Integrating Dance/Movement Therapy,

Guided Imagery and Mindfulness into

PT Treatment of Pain

Rivi Belach Har-El, PhD, RPTRiVision Healing Center

New York, NY

Clinical Assistant Professor

SUNY-Downstate, Brooklyn, New York

Illustrations by Ziv Lenzner-Lenzner Anatomy

Learning Objectives:

Practice therapeutic exercises in the form of Dance/Movement

Therapy (DMT),Guided Imagery (GI) and Mindfulness

activities to improve pain, mobility, mood and wellbeing in

people of various ages, background, and physical and

emotional states

Discuss benefits of therapeutic exercises in the form of DMT,

GI, and Mindfulness as a group therapeutic activity on pain,

mobility, endurance and wellbeing

Explain the impact of repetitive movement patterns and

expansion of movement capabilities on health, wellness, and

physical functioning

The Live Experience of

Dance/Movement Therapy

What is Dance Movement Therapy?

DMT is a form of intervention that uses movement rather

than words as the primary medium for assessment, insight,

and change. It starts at the patient’s physical and emotional

level and allows for change, growth, and the expansion of

movement and extension of self (Schmais, 1974)

DMT furthers the emotional, cognitive, physical and social

integration of the individual according to the American Dance

Therapy Association (2011)

Basic Premise of DMT

There is no division between mind and body behaviour. Body

movement reflects emotional states, and changes in movement

behaviour can lead to change in the psyche.

What happen to your body when you are:

Relax/tense

Happy /sad

Secure/insecure……...

Event/Interaction Feelings Sensations

Event/Interaction-Feelings-Sensations

(Cont’d) Basic Premise of DMT

● Approach that addresses the complexities of the human

movement experience, pain and pain management

● Integrates treatment of physical and psychosocial/emotional

aspects of pain

● Mindfulness aspect that improves awareness of conscious and

subconscious processes contributing to pain

● Relates the total movement experience to current physical and

emotional function

DMT as Therapeutic Modality for

Treating Pain

● Patient/Client centered

● Individualized even in a group setting

● Safe environment in which to explore movement

● Alternative to typical gym

● Access to the expert

● Recruit more patients

● Use of music and movement rather than words to shift mood

● Alternative to opioids

● Therapeutic exercise CPT codes (individual or group) for

insurance coverage

Dance/Movement Therapy As

Therapeutic Exercises

●Explore the participant’s dominant pattern of motion

(repetitive style) based on ROM and planes of motion

(vertical, sagittal, horizontal)

●Balance and coordination exercises

●Use music that has some positive meaning to the participant.

●Relate to function

●Relate to others in group

●Explore transitions between movements

Dance/Movement Therapy As Therapeutic Exercise

● Use repetitive rhythmic motions when using the following

movement factors:

1) Fine (light/weak)-------------------Firm (heavy/strong)

2) Sudden (quick speed)--------------Sustained (slow speed)

3) Direct (straight line)---------------Indirect (wave-like)

4) Bound Flow--------------------------Free Flow

Relating to Experiential Work

● What did you sense (physical sensations)

● What did you feel (emotions)

● What body motions did you notice● Direction

● Patterns and flow of movement through the body

Symbolic value for the individualComfort level

• With self

• With others in group

Sense of well-being

DMT Integrated with Guided Imagery (GI)

● Using images (thoughts) that draw on our senses. They may

involve one, several, or all the following senses:

● Hearing

● Taste

● Movement

● Vision

● Touch

● Smell

● Internal sensations

(Cont’d)DMT Integrated with Guided

Imagery (GI)

● The goal of GI is to make beneficial physical changes in

the body by repeatedly visualizing the sensations

associated with a particular experience.

● An image, like any other thought, sparks an electrical chain

of events in the brain.

● Imagery influences endorphin secretions which then affects

a person’s mood

● Relate GI to the experiential work

(Cont’d)DMT Integrated with Guided

Imagery(GI)

● The goal of GI is to make beneficial physical changes in

the body by repeatedly visualizing the sensations

associated with a particular experience.

● Dancing and music elicit happy memories/times

● Imagery influences endorphin secretions which then affects

a person’s mood

● Relate GI to the experiential work

(Cont’d) DMT Integrated with Guided

Imagery(GI)

“See in” pictures your pain

● Learn to remove the obstacle and pain away

● Learn to alter emotion/motion by altering an image

● Relate GI to the experiential work

Vision Statement for the Physical

Therapy Profession

● Transforming society by optimizing movement to improve

the human experience.

● http://www.apta.org/Vision/HumanExperience/

● Terrence M. Nordstrom, PT, EdD

● APTA's House of Delegates (House) in 2013.

Research support for:

Dance/Movement Therapy, Guided Imagery and

Neuroplasticity on mood, pain,

mobility/flexibility, well being and more

Evidence for

Dance /Movement Therapy and

Dance

Efficacy of DMT and Dance

● Koch et al, 2014● Found DMT and dance are effective for increasing quality of life,

decreasing depression and anxiety; as well as increasing well being,

positive mood, affect and body image

● Based on a meta analysis from 23 primary trails, (N=1078)

● Bruaninger, 2012

● 162 participants who suffered from stress were randomly assign to

DMT or control group.

● It was found that DMT was effective in the short and long term

improvement of Quality of life on six domains: physical and

psychological health, level of independence social relations,

environment and spirituality/personal beliefs

Efficacy of Guided Imagery

● Giacobbi, 2015

● Systemic review of randomized controlled trials(1960-2013) that

examined the effects of GI on pain, function, anxiety, depression and

quality of life in adults with arthritis and other rheumatic diseases

● Reported statistically significant improvement in outcomes

● Onieva- Zafra, 2015

● Sixty patients who diagnosed with Fibromyalgia were randomly

assigned to either GI or control group.

● The treatment group reported statistically significantly lower levels of

pain and depression than the control group at 4 week evaluation

Mindfulness & Regional Brain Gray Matter Density

● Holzel, 2011

● Functional and structural neuroimaging studies (2005-

2010) suggest that mindfulness practice is associated with

neuroplastic changes in the brain

● Lazar, 2005

● Increased thickness of cortical structure ,i.e., gray matter)

associated with body awareness, emotion regulation,

change in self perception

● The brain region associated with attention, introspection

and sensory processing was thicker among 20 participants

who practiced meditation extensively as compared to the

control group

Rivi Belach Har-El, Doctor of Philosophy, 2000

Major: Pathokinesiology

Title of Dissertation:

INFLUENCE OF NECK EXERCISES, COMBINED

WITH EITHER THE CHACE TECHNIQUE OF

DANCE THERAPY OR AEROBIC TRAINING,

ON PAIN PERCEPTION, MOOD STATE, AND

CERVICAL RANGE OF MOTION OF ADULTS

WITH CHRONIC MECHANICAL NECK PAIN

Committee Chair: Dr. Arthur J. Nelson

Theoretical Bases For Using Dance

Movement Therapy and Guided Imagery

to Treat Pain Impairments

● The muscle tension theory

● The therapy of catharsis and spontaneous expression in

movement

● The use of guided imagery

● Neuroplasticity

Theoretical Bases For Using Dance Movement

Therapy and Guided Imagery to Treat Pain

Impairments

● Payne,1992The effect of Chace technique of DMT on mood can be explained

by the theory of catharsis and spontaneous expression through

movement. Leste and Rust (1984) theorized that the catharsis

nature of dance, with its concomitant emotional expression,

release of tension, anger or frustration, can alter the individual’s

mood. It is postulated that in DMT, the spontaneous, pleasurable

expenditure of energy offers relaxation and the sublimation of

worries.

Theoretical Bases For Using Dance Movement

Therapy and Guided Imagery to Treat Pain

Impairments

● Achterberg, Dossy, &Kendkmeier,1994, p.38

Deliberate use of imagery- “images are thought that draw on

senses: they may involve one, several or all the following senses:

sound, taste, movement, vision, touch and inner sensation.”

● Zahourek,1988.p. 63

An image, like any other thought, sparks an electromechanical

chain of events in the brain. “Images stimulate biochemical

reactions in the brain that then affect several master glands that in

turn influence feelings states and behavior.” (Zahourek,1988.p.

63). For example, imagery influences endorphin secretion which

then affects the person’s mood.

Theoretical Bases For Using Dance Movement

Therapy and Guided Imagery to Treat Pain

Impairments

The dance itself allows for emotional release, which can

influence the individual’s flexibility and range of motion.

●(Chapman,1990) The muscle tension theory which attempts

to explain why mood and pain frequently coexist suggests that

anxiety, which is frequently associated with depression, can

elicit increased muscle tension

● Thompson (1988) described an elevated skeletal muscle

activity that may represent the participant's attempt to inhibit

the expression of emotions. Wright and Mitschel (1982)

described patients who had difficulty expressing emotions who

also increased tension in their muscles.

Theoretical Bases For Using Dance Movement

Therapy and Guided Imagery to Treat Pain

Impairments

●Neuroplasticity- A growing body of literature has

demonstrated that neural systems are modifiable networks

and changes in neural structures can occur in adults as a

result of mindfulness practice.●(Holzel, 2011 Lazer, et al. 2005, Pagnoni and Cekic

2007) Several cross-section anatomical magnetic

resonance imaging (MRI) studies have demonstrated that

experienced meditators exhibit a different gray matter

density in multiple brain regions when compared to non-

meditating participants

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Case study 2- Betty 23 y/o woman with chronic shoulder and neck pain.

Poor self esteem and body awareness