremendous fear of getting well. Insecurity arises from the thought that once the individual is healed, the support group will disappear. Instead, individuals should be encouraged that healing is an ongoing process and not one that ends after the achievement of a desired outcome.
* "Feeling pain means being destroyed by pain."17 The perception of pain ought to be reoriented to reflect pain as an indicator of disease, rather than pain as a punishment. Patients can be encouraged to learn from their pain or find alternatives methods for coping.
* "Illness is the result of negativity."17 Possibly at the root of all wounds is self deprecation and the feeling, "What did I do to deserve this?" A lack of self worth and a perception of being damaged at the core may be present. Lack of self worth is another expression of not loving oneself. Learning to love and approve of oneself is the first step in the nurturing process.17
* "True change is impossible."17 Often, the patient holds firm to the belief that nothing can be done or that every alternative has been tried. Myss challenges patients to consider what they would be willing to give up to heal.17 Would it be smoking? Would it be a job? Some patients set limitations on engaging the healing process within their body. When conditions are placed on healing, Myss believes the individual will only achieve conditional healing.17 In contrast, healing must be recognized as a fully integrated process of mind-body and spirit that is ongoing and requires effort and awareness on the part of the individual. The patient must be committed to heal. As Norman Cousins, a recognized editor of The Saturday Review who was diagnosed with ankylosing spondylitis in 1964 stated, "I had more or less disposed to let the doctors worry about my condition. But now I felt a compulsion to get into the act. It seemed clear to me... I had better be something more than a passive observer."2 His book, Anatomy of an Illness as Perceived by the Patient, is a tribute to power of healing and the capacity of the human mind and body to regenerate.
Clearly, a relationship exists between mind and body health, even though medical science cannot always explain the results. Wound care clinicians have, at their disposal, several techniques geared toward restoring the mind-body aspect of healing. Meditation, relaxation, guided imagery, and hypnosis assist patients in developing greater self-control.3,8,14,16 Conscious breathing and meditation have been shown to decrease pain.3,18 Each of these techniques promotes self-awareness of mind, body, and spirit. Active participation and personal control further strengthen autonomy and self worth in an individual; thereby, countering feelings of helplessness and dependence.
The following is a sampling of mind-body techniques that may be incorporated into the treatment plan for the wound care patient.
Affirmations. Affirmations help re-program the mind away from negative thoughts and onto nurturing messages of healing. The healing process begins the moment one considers making a change. The intentions or affirmations should be stated in the present tense, such as, I am open to change, I love and approve of my body, or I am at peace.10,19 Such statements will begin to alter the biochemical messages previously rooted in thoughts of anger, fear, and guilt. The positive and present tense statements also help establish a connection to the meaningfulness of one's job or home life. The affirmations can be repeated in the mind throughout the day, said aloud, or put into writing. One simple suggestion could be to post the affirmation on a conspicuous wall or door in the exam room to encourage patients to ponder its pretense. In her book, You Can Heal Your Life, Hay
Creative visualization. Creative visualization involves focusing one's awareness and mentally sending feeling tones of love and kindness to the wounded area. It generally begins by relaxing and recalling memories of a peaceful, safe, or happy place. Once marked in the brain, these feelings can be called up even during stressful times. When fully relaxed, the mind and body are open to receive new ideas such as, "My body is renewing and nurturing itself."
Creative visualization also can be used to imagine warmth or light energy and to visually send that energy to the wounded area.19 The patient visualizes the wound reducing in size and the body surrounding the area with love.19,20 Creative visualization also can be used to mitigate pain by visually asking the body where the pain is and what is the source in order to better understand the disease process.19
Relaxation and conscious breathing. The technique described by Benson21 involves picking a word or mantra and repeating it as the body surrenders into a comfortable resting position. Voluntary muscle relaxation from head to feet over a 10- to 20-minute period encourages a slow down of the sympathetic nervous system. The mind rests, allowing thoughts to float freely. This technique may be useful to diminish stress as well as incorporate a heightened body awareness and patient participation in care.
Conscious breathing. Another method of promoting awareness is through the conscious perception of breathing, focusing on the quality and life-giving nature of the breath. Repeating the mantra "in/out" maintains a presence and allows the mind to view the body in the breath.20 Awareness may be directed toward the perception of the rise and fall of the chest with each breath or the sensation of the air flowing through the nose. This exercise is often easier when coached by the practitioner or a voice recorded tape.
This technique can be further enhanced when combined with gentle stretching. When relaxed, the breath can teach the body how to move. Movement should naturally follow the cycles of the breath; thereby, allowing for deeper release into the posture with each exhalation. This type of awareness and coordination of breath and movement is a key element in the practice of Hatha yoga.
Prayer. Regardless of religion, spiritual prayer for healing can be extremely powerful. Several groundbreaking works have shown the relationship between the consciousness (brain and body) and the spirit.18,22,23 Many individuals with chronic diseases rely on their spirituality to cope with physical symptoms. Spiritual coping has been found to facilitate positive thinking and health-promoting behaviors.15 Likewise, intercessory prayer - ie, prayer by one or more persons on behalf of another - has been found to be successful in such areas as coronary artery disease.22-24 Pastoral care or other prayer groups often welcome the names of individuals for which an intention for healing is desired. This may serve as another means to encourage healing in someone who has simply not responded to conventional wound care treatment. At a minimum, it behooves the healthcare provider to at least acknowledge and support a patient's spirituality.
Accepting the Outcome
Healthcare providers often can become discouraged by a lack of progress with a particular patient. However, in actuality, it may be the healer who requires healing. Healthcare providers are no different than their patients. Each individual carries emotional baggage that can permeate one's health and general wellness. Energy, whether positive or negative, is communicated through the healthcare provider's touch; therefore, clinicians should develop more self-awareness and take notice of the role stress plays in their own well being.25
In addition, an inner struggle may develop for the clinician when ego threatens the healer relationship. When clinicians become deeply invested in the outcome (such as a fully healed wound), the paradigm can potentially shift to a co-dependent relationship with the patient. The patient may assume a more passive role and neglect his or her own healing capabilities, deferring to the clinician. A patient's lack of compliance with a recommended program will inevitably lead to frustration by the clinician. When treating such a patient, emphasis needs to be placed on revealing the deeper wound, the lack of self-approval or love, and the feelings of anger or guilt. Instead of participating in the patient's failure, the clinician can facilitate and empower the patient in the healing process.
Weil26 encourages healthcare providers to embrace the miracle of healing and resist the urge to label healing as a coincidence or to take personal credit. As a result, clinicians can honor the process that has been facilitated, the intention, and consciousness of healing. Meditating on the patient problem may be necessary when the results of treatment do not match the clinical goals. Perhaps the message revealed is not what was expected. To serve as co-facilitators of the healing process, clinicians may need to refrain from having, or at least reconsider, expectations. Keeping a journal of this practice may help to clarify, and ultimately quantify, the results that develop.
Further research is needed to document the direct effect of the above-mentioned techniques in wound healing. This review presents the literature related to the negative impact of stress on wound healing. In addition, the use of mind body techniques for stress reduction is reviewed in an attempt to offer an adjunct to conventional wound care. However, healing is not guaranteed. The complexity of healing entails that some wounds will not physically heal despite the discovery of the inner self or trust in the clinician. Not included in this discussion were other promising mind-body techniques such as sound therapy, energy, and aromatherapy for stress reduction. These limitations warrant further research to clearly establish the direct effect of mind-body techniques in wound healing.
Wound care, like medicine, blends both art and science. It involves trust and the discovery of one's inner self. The patient is a partner with the healthcare provider in that relationship. Facilitation of this process and the release of the deeper wound may ultimately serve to enhance the healing potential of the patient. This may result in resolution of the physical wound as well as the discovery of inner peace. The perceptive healthcare provider will recognize the deeper wound as it is exposed through the behavioral attitudes displayed by the chronic nonhealing patient. In this respect, mind-body medicine warrants a consideration as a complement to the traditional wound care treatment regimen. - OWM