Movement With Awareness: The Wellness Program

by Carolyn McManus, PT, MA, MS from PT Magazine, Vol. 8, No. 3, 2000

Developing a successful wellness program takes initiative, support and commitment. It also takes a thoughtful — even philosophical — understanding of what it means to be “well.” One PT with an innovative group therapy program shares her story.

Fitness centers and wellness programs are being established in medical centers in increasing numbers. Fueling the demand for these programs are aging baby boomers seeking to maintain their health, businesses wanting to lower health care costs and hospitals in search of new sources of revenue. Many people assume these programs are for the healthy who want to continue in good physical condition. However, another group benefiting from these programs are people living with chronic medical conditions. Physical therapists have a leading role to play in the design and execution of wellness programs which help these patients improve their health and function.

In the spring of 1997, while in private practice, I developed The Wellness Program for patients with chronic pain, illness and stress-related medical conditions. The intent of The Wellness Program is to help patients maximize what they can do for themselves to heal and improve their quality of life. The group meets once weekly for 2.5 hours for eight consecutive weeks. At each meeting, participants discuss their experiences integrating program material since the previous class. I present and facilitate a discussion of a wellness topic and lead an hour of therapeutic exercise. Homework is assigned at the end of each session which focuses on integrating class material into daily life.

Choosing and presenting wellness subjects is a creative and challenging process. Because stress is a hot topic in health care and one to which everyone relates, I look at the body’s response to stress and what we can do to control this response. Other topics covered in the program include the benefits of stretching and strengthening, proper posture, mind-body awareness, the importance of pacing and how attitude influences health.

I introduce mindfulness as a way of touching life deeply and living more fully. Mindfulness, put simply, is present moment awareness. It is a practice I have studied in addition to my physical therapy training. Life is rich and full when our attention is in the here and now and not distracted by thoughts about the future or past. Patients with chronic medical conditions can spend a lot of time and energy worrying about how their health may worsen and impact their future. I tell them, “It is easy to feel overwhelmed when the unknowns of tomorrow are added to the challenges you face today. It is important to plan for the future, but don’t spend your life there. Put your energy into living and caring for yourself as best you can in this moment. The present moment is all any of us have for experiencing life.” Mindfulness has many benefits and one is to help patients stay focused on the here and now where often their circumstances are manageable. This practice of present moment awareness is integrated throughout the program.

Whenever possible, a discussion component is included with the didactic presentation. This offers the opportunity to support the participants’ strengths and self-confidence by drawing out their experiences, insights and wisdom. As the instructor, the key is not to be the person with the answers, but rather to help participants recognize that many answers can come from within themselves.

One theme emphasized in the program is one’s diagnosis is not one’s identity. So often people become identified with their symptoms or disease processes. They think, “I am this pain” or “This fibromyalgia is me.” In The Wellness Program, participants are coached to recognize themselves as whole human beings who happen to have medical conditions. Identifying with wholeness rather than illness is empowering.

Throughout the program patients learn to observe automatic habit reactions that aggravate symptoms and to make conscious choices that improve their situation. For example, many people automatically react to the onset of pain with increasing muscle tension, shallow breathing and fear. I teach patients to compassionately observe this reaction and notice how it affects them. They quickly recognize their reaction to pain adds to their suffering. Next I introduce how to recognize options and make conscious choices. For example, with the onset of pain, a patient can choose to focus on diaphragmatic breathing and in doing so, prevent the escalation of tension and remain calm and clear-headed. This ability to observe automatic reactions, recognize options and make conscious choices, when applied to daily challenges, improves a patient’s quality of life and ability to cope.

The therapeutic exercise component of the program is presented in one 60-minute session or in two 30-minute sessions. Diaphragmatic breathing exercises, relaxation techniques, and stretching and strengthening exercises emphasizing breathing and body awareness are taught. Participants are guided to exercise with an understanding and respect for their body’s abilities and limits. Fear of movement prevents some patients with chronic illness from progressing in physical therapy. Other patients place themselves at increased risk for flare-ups or re-injury by overdoing exercise or doing it improperly.

In The Wellness Program, participants perform each exercise slowly and with awareness. This approach helps patients explore the boundary between what is possible and what is not. When patients meet this boundary they are invited to respond to their body with acceptance and patience. They are asked to breathe deeply and relax into their experience. By emphasizing movement with awareness, patients develop confidence in their body and in their ability to listen to its signals. They build body awareness along with strength and flexibility. When living with chronic pain or illness, this ability to be aware of his or her body and to respond appropriately to its signals has a direct influence on a person’s quality of life.

Guiding therapeutic exercises for a group of patients with varied medical conditions and physical abilities is an art. Often in a group, people pressure themselves to keep up with others or impress the instructor, pushing beyond what is appropriate. Participants are cautioned to avoid overdoing any exercise. Exercises are modified to accommodate individual needs when possible. “Start low and go slow” is the motto. One important goal is for patients to be independent on a relaxation and exercise program.

A central component of the program is weekly homework. Participants receive handouts reviewing material presented in class and specific guidelines to integrate the strategies into their day. They are provided with relaxation, mindfulness and stretching/strengthening exercise cassette tapes that were recorded specifically for the program. They are instructed to practice one or more of these exercises daily. Also emphasized is how simple breathing exercises can be used throughout the day to decrease muscle tension and control the body’s stress reaction. “Breathe” stickers, made at a local print shop, are provided to patients with instructions to place them on the dashboard of their car, computer terminal, telephone or anywhere they might catch their eye and remind them to stop, breathe and touch their present moment experience. As the instructor, I bring credibility and understanding to my teaching when I, too, practice class material, so along with the participants, I include the homework in my daily activities.

Participants are interviewed both prior to enrolling and upon completing the program. During the initial interview I gather information on a patient’s medical history and current systems review. His or her reasons for enrolling in the program and specific goals are identified. Tests and measures are performed as appropriate and the patient’s diagnosis and prognosis are determined. All participants fill out symptom assessment questionnaires prior to and upon completion of the program. I explain the program’s emphasis on the active role patients play in their health and discuss the home program which requires a commitment of 30 - 45 minutes per day. This meeting also gives the patient the chance to get to know the instructor and have questions answered.

The closing interview offers the participant the opportunity to discuss their experiences in the program receiving individual attention and guidance. Connecting patients with community resources that offer continued support are discussed at this time. Examples of these include gentle yoga classes, support groups and also exercise programs sponsored by the Arthritis Foundation.

In the final class, participants are asked what they learned of value. One common response is, “The conscious breathing exercises.” This simple strategy of observing the sensations of stomach and rib cage movement with diaphragmatic breathing makes a powerful difference in people’s ability to manage pain and stressful situations.

Sometimes responses to this question are deeply moving as when one woman, diagnosed with lupus, answered, “Compassion for myself.” Prior to the program she described herself as critical of her body and its limitations. The class material and other people’s stories had taught her to meet herself with greater kindness, understanding and acceptance. Other participants speak of the relief that comes with getting to know other people living with chronic illnesses. Often friendships develop that last beyond the program.

Getting Started

The inspiration to create this program came from two sources. One was my own experience recovering from a work-related back injury. My healing included not only excellent medical care, but also time for reflection, finding a new perspective on work and life, and making life style changes. I saw The Wellness Program as an opportunity to bring this whole person approach to patients coping with chronic pain and illness.

The second source of inspiration was Jon Kabat-Zinn, Ph.D. at the University of Massachusetts Medical Center. Kabat-Zinn teaches patients yoga and mindfulness meditation and has published favorable results in the medical literature. Many of his yoga postures are identical to basic stretching and strengthening positions commonly taught by physical therapists. The difference in his teaching is his emphasis on breathing and present moment awareness of the body. Kabat-Zinn’s book, Full Catastrophe Living, was an invaluable resource as I designed the program.

It is one thing to know you have a good program that meets an important need, it is another to get the word out. I confess to being one of those PT’s who dreads marketing, but know it is necessary for a program’s success. To help myself ease this reluctance, I define marketing as planting seeds and building relationships. Talking with people about The Wellness Program is like planting seeds. With time, some of these seeds blossom as referrals. Building relationships is something physical therapists do all day with patients and peers. Marketing is simply extending this natural skill to building referral sources.

Because I was in private practice, I already had a referral base to which I could market the new program. Initially I sent letters and fliers to physicians, targeting those who specialized in the care of patients with chronic illness, including psychiatrists, rheumatologists, neurologists and cardiologists. I arranged individual meetings with these sources to provide detailed information and answer questions. Most of my initial referrals were received from physicians who already sent patients for individual services.

I began by offering one evening program in each of the fall, winter and spring quarters at a local community center. Eight to 10 participants enrolled in the first classes. This small group size was ideal for the experimentation and adjusting that go along with starting any new program. Patients entered the program with diagnoses such as fibromyalgia, ankylosing spondylitis, low back and neck pain, headache pain, Crohne’s disease, diabetes, hypertension, lupus and multiple sclerosis.

As the first class got underway, it was quickly clear that the group dynamic created the opportunity for people to inspire, support and learn from one another in ways which can never occur in a one on one treatment session. A good example of this was when one participant, Ann, described undergoing an uncomfortable medical procedure. Rather than become tense and anxious, she focused on diaphragmatic breathing exercises and stayed relaxed. Other group members were inspired. In the following weeks as other participants faced similar situations, they described thinking of Ann and saying to themselves, “If she can do it, so can I.”

On another occasion, a participant described the feeling of always running from her pain. The class gave her the skills and confidence to face and manage pain so that she no longer had to run. Her pain hadn’t changed, but the fear was gone. This powerful insight, coming from someone living with pain, had much more impact on other members of the group than it would have coming from a clinician.

I see the people who enroll in The Wellness Program as heroes. Many live daily with pain or fatigue. In a culture that idealizes physical health and activity, many have decreased physical abilities because of their medical condition. Patients in this program choose to relate directly to their circumstances and seek wise and skillful ways of responding. They uncover inner strengths and resources and have insights on how to help themselves. Many experience a decrease in symptoms or an improved ability to manage their symptoms. They often describe an increase in control and a renewed sense of well-being. Their stories are inspiring.

The Program Expands

By the spring of 1998, the program had an established track record and I was ready for a change from the business responsibilities inherent in private practice. I met with David Clawson, MD, the Medical Director for Rehabilitation Services at Swedish Medical Center, a 600-bed hospital and medical center in Seattle and discussed my interest in offering The Wellness Program through the Outpatient Physical Therapy Department. Dr. Clawson is an enthusiastic supporter of PTs taking an active role in wellness and preventive medicine. We reached an agreement for me to offer the program through this facility.

Offering the program at a major medical center has had several advantages. In addition to benefiting from the outstanding reputation Swedish Medical Center holds in our community, I have found my marketing opportunities substantially broadened. I have participated in multidisciplinary pain clinic, in hospital-sponsored professional conferences and in programs for the public organized by the medical center’s Community Health Education Department. Also, Swedish sends quarterly newsletters to the surrounding community that include a detailed description of the program. I have learned that informing the public directly is as important as building physician referrals. As our medical system primarily focuses on disease treatment, a wellness program may not be on a physician’s list of options, yet may be high on a patient’s list of interests. Educating the public directly increases class enrollment.

Working at Swedish has also provided an instant network of talented physical therapist colleagues who offer new ideas, support and recommend their patients to the program. As the class series has grown, the experience and expertise in program development of the department leadership team has been a key factor in meeting administrative challenges.

Currently I offer a daytime and an evening program in fall, winter and spring quarters. The class size has grown to 12 participants in each group. In addition, to help patients maintain the positive health habits they establish in the program, I offer a once a month “drop-in” class for Wellness graduates. This 2 hour class gives patients the chance to reconnect with others, review program material and practice relaxation, mindfulness and stretching exercises in a group. They receive continued encouragement and guidelines to integrate wellness strategies into daily life.

The Wellness Program grew out of my personal experience and professional passions. I would encourage any colleague interested in developing a similar program to build it on the foundation of their own experience, strengths, abilities and understanding of healing. As a major element of physical therapy is educating patients, many of us are natural teachers. A wellness program is an ideal teaching opportunity and forum for reaching more patients with strategies to improve function and quality of life.

Most PT’s work individually with patients and may have little experience running groups. I have additional training in psychology that contributes to my confidence leading groups. If a PT is uncertain about his or her skills in this area, I recommend attending classes and support groups sponsored by organizations such as the Arthritis Foundation, the Multiple Sclerosis Society and the American Heart Association. Much can be learned by observing other professionals guide a group. Also, Kabat-Zinn offers health professional training opportunities through the University of Massachusetts Memorial Medical Center and Medical School. His programs also provide additional training in mindful awareness. Another alternative would be to co-lead a program with a medical social worker or counselor.

Recently, a physical therapist from a nearby town attended the program to gain the knowledge and experience necessary to establish a similar class series at her hospital. Physical therapy student interns also participate. It is rewarding to share the program and my vision of wellness in these ways. My plans for the future include research assessing the program’s cost effectiveness and the development of The Wellness Program, Level II for patients who complete the initial program and want to continue to advance their wellness skills in a group setting.

Although I am the sole instructor for The Wellness Program, I see the class series as a team effort. Without the pioneering work of Kabat-Zinn, the enthusiastic backing of the medical director, the administrative skills of the department leadership and the support of the many physicians and physical therapists who recommend the program to their patients, The Wellness Program would not enjoy the success it does today. Together we are leading the way in making wellness services available to people living with chronic pain and illness in our community. So often when a person has a chronic medical condition they are told “You’ll have to learn to live with it.” This program helps patients to do just that.

References

1. Kabat-Zinn J. An out-patient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry (1982) 4: 33-47.

Kabat-Zinn J., L. Lipworth and R. Burney. The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine (1985) 8: 163-90.

2. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. Dell Publishing, New York, NY, 1990.