Abstract

In this article, I present dissolving pain mind exercises created by myself on the basis of the Open Focus theory.

I explain the Open Focus theory and I relate it to some aspects of current theories describing neurophysiological processing of pain within the brain.

Event-related potentials induced by a painful stimulus are associated with modulations of ongoing oscillations. They appear as event-related synchronisation or desynchronisation (ERS/ERD) in different frequency bands. It has been suggested that these ERD/ERS activities reflect various aspects of pain perception, including the representation, encoding, integration and behavioural responses to pain. ERD/ERS pattern may also facilitate focal cortical activation (focal ERD) and simultaneous deactivation or inhibition of surrounding cortical areas, which are outside the focus of attention (surrounded by ERS).

The Open Focus theory recognises four styles of attention. Switching between attention styles during simple mind exercises strengthens the alpha band rhythm synchronisation (alpha ERS). It can inhibit information processing in the brain structures affected by pain.

This mechanism represents a ‘top-down’ control inhibitory process and is exploited in the pain dissolving exercises.

Introduction

The dissolving pain in Open Focus exercises described in this article last 10 – 20 minutes which makes them easy to perform in my everyday GP setting.(1) They require a participant to listen to a set of simple instructions while sitting in a comfortable position with closed eyes. The participant is fully aware during the exercises and can stop them at any moment. They always trigger a nice, relaxed state and a feeling of slight drowsiness which fades down within 1-2 minutes. They do not involve hypnosis or subliminal messages. They do not have contraindications and they cannot trigger unpleasant side effects.

I have been practising these exercises with my patients during my regular GP clinics for the last 8 years. I have suggested them mainly to patients who had already tried various types of anaesthesia and still suffered from chronic pain. They were usually very keen to try a new and non pharmaceutical approach.

The effects of the exercises varied depending on the patient and the character of pain. Pain was often reduced after the first try, and in some cases, it dissolved completely. I witnessed many sudden recoveries straight after performing the exercise. Most of the patients achieved significant pain reduction after 4-5 days of regular exercising. I also witnessed the improvement in mobility which often at first went unnoticed by the patient. My consulting room is located at the end of a long corridor and, without their awareness, I saw people who had come in with limb/back problems, leaving either walking better or moving their arms more easily.

To check if my presence played any role, I uploaded some exercises to the internet. They have been tried by people from all over the world with often good effects. I have also received positive reviews from people performing the exercise from the script.

I must admit that in some cases they do not work. It usually (but not exclusively) happens to elderly patients who may have difficulty understanding the concept of diffusing their attention.

It also could be that the benefits of performing the exercises fade down after a few hours. I always suggest to these patients to repeat the exercise regularly for a few days to achieve long term improvement. However, some of them show disappointment after a recurrence of the pain and do not continue with exercising. I think, this can be explained by the very limited time I have for communicating the idea of this approach.

To avoid confusion, I always make sure that the reason of the pain has been established before I suggest this approach. Sensing the pain can be important in any investigation process and these exercises once successful can make the situation less clear.

The Open Focus and The four attention styles theory

The Open Focus is the name of an attention training program created by Dr Lester Fehmi, neuroscientist and psychologist from Princeton, New Jersey, US. Dr Fehmi has been running a neuro-feedback clinic for attention disorders for almost 40 years. He created a series of mind exercises which help to cultivate the whole brain waves synchronisation in alpha frequency. This training is supported by a neuro-feedback EEG machine designed by Dr Fehmi’s which is calibrated to detect this specific brain waves pattern. On the basis of his findings, Dr Fehmi has developed The Four Attention Styles Theory (2). His theory describes four different styles in which we can pay attention and relates these styles to electrical processing in the brain.

  •  The most common understanding of attention is when we say that we “pay attention” or we “concentrate on something”. For example, a reader of this article must focus on the lines of text in order to understand it. It limits the reader’s conscious awareness to a narrow stream of stimuli which are being voluntary narrowly selected from a wide array of stimuli constantly available to him/her. According to Dr Fehmi’s theory, this type of attending can be described as the narrow attention style also known as selective attention.
  • The opposite to the narrow style is the diffused attention style when one is simultaneously aware of all available stimuli (visual, auditory, tactile, olfactory, etc) and/or three dimensional space which is continuously present around us.

The other two styles of attention include.

  • The objective attention style – when one feels separated from an attended object (the object can be everything one can focus on; like a physical object, a sound, a taste, a thought, a feeling, sensation from the body, etc). For example, it can be triggered when one is confronted with danger or during an argument.
  • The immersed attention style – when we feel connected, for example, while reading a good book, or during an involving activity like playing an instrument. (3)

According to Dr Fehmi, stress, anxiety, pain and life’s challenges make our attention narrow and objective. It is natural to narrow our attention (to focus) on pain or a problem in order to deal with it efficiently, but most people overuse this style in everyday life. Often, habitual focusing creates an impression that the reality consists of separated objects making our attention objective. This is because one can concentrate on only one thing or sensation at a time leaving the rest outside of the focus. It can make us feel distant, alienated and lonely.

Dr Fehmi says we can support ourselves in relating to what’s difficult by diffusing (broadening, opening focus of) our attention. Diffusing allows us to see the big picture and connect (immerse) with its elements. It helps to realign with the world and to create healthy relationships. According to Dr Fehmi, simultaneous diffusing and immersing our attention makes the brain activity more synchronous in alpha frequency.

Dr Fehmi suggests everyone should be flexible in paying attention and practice ability to attend in Open Focus.

Attentional flexibility means that one can alternate between different attention styles.

Open Focus attention means that one can balance all attention styles at the same time. For example, a reader of this text can stay focused on the lines of text while diffusing attention by becoming aware of the space at the same time. Please, try an example below.

Can you become aware of space between lines of this text and between these words? Do it now, please. Keep reading and become aware of space which is between you and a screen you are reading from now? Do not stop reading and become aware of space around the screen at the same time. There is also space on both sides of you. Become aware of it and feel your shoulders gently dropping now. Become aware of space behind you. There is a lot of space around us all the time but we tend to ignore it. Stay aware of space on both sides of you and become aware of space below and above you. Feel muscles around your eyes gently relaxing. Stay aware of space and keep reading.

Dr Fehmi says, that the way in which we pay attention is directly linked to our well-being. He links habitual attending in the narrow/objective style with the sympathetic system overstimulation and attending in the diffused/immersed style with the para-symphatetic system activation (4). He claims that once we learn to balance our attention, we can positively influence the mind and body. It means that attention flexibility can be regarded as an integral part of a healthy lifestyle together with a healthy diet and physical activity.

Open Focus training starts from simultaneous awareness of many objects. Then one can progress to awareness of space between objects (it might be space between physical objects, silence between sounds or breaks between thoughts, etc). Finally one practices awareness of space between and inside objects which according to Dr Fehmi helps us attending in the diffused and immersed attention style and generates the whole brain synchrony in alpha frequency.

Elements of the brain’s response to pain

Event-related potentials induced by a painful stimulus are associated with modulations of ongoing oscillations. They appear as event-related synchronisation or desynchronisation (ERS/ERD) in different frequency bands. It has been suggested that these ERD/ERS activities reflect various aspects of pain perception, including the representation, encoding, integration and behavioural responses to pain. (5, 6, 7, 8)

ERD/ERS pattern may also facilitate focal cortical activation (focal ERD) and simultaneous deactivation or inhibition of surrounding cortical areas, which are outside the focus of attention (surrounded by ERS). (9, 10, 11, 12, 13)

It has been suggested that mechanism helps to fully concentrate on pain and deal with it efficiently while not being distracted by other stimuli. (14)

It seems plausible to expect that increasing alpha synchronisation (alpha ERS) in the brain network involved in pain processing will result in diminishing the pain experience. Not surprisingly it had been already researched with promising results (29, 30, 31).

The functional inhibition role of alpha band synchronisation has been already well documented (15, 16, 17, 18). It also has been shown that strong pre-stimulus alpha power in task-relevant regions negatively affects subsequent stimulus processing (19, 20, 21, 22, 23). Degree of alpha lateralisation has been linked to ability to ignore task irrelevant hemifield and sustain attention (24, 25, 26, 27). The functional inhibition role of alpha band synchronisation is likely responsible for an attentional failure in a famous inattentive blindness experiment (28).

The inhibition role of alpha band synchronisation is utilised by the dissolving pain in Open Focus exercises. The enhancement of alpha band is created by switching attention styles from narrow/objective to more diffused and more immersed (32).

This represents a ‘top-down’ control inhibitory process.

The four attention styles theory and a process of dissolving the pain

According to the four styles attention theory, pain triggers the narrow objective attention style (upper, left quadrant of the graph).

The pain triggered style of attention is narrow because the pain constantly redirects the attention towards itself – ‘I cannot stop feeling this pain’.

It is also objective because the pain creates an impression that the painful part of the body is separated from self (I, ego) – ‘I have this pain and I want to get rid of it‘.

According to Dr Fehmi, in order to dissolve the pain, the attention should be shifted from the narrow/objective style to more diffused (‘become aware of the wide array of sensations including the pain‘) and more immersed (‘connect with the pain’). This shift of attention generates strong, synchronous waves in alpha frequency in the brain network processing the pain (32).

Diffusing attention makes the pain less disturbing as it becomes only one of many processed stimuli (although it is still experienced). The simplest way to diffuse attention is to become aware of sensations coming from both hands at the same time and/or the empty space around and inside the pain. It must be pointed out that including the pain into broad attention (diffusing) is distinct from redirecting attention from the pain (distracting) (33).

Immersing with the pain helps not to experience it as a separated from self (I, ego). The easiest way to immerse with the pain is to become aware of the centre of the pain and to let go. The difficult part of ‘letting go’ is that one does not have to do anything in order to achieve it. Immersing happens on its own and one can only let it happen. Once it is done by sufficient time one can merge (unify) with the pain. This process might be facilitated by a cross-frequency synchronisation between gamma band waves representing the pain stimulus and low frequency activity in deep brain structures (34).

During the dissolving pain in Open Focus exercises, the participant is initially asked

1. To become aware of sensations coming from both hands, lips and the tongue at the same time in order to diffuse an attention between those three areas. They have been chosen specifically due to their biggest representation in the brain sensory area.

2. Once it happens the participant is asked to become aware of space in the room (to diffuse attention even more).

3. Then the participant is asked to feel space together with hands, lips, tongue and the pain. This enhances alpha band synchronisation in the whole brain.

4. Then the participant is asked to add to the experience a sensation of pain which introduces synchronous alpha brain waves to brain networks processing the pain experience.

Open Focus, Mindfulness and meditation techniques as types of attention training affecting pain experience

Open Focus attention training can be regarded as one of many approaches to attention training, together with Mindfulness and many traditional meditation techniques.

Mindfulness has been defined by its creator as paying attention on purpose, in the present moment and without judgment. There are dozens of research looking at Mindfulness effects on the brain in pain (35, 36, 37, 38). Interestingly, some of them describe a similar mechanism to the one presented in this paper. (39)

Equally many ancient meditation techniques can be regarded as an attention training. (40, 41, 42). There is also research available showing that experienced meditators change their appraisal of pain (43, 44, 45).

The advantage of the Open Focus Attention training

I believe, the advantage of the Open Focus method over other attention modulation approaches is that it has identified four attention styles, which for most people, makes it easy to learn. It also does not require the assistance of a health professional (after initial introduction). It can be presented during a 10-20 minute appointment or can be learned from a script or recording.

The recognition of attention styles and the brain physiology related to them enables

  • a very fast induction (immersing through diffusing),
  • simplicity (simple and direct instructions, easy to practice shortly after introduction to the method, no need to engage with a health professional),
  • possibility of adjusting the exercise to the particular patient by calibrating a personal attention preference,
  • no need for readjusting personal believes and behaviours (can be used as a stand alone technique),
  • easy switch to other popular applications of the Open Focus method (dissolving unwanted emotions, fast falling asleep),
  • based on short lasting exercises without compromising efficiency (important in GP setting),
  • no need for time consuming introduction to the method (important in GP setting),

It is worth mentioning that the same principle (augmenting the perception by changing an attention style and increasing alpha power in the brain structures processing a stimulus) can be used to inhibit perception of many internal or external stimuli like itch, hunger, anxiety, fear, cold, etc.

I have been experimenting with this approach for the last 9 years with many interesting results. Changing attention style helps in many everyday situations like walking into a swimming pool with cold water, after sitting for a prolonged time with legs crossed and slowly getting up experiencing pins and needles in my legs, small burnings, injuries and eating very spicy food.

I (and some of my friends and patients) have already experimented with unpleasant smells, itch, anxiety, fear, hunger, etc. In all these situations there is a significant shift of perception. It sometimes requires training, but it is achievable by many.

By regular practice, I have significantly improved my attention span, I have learned how to control my physical pain and to reduce stress. I can fall asleep every time when I want, I communicate better with my patients and I can be creative on demand.

These exercises are safe, easy to learn, effective (immediately or after a short training), based on neuro-feedback research and free. I believe, they could be added to an already existing list of pain remedies which can be recommended by health professionals to their patients.

References:
1. Please, follow a link below to download an example of the pain dissolving exercise.
[Link]
2. Fehmi L.G. Attention to Attention
[Link]
for other publications see following [Link]
3. Please, follow this [Link] to see a short presentation explaining the four attention styles theory
4. Fehmi L.G., Robbins J. The Open-Focus Brain: Harnessing the Power of Attention to Heal Mind and Body (2010) Shambuhala Publications, Inc. [Link]
5. Event-related EEG/MEG synchronization and desynchronization: basic principles. Pfurtscheller G, Lopes da Silva FH, (1999), Clin Neurophysiol. Nov; 110(11):1842-57.
[PubMed]
6. Gamma Oscillations in Human Primary Somatosensory Cortex Reflect Pain Perception Gross J, Schnitzler A, Timmermann L, Ploner M (2007) PLoS Biology 5(5): e133
[Link]
7. Neuronal gamma-band synchronization as a fundamental process in cortical computation. Fries P, (2009), Annu Rev Neurosci.; 32:209-24.
[PubMed]

8. Oscillatory synchronization in large-scale cortical networks predicts perception. Hipp JF, Engel AK, Siegel M
Neuron. 2011 Jan 27; 69(2):387-96.
[PubMed]

9. Subjective pain perception mediated by alpha rhythms.
Peng W, Babiloni C, Mao Y, Hu Y., (2015) Biol Psychol., Jul; 109:141-50
[Link]
10. Changes of spontaneous oscillatory activity to tonic heat pain.
Peng W1, Hu L2, Zhang Z3, Hu Y1., PLoS One. (2014) Mar 6;9(3)
[PubMed]
11. Top-down and bottom-up modulation of pain-induced oscillations.
Hauck M, Domnick C, Lorenz J, Gerloff C, Engel AK.
Front Hum Neurosci. 2015 Jul 2;9
[PubMed]
12. Synchronised oscillations of the human sensorimotor cortex.
Schnitzler A, Gross J, Timmermann L, (2000) Acta Neurobiol Exp (Wars); 60(2):271-87.
[PubMed]
13. Functional features of nociceptive-induced suppression of alpha band electroencephalographic oscillations.
Hu L, Peng W, Valentini E, Zhang Z, Hu Y, (2013) J Pain. Jan; 14(1):89-99.
[PubMed]
14. The importance of ignoring: Alpha oscillations protect selectivity.
Lisa Payne, Robert Sekuler, Curr Dir Psychol Sci. 2014 Jun; 23(3): 171–177 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4266987/
[PubMed]
15. Shaping functional architecture by oscillatory alpha activity: gating by inhibition. Jensen O, Mazaheri A, Front Hum Neurosci. 2010; 4():186.
[PubMed]
16. The Role of Alpha-Band Brain Oscillations as a Sensory Suppression Mechanism during Selective Attention. Foxe JJ, Snyder AC, Front Psychol. 2011; 2():154.
[PubMed]
17. An oscillatory mechanism for prioritizing salient unattended stimuli Jensen O, Bonnefond M, VanRullen R, Trends Cogn Sci. 2012 Apr; 16(4):200-6.
[PubMed]
18. Pulsed out of awareness: EEG alpha oscillations represent a pulsed-inhibition of ongoing cortical processing. Mathewson KE, Lleras A, Beck DM, Fabiani M, Ro T, Gratton G, Front Psychol. 2011; 2:99. [PubMed]
19. Alpha rhythm of the EEG modulates visual detection performance in humans. Ergenoglu T, Demiralp T, Bayraktaroglu Z, Ergen M, Beydagi H, Uresin Y, Brain Res Cogn Brain Res. 2004 Aug; 20(3):376-83.
[PubMed]
20. Visual discrimination performance is related to decreased alpha amplitude but increased phase locking. Hanslmayr S, Klimesch W, Sauseng P, Gruber W, Doppelmayr M, Freunberger R, Pecherstorfer T., Neurosci Lett. 2005 Feb 25; 375(1):64-8.
[PubMed]
21. Prestimulus oscillations predict visual perception performance between and within subjects. Hanslmayr S, Aslan A, Staudigl T, Klimesch W, Herrmann CS, Bäuml KH, Neuroimage. 2007 Oct 1; 37(4):1465-73. [PubMed]
22. Prestimulus oscillatory activity in the alpha band predicts visual discrimination ability. van Dijk H, Schoffelen JM, Oostenveld R, Jensen O, J Neurosci. 2008 Feb 20; 28(8):1816-23. [PubMed]
23. Prestimulus alpha and mu activity predicts failure to inhibit motor responses. Mazaheri A, Nieuwenhuis IL, van Dijk H, Jensen O, Hum Brain Mapp. 2009 Jun; 30(6):1791-800. [PubMed]
24. Attention-dependent suppression of distracter visual input can be cross-modally cued as indexed by anticipatory parieto-occipital alpha-band oscillations. Fu KM, Foxe JJ, Murray MM, Higgins BA, Javitt DC, Schroeder CE, Brain Res Cogn Brain Res. 2001 Aug; 12(1):145-52. [PubMed]
25. Top-down controlled alpha band activity in somatosensory areas determines behavioral performance in a discrimination task. Haegens S, Händel BF, Jensen O, J Neurosci. 2011 Apr 6; 31(14):5197-204.
[PubMed]
26. Alpha activity reflects individual abilities to adapt to the environment.
Horschig JM, Jensen O, van Schouwenburg MR, Cools R, Bonnefond M, Neuroimage. 2014 Apr 1; 89():235-43.
[PubMed]
27. Alpha entrainment is responsible for the attentional blink phenomenon. Zauner A, Fellinger R, Gross J, Hanslmayr S, Shapiro K, Gruber W, Müller S, Klimesch W, Neuroimage. 2012 Nov 1; 63(2):674-86. [PubMed]
28. The Monkey Business Illusion [Link]
29. Alpha-range visual and auditory stimulation reduces the perception of pain. Ecsy K, Jones AK, Brown CA, Eur J Pain. (2017) Mar; 21(3):562-572
[PubMed]
30. Cortical nociceptive processes are reduced by visual alpha-band entrainment in the human brain.
Ecsy K, Brown CA, Jones AKP, Eur J Pain. 2018 Mar;22(3):538-550
[PubMed]
31. Neurogenic pain relief by repetitive transcranial magnetic cortical stimulation depends on the origin and the site of pain. Lefaucheur J, Drouot X, Menard-Lefaucheur I, et al, Journal of Neurology, Neurosurgery & Psychiatry 2004;75:612-616. [Link]
32. Simple Brain-Training Exercises for Overcoming Chronic Pain
Fehmi L.G., Robbins J. (2010) Shambuhala Publications [Link]
33. Counter-stimulatory effects on pain perception and processing are significantly altered by attention: an fMRI study Longe, S. E.; Wise, R.; Bantick, S.; Lloyd, D.Johansen-Berg, McGlone, F. Tracey (2001) Neuroreport July Vol. 12 Issue 9 pp 2021-2025
[PubMed]
34. Cross-frequency coupling in deep brain structures upon processing the painful sensory inputs Liu CC, Chien JH, Kim JH, Chuang YF, Cheng DT, Anderson WS, Lenz FA., Neuroscience. (2015) Sep 10;303:412-21
[PubMed]
35. Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation Fadel Zeidan, Katherine T. Martucci, Robert A. Kraft, Nakia S. Gordon, John G. McHaffie, Robert C. Coghill (2011) The Journal of Neuroscience, 6 April , 31(14): 5540-5548
[Link]

36. Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, Colaiaco B, Maher AR, Shanman RM, Sorbero ME, Maglione MA, .Ann Behav Med. 2017 Apr;51(2):199-213 [PubMed]

37. Does mindfulness meditation improve chronic pain? A systematic review Ball EF, Nur Shafina Muhammad Sharizan E, Franklin G, Rogozińska E.Curr Opin Obstet Gynecol. 2017 Dec;29 (6) :359-366 [PubMed]
38. Mindfulness meditation-based pain relief: a mechanistic account.Zeidan F1, Vago DR2.Ann N Y Acad Sci. 2016 Jun;1373(1):114-27 [PubMed]

39. Mindfulness starts with the body: somatosensory attention and top-down modulation of cortical alpha rhythms in mindfulness meditation
Kerr CE, Sacchet MD, Lazar SW, Moore CI, Jones SR., Front Hum Neurosci. (2013) Feb 13;7:12.2013. [PubMed]
40. Attention regulation and monitoring in meditation Lutz A., Slagter H.A., Dunne J.D., Davidson R.J. (2008) Trends in Cognitive Science 12(4): 163– 169
[PubMed]
41. Focused attention, open monitoring and automatic self-transcending
Fred Travis, Jonathan Shear (2010) Consciousness and Cognition, 10.1016
[Link]
42. Meditation States and Traits: EEG, ERP, and Neuroimaging Studies
B. Rael Cahn, John Polich (2006) Psychological Bulletin Vol. 132, No. 2, 180–211[Link]
43. Pain sensitivity and analgesic effects of mindful states in Zen meditators: a cross-sectional study Grant JA, Rainville P. (2009) Psychosomatic Medicine Jan;71(1):106-14.
[Link]
44. Meditation experience predicts less negative appraisal of pain: Electrophysiological evidence for the involvement of anticipatory neural responses Christopher A. Brown, Anthony K.P. Jones (2010) PAIN 150 428–438 [Link]
45. Cortical thickness and pain sensitivity in zen meditators.
Joshua A.; Courtemanche, Jérôme; Duerden, Emma G.; Duncan, Gary H.; Rainville, Pierre (2010) Emotion, Vol. 10(1), Feb, 43-53. [Link]
46. Neuroimaging of meditation’s effect on brain reactivity to pain.
Orme-Johnson DW, Schneider RH, Son YD, Nidich S, Cho ZH. (2006) Neuroreport Aug 21;17(12): 1359-63 [Link]