Kinesither Rev 2015;15(168):e1–e10 File /Hypnosis

Hypnosis and physio

therapy

Hypnose et kinésithérapie

Jad Wehbe a

Yendi Safar b

aAchrafieh, Beyrouth, LebanonbAdonis, Beyrouth, Lebanon

KeywordsAnxietyBurns

Received 28 September 2014; accepted 11 March 2015

ConsciousFibromyalgiaHeadacheHypnosisHypnotherapyInductionInterviewLumbagoMigraineNeurophysiologyOsteoarthritisPosturePhysiotherapyRehabilitationStressSubconsciousSuggestionUnconsciousVisualization

Mots clésAnxiétéBrûléConscientFibromyalgieCéphaléeHypnoseHypnothérapieInductionEntretienLombalgieMigraineNeurophysiologieArthrosePostureKinésithérapieRééducationStressSubconscientSuggestionInconscientVisualisation

Corresponding author:J. Wehbe,Achrafieh, Lebanon.E-mail addresses:jad__w@hotmail.com,yendi.safar@gmail.com

SUMMARYHypnotherapy is now a validated evidence-based science, demonstrated on brain imaging,especially thanks to modern techniques of medical imaging. Imaging studies further enabled thehypnotic state to be described as a specific state of consciousness, differentiating it from otherstates of consciousness. This state of consciousness is primarily characterized by a state ofmental permeability or suggestibility, showing an increased ability to produce desirable changesin motivation, habits, lifestyle, health, perception and behavior as well as modifying physicalsensation. Its usefulness is interesting for physiotherapists since hypnosis has higher levels ofevidence than many other conventional tools used in physiotherapy. The basic techniques ofhypnosis are: the interview which seeks to put the patient at ease, eliminating all preconceivedmisconceptions about hypnosis and creating treatment expectations that are as positive aspossible; suggestion which is themost powerful technique in hypnosis: direct suggestion, indirectsuggestion, post-hypnotic suggestion, and self-suggestion; induction which is the process oftransition from the usual waking state to the hypnotic state; visualization which consists in avirtual experience of a specific event proposed by the therapist. It is often used by physiothera-pists in traumatologic, rheumatologic and neurologic rehabilitation, where efficacy is improved byhypnosis. Hypnosis affects the subconscious, which is the center of emotions, habits andautomatisms. The subconscious transmits commands to the unconscious mind, which in returntranslates these emotions into somatic feelings and reactions. In parallel, the neurophysiology ofhypnotic suggestion is currently well-defined, as is the brain permeability associated withincreased regional cerebral blood flow in the attentional system of the brain. Furthermore,positive expectation and labeling of "hypnosis'' seem to have remarkable effects on the efficacyof the procedure. Clinical randomized controlled studies have shown efficacy on pain in general,tension headache and migraine, temporomandibular pain, chronic low back pain, osteoarthritisand bone and joint pain, fibromyalgia, regional pain syndrome, phantom limb pain, sportsrehabilitation, irritable bowl syndrome, stress and anxiety, and many other pathologies. Hypnosisis a powerful and very useful tool in everyday physiotherapy.Level of evidence. – NA.© 2015 Elsevier Masson SAS. All rights reserved.

RÉSUMÉL'hypnothérapie est désormais une technique scientifiquement validée, démontrée par imageriecérébrale, surtout grâce aux techniques plus modernes d'imagerie médicale. Les études enimagerie médicale ont aussi permis de décrire l'état hypnotique comme un état de consciencespécifique qui le différencie des autres états de conscience. Cet état de conscience se définitsurtout par un état de perméabilité mentale ou suggestibilité. Celle-ci est caractérisée par unecapacité accrue à produire des changements souhaitables aux niveaux de la motivation, de

DOI of original article: http://dx.doi.org/10.1016/j.kine.2015.03.014

http://dx.doi.org/10.1016/j.kine.2015.06.007© 2015 Elsevier Masson SAS. All rights reserved.

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l'habitude, du mode de vie, de la santé, la perception, et le comportement, ainsi qu'une modification des sensations physiques.L'hypnose intéresse le kinésithérapeute dans lamesure qu'elle comporte un niveau de preuve plus important que bien d'autres desoutils conventionnels utilisés dans la kinésithérapie. Les techniques de base de l'hypnose sont les suivantes : l'entretien vise àsécuriser le patient, en éliminant toutes les idées fausses préconçues à propos de l'hypnose et créer une attente la plus positivepossible ; la suggestion : c'est la technique la plus puissante de l'hypnose : suggestion directe, suggestion indirecte, suggestionpost-hypnotique, autosuggestion ; l'induction : c'est le processus de passage d'état d'éveil habituel vers l'état hypnotique ; lavisualisation consiste à vivre virtuellement un événement précis proposé par le thérapeute. Elle est récemment et fréquemmentutilisée par les kinésithérapeutes dans la rééducation en traumatologie, rhumatologie et neurologie, où efficacité est améliorée parl'usage de l'hypnose. L'hypnose agit au niveau du subconscient, le siège des émotions, des habitudes et des automatismes. Lesubconscient transmet la commande à l'inconscient qui à son tour traduira ces émotions en réactions somatiques. En parallèle, laneurophysiologie des suggestions hypnotiques est actuellement bien définie, ainsi que celle de la perméabilité cérébrale qui estassociée à l'augmentation du débit sanguin cérébral régional au niveau du système attentionnel du cerveau. D'autre part, l'attentepositive et l'appellationde« l'hypnose »semblent avoir deseffets remarquablessur l'efficacité de laprocédure. Lesétudescliniquesont démontré une efficacité sur les douleurs en générales, les céphalées de tension et la migraine, les douleurs temporo-mandibulaires, la lombalgie chronique, l'arthroseet lesdouleursostéo-articulaires, le syndromedouloureux régional, lafibromyalgie,les douleurs du membre fantôme, la rééducation sportive, la colopathie fonctionnelle, le stress et l'anxiété, et bien d'autrespathologies. L'hypnose est un outil puissant et utile pour la pratique quotidienne des kinésithérapeutes.Niveau de preuve. – NA.

J. Wehbe, Y. SafarFile / Hypnosis

basic techniques and the principles of hypnotherapy. Finally, it

Editor's Note

This article is part of an indivisible whole pub-bound asa folder named "Hypnosis: act on the unconscious for acomprehensive rehabilitation'' and consists of the fol-lowing texts:� Gedda M. Hypnose : agir sur l'inconscient pour unerééducation intégrale. Kinesither Rev 2015;15(162).

� Moreni A, Barber A. Origines et histoire de l'hypnose.Kinesither Rev 2015;15(162).

� Wehbe J, Safar Y. Hypnose et kinésithérapie. Kine-sither Rev 2015;15(162).

� Ansel B, Mareau C. Hypnose en rééducation pédia-trique : de la suggestion hypnotique à l'hypnoseconventionnelle. Kinesither Rev 2015;15(162).

� Théron JN. L'hypnose peut-elle être un adjuvant à larééducation des dystonies de fonction et des ampu-tations de la main ? Kinesither Rev 2015;15(162).

� Barber A, Moreni A. Place de l'hypnose dans letraitement des syndromes douloureux régionauxcomplexes. Kinesither Rev 2015;15(162).

� Cercleron F. Hypnose, douleurs et kinésithérapie :données de la littérature et réflexions. Kinesither Rev2015;15(162).

Hypnosis exists since the beginning of humanity and isan integral part of our daily life. It is a complement ofgreat importance and usefulness to techniques and

treatments available for all health professionals.Hypnotherapy is a procedure by virtue of which the professionalproposes to patients suggestions resulting in changes at bothphysical and psychical levels. It can eventually have desirablechanges at the following levels: motivation, self-image, habits,style of living, health, perception, way of thinking, behavior, inaddition to a modification of physical sensations [1,2].This article will in the first place bring up the classical definitionof hypnosis as well as the neurophysiological and neurovas-cular changes under hypnosis. Then, it will treat in details the

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will consider the various fields of application where hypnosismay represent an added value to the practice of physiotherapy.At the beginning of 1990s, the neuronal mechanisms related tothe hypnosis were only identified by electroencephalogram(EEG).The introduction of the most modern medical imaging, such asthe Functional Magnetic Resonance Imaging (FMRI) and thePositron Emission Tomography (PET) in the neurosciencesfield, has allowed the functional and morphological study of thebrain [3–5].Such measurement tools have brought elements of under-standing at the level of hypnosis phenomenon as well as atthe function of the brain under hypnosis. They have allowedestablishing a parallelism between the subjective impressionsa patient under hypnosis feels and the visible physical changesthat appear at the different cerebral regions. The studies ofmedical imagery have allowed in their turn to describe thehypnotic state as a specific conscious state distinguishing itfrom other states of conscious, such as sleep, wakefulness,and meditation [3–6].The number of scientific articles and publications related tomedical applications of hypnosis are multiplying and theirquality is improving day after day.The goals of hypnotherapy are generally:� a better life quality;� a better health;� a better function;� a reduction of pain.It is also worth mentioning that sophrology was born fromhypnosis. In 1932, Doctor Alfonso Caycedo founded thesophrology called Caycedian inspired by oriental techniques,therapeutic hypnosis, and progressive muscle relaxation ofJacobson method. Sophrology was officially represented asa new profession in 1992 [7].Therefore, why not consider hypnotherapy as a new discipline,integrating and associating it to physiotherapy?There is no consensus defining hypnosis [8], however, thereare many definitions of hypnosis in the bibliography. Selectingthe definitions in this article was not easy, even the definition ofthe American Psychological Association (APA) is criticized byvarious schools of hypnotherapy [9,10]. There are even liter-ature reviews solely about the definition of hypnosis or

Figure 1. The basic principles.

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hypnotherapy.We have only chosen themost pertinent ones inorder to have a right understanding of this mixed state:� the French Association of Medical Hypnosis Study (AFEHM)defines hypnosis as "a relational process accompanied by asuccession of physiological phenomena, such as a modifi-cation of muscle tone, a reduction of sensory perception(dissociation), a focus of attention, in order to connect anindividual with the totality of his existence and to get physi-ological changes, behavior and thinking changes'';

� the British Medical Association Committee has definedhypnosis in 1955 as "a temporary state of attention modifiedamong a subject, a state that may be produced by aperson where different phenomena may appear whetherspontaneously or as a response to verbal or other stimulus.These phenomena include a change of conscious andmemory, an increased susceptibility of the subject to thesuggestion and appearance via responses and ideas famil-iar to him in his usual spirit state. In addition, phenomenasuch as anesthesia, paralysis, muscle rigidity and flushingchanges may in the hypnotic state be produced oreliminated''.

Despite these definitions, understanding the mechanisms ofhypnosis state remains vague. Only the neurological tests ofthis state provide a better understanding of thesemechanisms.This difficulty in defining hypnosis refers to many factors:� the state of hypnosis itself is highly influenced by the socio-cultural dimension and individual perception;

� the reliable tools of measurement are used in a relativelyrecent way in order to understand the neurophysiology ofthis state;

� the definition and the absolute understanding of hypnosisare closely connected to the understanding of various statesof conscious, which in turn are subject to debate [10].

All this leads us to believe that future definitions of hypnosis willfurther appear in order to better understand neurological phe-nomena that define the hypnosis state.The spontaneous states of hypnosis, appearing almost on adaily basis, are no doubt the most controversial points ofdebate [9], but are also part of the daily clinical discourse ofhypnotherapists.And here are the two most frequent examples:� the spontaneous hypnosis resulting in an abolition of theauditory message. When you speak to a person largelyfocusing on a mission, to such extent that he does not hearyou and startle after calling him many times: he was on aspontaneous state of hypnosis;

� the negative hallucination that may take place when theeyes do not emit to the brain the presence of an objectwithin your visual field.

We shall discuss successively the following points:� the basic principles and concepts;� the principles of hypnosis;� the field of application.

BASIC PRINCIPLES

The interview

In hypnosis, the interview is considered as the most importantpart of a session, since it conditions its success. It seeks to putthe patient at ease, eliminating all preconceived misconcep-tions about hypnosis [11]. In fact, wrong ideas concerning

hypnosis are highly frequent and very often not related toreality.Here are some examples of wrong ideas found in clinicalpractice: "I am afraid that you are going to make me sleepand I won't know what happened; I don't want to lose control; Iam afraid that hypnosis is dangerous; it won't work with mebecause I have a strong character and hypnosis only workswith weak persons'' (Fig. 1).Thus, the main goal of interview is to create treatment expec-tations that are as positive as possible. A linear relation existsbetween optimistic expectation and the result of the treatment[12].During hypnosis courses, a special attention is often paid to thepart that includes the techniques of communication andadvanced listening, based on body language, neuro-linguisticprogramming and the latest neuropsychological knowledge ofcommunication.Some schools of hypnosis recommend the use of suggestibil-ity tests during the interview while others stand against it; aneventual classification of the level of suggestibility may then bepracticed during this phase. But regardless of the school, theuse of suggestion already starts during the interview (Fig. 2).

The suggestion

It is without doubt the ultimate and most powerful technique ofhypnosis, whose definition in itself is merged with this latter.We may even talk about an "art of suggestion''.In fact, several physiotherapists use this technique with muchtalent without even realizing it.There are many types of suggestions related to variousschools of hypnosis (Fig. 3):� the direct suggestion is a simple expression that includes aproposal/invitation to the patient, with a defined goal, andwaits for a near-instant reply. It should be clear, positive andrealistic. It is very often used for pain and relaxation;

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Figure 4. The induction.

Figure 2. Interview.

J. Wehbe, Y. SafarFile / Hypnosis

� the indirect suggestion characterizes the Eriksonian hypno-sis school. It uses the metaphor to carry the proposal/invita-tion indirectly, having recourse to the imagination of thepatient;

� the post-hypnotic suggestion is the most used one for long-term results and creates new automations for the patient. Itconsists of proposing a conditioning: "response by an actionX when a situation Y occurs'' [13]. Examples: when aninstable situation occurs, the action X may be some sortof muscle contraction; a specific advice to be followed duringa risky condition; a posture to be adopted during a sportinggesture or a daily gesture; or an exercise to be done at adefinite moment of the day. . . The conditioning principle is

Figure 3. The suggestions.

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frequently used in physiotherapy but hypnosis makes thisprocedure clearly faster [13]. Moreover, it allows the thera-pist to have a valuable positive impact on the patient compli-ance to follow various advices. In fact, the "Orange flags'' orthe psycho-socio-cultural and behavioral circumstancescondition the results of the majority of consultation motivesin physiotherapy. The therapist has little therapeutic toolsdirecting these metrics. The post-hypnotic suggestionproved to be a factual tool of useful changes in the circum-stances that deeply condition the success of everytreatment.

� the conviction or realization suggestion may be either director post-hypnotic. It doesn't have a therapeutic goal. It onlyleads the patient to realize the powerful effect of hypnosis,reinforcing his optimism regarding the procedure, and thusimproving the therapeutic result. Such as the eyelids or amember catalepsy.

� the deepening suggestion aims at leading the patient todeepest hypnosis levels. A realization suggestion is alsoconsidered as a deepening suggestion.

� the self-suggestion aims at teaching the patient to repeatdirect suggestions or post-hypnotic ones, in order tostrengthen the suggestions stated during hypnosis.

Induction

It is the term used in hypnosis to indicate the process oftransition from the usual waking state to the hypnotic state(Fig. 4). It includes a series of direct and deepening sugges-tions that propose most often a deepest relaxation state. It isfrequently followed by one or several realization suggestions.

Visualization

It consists in a virtual experience of a specific event proposedby the therapist. It is often used by physiotherapists in trau-matologic, rheumatologic and neurologic rehabilitation, whereefficacy is improved by hypnosis [14].These techniques do not summarize all the basic techniques ofhypnosis, however they are the ones that suit the most thenature of our profession, whose efficiency is supported by ahigh level of evidence.

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PRINCIPLES AND CONCEPTS

The brain flaps

The brain is complicated by its conception but mainly by itsphenomenal capacity. Here is a brief summary of the threeflaps we use of our brain: the conscious, the unconscious andthe subconscious.

The conscious

It is no doubt the part of spirit we are most familiar with since itis "the tip of the iceberg''.The conscious is the sense of awakening, self-awareness andthe perception of the environment. It covers all what is rational,logical, analytic, abstract and verbal. It is responsible of every-day missions.It allows us to take decisions, to think, to choose our activitiesor our actions, to make comparisons or assumptions, to rea-son, to analyze and to summarize. The information comesthrough conscious that treats and filters them. The consciousis involved every time we need reasoning and represents thewillingness in the human spirit.Olivier Lockhert summarizes this concept as follows: "Theconscious is the state of being and of perception where weordinarily live'' [15].

The unconscious

The unconscious is the guardian of our existing and automatesour actions. It is on a continuous alert; it is the cradle of themechanisms of defense and solutions we think of to resolve aproblem.We use the unconscious without even realizing. It guaranteesthe control of all automatic biological functions, such as respi-ration or heartbeats and immune system. It manages as well allautomatic actions or reactions we do without thinking of, likedriving a car while thinking about another thing for example.

Figure 5. Brain states.

The subconscious

The subconscious is represented as being the "hard disc'' ofour brain that memorizes all the data and redistributes them toour conscious when needed.The subconscious records all what we see, hear and live, whilebeing neutral and not reasoning. Our entire environment, allthe feelings we experience are recorded by our subconsciousthat stores as well all the perceptions of our five senses.Childhood is of a particular sensitivity and importance for thedevelopment of subconscious. Thus, negative or false beliefs,sometimes destructive or disabling – voluntarily or involun-tarily transmitted to a child – are stored and gradually becomeas restraints and inhibitors for the development of the adult.It has been found that subconscious controls, through a vege-tative nervous system and its correlation with the cerebro-spinal system, the whole physiology and automatism of thehuman body [16].Finally, subconscious is the base of instinct, survival andemotion [17].The subconscious is the center of the brain, it acts on ourdecisions and our choices that we think are stemming from theconscious part of the brain.

Likewise, the subconscious transmits the order to the uncon-scious that in turn translates these emotions via somatic reac-tions (Fig. 5).Hypnosis works at this level of the brain.

Depth levels

There are different levels of depth in hypnosis depending onthe subject. Susceptibility to hypnosis is usually classified as"high'', "middle'' and "low''.One of the key factors of development of researches abouthypnosis has been the set-up of scales for reliablemeasures ofsusceptibility to hypnosis.The scales aim at defining the depth level of hypnosis. Manyscales were developed with various properties. There arequalitative and quantitative scales.

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Among the qualitative scales, the best-known ones are thoseof Braid (1843), Liebault (1866) and Biernhein (1891). Thesescales remained vague at both the administration conditionslevel and evaluation criteria.Among the quantitative scales, those of White (1930), Davisand Husband (1931) and Friedlander and Sarbin (1938), how-ever, the non-standardization of induction and the ambiguity ofevaluation criteria made the scales unsatisfying. The mostreliable scale of susceptibility to hypnosis is the one of Water-loo-Stanford Group Scale of hypnotic susceptibility (WSGS).The test consists of a list of standardized suggestions, followedby questions, allowing measuring the subject hypnotisabilityand the responsiveness to various stimulations. The analysisof EEG recurrence quantifiers and the analysis of brain activityby EEG both allowed demonstrating high reproducibility, valid-ity, loyalty and sensitivity [18–20].

Suggestion and permeability

It is of high interest to demonstrate the influence of suggestionused during hypnosis since the changes of brain activitydepend on the semantic content of suggestions.

Auditory suggestion

In 1998, Szechtman and colleagues used imagery by PETscan to study the brain effect of positive auditory hallucinationsin hypnosis, in other words the perceptions of sound in theabsence of auditory stimulation. The authors note an activationof areas 41 and 42 of Brodmann in subjects actually stimulatedand hallucinated in relation to the control group [21].

Visual suggestion

Concerning visual stimuli, Kosslyn shows, during a suggestionof a color stimulus under hypnosis, the bilateral activation ofoccipito-temporal gyrus or area 37 of Brodmann. The changes,stemmed from hypnosis in the vision or perception of colors,were accordingly correlated to a change in the visual cortex.Furthermore, imagination activates only the right occipito-tem-poral gyrus and not the left one, which reinforces the idea thathypnosis is not just a mental imagery activity [22].

Analgesia suggestion

Crawford highlighted that the effort needed under hypnosis inorder to control ischemic pain causes an increased regionalcortical blood stream. The regions in question seem to be theanterior cingulate cortex and the anterior temporal cortex.Under hypno-analgesia, the pain control suggestion reducesthe evoked potentials within these regions of the suggestiblesubject [23].Rainville and colleagueswanted to highlight the characteristicsof the anterior cingulate cortex. Hypnosis has been used as acognitive tool to modify the unpleasant sensation of pain. Thesensory and affective dissociation of pain were obtained byhypnotic suggestions, in order to increase or decrease the painwithout however changing the perception of the painful sen-sations intensity. Researches about the increase of regionalcerebral blood flow were focused on the right side of the areasS1, S2, ACC and IC, in order to confirm that only these limbicregions are modified during the control of the painful emotionalcomponent. The analgesia and hyperalgesia suggestionsunder hypnosis modify the perception of the pain emotional

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component as well as the cerebral blood flow in the regionsinvolved. The work required under hypnosis to control thiscomponent causes an increase of the cingulate cortex bloodflow [24].

Motor suggestion

The suggestions influencing the movement lead to believe thatthe motor nervous system is impacted by hypnosis. In fact, thepower of an executed mission may be increased following ahypnotic suggestion. The motor suggestions increase the cor-ticospinal excitability [25]. The hypnotic suggestion of motorimagery ranges from the motor imagery alone; in fact thehypnotic suggestion involves as well a modulation of thefunction of the thalamic control exclusive to the hypnotic state[26].

Suggestion and automation

The hypnotic suggestion enjoys a powerful impact over auto-mation and de-automation [27]. It facilitates the action ofexpressing a response X when the situation Y occurs [13].

Brain permeability

The increase of mental absorption during hypnosis is associ-ated to the increase of regional cerebral blood flow within adefinite system, distributed at the level of cortical and subcor-tical structures called the "brain attentional system'' [3].

Expectation

During the first session, the subject doesn't know what toexpect, he is filled with concerns that may be questionable,wrong or right.As the therapy progresses, the patient's outlook regarding thetherapy and the therapist changes. This change of perspectiveleads to the progress and improvement of treatment underhypnosis [12].The other aspect of expectation is the one of the patient inorder to be involved in his therapeutic journey. Hypnosis andself-hypnosis may help in this respect [28].

Appellation

Another interesting approach concerning a modification of thesuggestibility has been looked for related to "hypnosis'' label.Ghandi and Oakley introduced a series of eight standard testsof suggestions before and after the administration of hypnoticinduction. They told half of the participants that induction washypnotic, while the term "hypnosis'' wasn't mentioned to theother half but replaced with the term "relaxation''. These twoauthors noted that induction of the "relaxation'' group resultedin a modest increase of suggestibility, but that the suggestibilityincrease would have been very significant if labeled "hypno-sis''. These facts suggest that the perceptions of an individualand his expectations vis-à-vis a hypnotic procedure may haveremarkable impacts on the efficiency of the procedure [29].Another study has shown that the use of the term "hypnosis'' todescribe a recording of relaxation has given better resultscompared to the same recording called "relaxation''. This"hypnosis'' recording has increased the feeling of being hyp-notized and decreased the pain more. To conclude, hypnosisdoes not facilitate in itself the reduction of pain while the label"hypnosis'' reduces actually the pain [30].

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Cooperation principle

For Milton Erickson, "without the full cooperation of the patient,the therapeutic results may be delayed, distorted, limited oreven hindered''.Every person could be hypnotized. However, hypnosis doesn'tfunction without the willingness, the cooperation and the highspirits of the patient: willingness to subject and willingness toreach his goal [31].The duration of the hypnosis session depends on the cooper-ation of the patient and his acceptance of suggestions [32].

Fields of application

The efficiency of hypnotherapy is actually recognized by alarge number of pathologies. It is starting to be part of recom-mendations for the treatment and improvement of many dis-eases in medical and paramedical fields.

Pain

Several randomized controlled clinical trials have shown thathypnosis had a real efficiency over pain.In 1977, Stern's team compared the efficiency of hypnosis,acupuncture, morphine, Diazepam, aspirin and placebo indealing with pain. Hypnosis proved to be the most efficientway to alleviate pain [33]. The results of this study show that,concerning the chronic and acute pains, analgesia under hyp-nosis results in a more important reduction of pain against theabsence of treatment or the standard treatment.The hypnosis is often more efficient than non-hypnotic inter-ventions (e.g.: education, supportive therapy) in alleviating thepain [34].A meta-analysis has evaluated the efficiency of hypnosis indealing with chronic pain. The hypnosis has shown a greatereffect than other psychological interventions and standardtreatments to lessen a chronic pain [35].

Chronic low back pain

In a comparative study on 17 individuals, Mc Cauley hasdemonstrated that hypnosis and relaxation had a significantalleviation of pain measured by McGill Pain Questionnaire andthe visual analog assessments of pain, and that self-hypnosiswas more efficient over low back pain than the simple educa-tion information of the back, even if associated with a biofeed-back [36].Fifteen participants in an experimental study noted, after 3hypnosis sessions, an alleviation of their chronic pains.According to the authors, hypnosis should be introduced atearly stages as a complement to medical treatment, at the verystart of the pain before it becomes chronic [23].

Arthrosis and joint pains

Within the framework of randomized controlled clinical trials,and following hypnosis sessions, 19 patients suffering fromarthritis noticed a clinical and statistically significant reductionof pain, anxiety and depression, as well as an increase ofimmunoreactive materials, similar to the beta-endorphin [23].The randomized controlled trial of Gay and colleagues havedistributed 36 patients suffering from knee osteoarthritis and/orarthrosis of the hip within 3 groups (a "hypnosis'' group, a"relaxation of Jacobson'' group and a "control'' group). A56% (EVA from 4.16 to 1.97) reduction of pain was observed

after 4 weeks in the group "hypnosis'', 31% in the group"relaxation'' (EVA from 3.68 to 2.37) after eight weeks. Areduction of painkilling consumption was also noted withinthese two groups [37].

Temporomandibular pains

The results of Simon and Lewis study suggest a significantreduction of the frequency and duration of pain and a dailyfunctional improvement. Analyses show that these gains weremaintained for 6 months after the treatment. Moreover, afterthe hypnosis treatment, patients reported a signification reduc-tion in the use of medicines [38].Hypnosis was more efficient than the education/advice toalleviate the tenderness to palpation. Only the patients ofthe group "hypnosis'' reported a significantly high reductionof the pain intensity: a 57% reduction of the current painintensity and a 51% reduction of the worse pain intensity,compared to the patients of the education/advice group [39].

Fractures

Hypnosis had the power to encourage the fracture healing, atboth anatomic and functional level [40].

Sport

Hypnosis is a procedure during which a health professionalsuggests a change in sensations, perceptions, thoughts orbehavior.The visualization under hypnosis allowed the professionalgymnasts to carry for the first time-complicated maneuversthey worked on for more than one year. The gymnasts wereable to eliminate techniques errors, increase their flexibility andlikely concentrate the strength [41].Another study sought to describe the use of hypnosis toimprove sportive performance: the group "hypnosis'' was moreefficient and achieved better results than the control group.Another study shows that hypnosis may be used to improveand maintain the self-efficacy and performance of volleyballplayers [42].There are researches implying that hypnosis significantlyimproves visualization and performance of athletes [14].

Complex regional pain syndrome

There is an article that explores some promising results ofhypnosis on three persons suffering from complex regionalpain syndrome. The author discusses the role of hypnosis andits relation to medical treatment [43].

Tension headaches and migraines

Hypnosis is more efficient in treating chronic migraines thantreatments based solely on pharmacologic approaches.Among 23 patients treated with hypnosis, 10 noted a signifi-cant reduction in the severity and number of attacks, whilewithin the control group, consisting of 24 patients treated withmedicines, only 3 felt better. After one year, the number ofpatients in the group "hypnosis'' experiencing no headache formore than three months was significantly elevated [14].In 1992, Gutfeld and Rao divided into two groups ("hypnosis''and "control'') persons suffering from migraines and lessresponsive to conventional treatments. Hypnosis helped

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reducing the occurrence and duration of headaches as well asthe intensity [44,45].The improvement of migraine patients has also been con-firmed by subjective assessments collected through question-naire, with a high reduction of anxiety [46].In Netherlands, patients suffering from tension headachesparticipated in a clinical trial assessing the efficiency of hyp-nosis and self-hypnosis; the results have shown alleviationamong all participating patients and a greater spacing betweenmigraine attacks.Through a focused hypnosis, we came to reduce the impact ofencouraging factors or triggers (stress and emotions being themost frequent triggers of an attack) on those rebel migrainepatients, where two thirds (62%) were relieved [47]. Likewise,specialists of National Institute of Health (NIH) have demon-strated that hypnosis may be efficient for the treatment of somechronic pains, namely tension headaches and migraines; thestudy concluded that hypnosis allows the patient to almosttotally avoid side effects, adverse effects and the long termexpenses related to the consumption of medicines [48].

Fibromyalgia

Haanet and colleagues compared the efficiency of hypnosis tothat of physiotherapy on 24 patients. The "hypnosis'' groupshowed a subjective improvement of pain, and the only autho-rized consumption of paracetamol during the experiment wasreduced by 80% within the "hypnosis'' group compared to only35% within the "physiotherapy'' group.Hypnosis proved to be better than physiotherapy on bothmorning fatigue and sleeping disorder, as well as muscle painand overall impression of the patient [49].The study of Grondahl and colleagues demonstrates that thehypnosis treatment may have a positive effect on pain andquality of life of patients suffering from chronic muscle pains;the effect of the treatment seems to persist for at least one year[50].In the study of Castel and colleagues, patients suffering fromfibromyalgia were randomized within three groups (hypnosiswith analgesic suggestions, hypnosis with relaxation sugges-tion and only relaxation). The three techniques reduced theintensity of pain (EVA), and the sensitive and emotional com-ponents of pain analyzed with pain evaluation questionnaire ofMcGill, however only hypnosis with analgesic suggestions hasshown a remarkable effect on the intensity of sensitive com-ponent [51].

Phantom limb pain

The hypnosis seems to be a useful complement to strategiesdeveloped to treat phantom limb pains [52].

Irritable bowel syndrome

According to the "Clinical Psychology Division of AmericanPsychological Association'', hypnosis is the technique with thehighest level of acceptance, for being both efficient and spe-cific for irritable bowel [53].In addition to the alleviation of the symptoms of irritable bowelsyndrome [54–57], hypnotherapy highly improves the life qual-ity of patients and reduces periods of work absenteeism [58].According to another study, the effects of hypnosis last for atleast five years [59].

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Stress and anxiety

Hypnosis may be used to better control anxiety-relatedsymptoms through relaxation. It allows the patient to antici-pate the events that trigger anxiety. These different uses ofhypnotherapy may be either exclusive or complementary[34].According to Dr. Stanley Krippner, "hypnosis focused on stressreduces its effects by 63% within 3 weeks of practice''. Stresshormones, such as adrenaline, halved after a 15-minute ses-sion of hypnosis [60].

Burns

Paterson and colleagues have studied three groups of burns:hypnosis, psychotherapy and analgesic alone. The group"hypnosis'' shows the greatest reduction of pain; this differenceis significant [61].Wakeman and Kaplan weighed hypnosis versus analgesicmedicines: regardless of the extent of injuries, hypnosisproved to be efficient on pain by encouraging less analgesicintake [62].Another study has shown that pain in the group "hypnosis'' wassignificantly lower than in the control group, and has reported asignificant reduction of basic pain [63–66]. There was a signif-icant reduction of a big number of trauma revivification withinthe "hypnosis'' group but not the control group.Other works support the efficiency of hypnosis in managing thepain and revivification of trauma and burns [64].

CONCLUSION

Hypnotherapy has become an approach scientifically basedon increasingly solid evidences. It also benefits from a defini-tion by brain imagery well specified and different from any otherstate of conscious. A great part of the population may benefitfrom "neural benefits'' of suggestions and mental permeability.Nowadays, bibliographic researches don't disclose scientificstudies in all fields of rehabilitation. Unfortunately, a big part ofavailable therapeutic tools in physiotherapy offers very weakevidences, while hypnotherapy is represented to us, physio-therapists. It offers an interesting efficiency in a number ofapplication fields.Many among us have already used (from their personal expe-rience) suggestion, which is the main tool of hypnotherapy (thehypnosis training highly focused on the art of formulating andusing suggestions). So why not deepening some and integrateit in our practice?

Disclosure of interestThe authors declare that they have no conflicts of interest concerningthis article.

REFERENCES

[1] Eslinger MR. Hypnosis principles and applications: an adjunct tohealth care. CRNA 2000;11:190–6.

[2] Newmark TS, Bogacki DF. The use of relaxation, hypnosis, andimagery in sport psychiatry. Clin Sports Med 2005;24:973–7 [xi].

Kinesither Rev 2015;15(168):e1–e10 File /Hypnosis

[3] Rainville P, Hofbauer RK, Bushnell MC, Duncan GH, Price DD.Hypnosis modulates activity in brain structures involved in theregulation of consciousness. J Cogn Neurosci 2002;14:887–901.

[4] Maquet P, Faymonville ME, Degueldre C, Delfiore G, Franck G,et al. Functional neuroanatomy of hypnotic state. Biol Psychiatry1999;45:327–33.

[5] Faymonville ME, Laureys S, Degueldre C, DelFiore G, Luxen A,Franck G, et al. Neural mechanisms of antinociceptive effects ofhypnosis. Anesthesiology 2000;92:1257–67.

[6] Rainville P, Hofbauer RK, Paus T, Duncan GH, Bushnell MC,Price DD. Cerebral mechanisms of hypnotic induction and sug-gestion. J Cogn Neurosci 1999;11:110–25.

[7] Le site de l'École française de sophrologie de Montpellier; 2014,http://www.ecole-formation-sophrologie.fr.

[8] Kihlstrom JF. Convergence in understanding hypnosis? Perhaps,but perhaps not quite so fast. Int J Clin Exp Hypn 1997;45:324–32.

[9] Barabasz AF. Whither spontaneous hypnosis: a critical issue forpractitioners and researchers. Am J Clin Hypn 2005, 2006;48:91–7.

[10] Woody E, Sadler P. Some polite applause for the 2003 APADivision 30 definition of hypnosis. Am J Clin Hypn 2005, 2006;48:99–106.

[11] Banyan CD, Kein GE. Hypnosis and hypnotherapy. BHCTS;2001. p. 57.

[12] Kirsch I. The response set theory of hypnosis. Am J Clin Hypn2000;42:274–92.

[13] Kirsch I, Lynn SJ. Hypnotic involuntariness and the automaticityof everyday life. Am J Clin Hypn 1997;40:329–48.

[14] Liggett DR. Enhancing imagery through hypnosis: a performanceaid for athletes. Am J Clin Hypn 2000;43:149–57.

[15] Lockhert O, Hypnose. IFHE Éditions, 2e édition, Paris; 2001–2003. p. 22.

[16] Pageau P. Tous les secrets de l'hypnose. Montréal: Éditions dujour; 1966, 141 p.

[17] Murphy J. La puissance de votre subconscient. Les éditeurs del'Homme; 2013.

[18] Yargholi E, Nasrabadi AM. Recurrence quantification analysis ofelectroencephalograph signals during standard tasks of Water-loo-Stanford group scale of hypnotic susceptibility. J Med EngTechnol 2015;39:26–34.

[19] Michaux D. Mesure de l'hypnose et formes d'hypnose; 1991;6.[20] Yargholi E, Nasrabadi AM. The impacts of hypnotic susceptibility

on chaotic dynamics of EEG signals during standard tasks ofWaterloo-Stanford Group Scale. J Med Eng Technol 2013;37:273–81.

[21] Szechtman H, Woody E, Bowers KS, Nahmias C. Where theimaginal appears real: a positron emission tomography study ofauditory hallucinations. Proc Natl Acad Sci 1998;95:1956–60.

[22] Kosslyn SM, Thompson WL, Costantini-Ferrando MF, AlpertNM, Spiegel D. Hypnotic visual illusion alters color processing inthe brain. Am J Psychiatry 2000;157:1279–84.

[23] Crawford HJ, Knebel T, Kaplan L, Vendemia JM, Xie M,Jamison S, et al. Hypnotic analgesia: 1. Somatosensoryevent-related potential changes to noxious stimuli and 2. Transferlearning to reduce chronic low back pain. Int J Clin Exp Hypn1998;46:92–132.

[24] Price DD, BrushnelleMC. The neurophenomenology of hypnosisand hypnotic analgesia; psychological methods of pain control:basic science and clinical perspectives. Prog Pain Res Manag2004;29:235–67.

[25] Takarada Y, Nozaki D. Hypnotic suggestion alters the state of themotor cortex. Neurosci Res 2014 [pii: S0168-0102(14)00103-5].

[26] Müller K, Bacht K, Prochnow D, Schramm S, Seitz RJ.Activation of thalamus in motor imagery results from gating byhypnosis. Neuroimage 2012;66C:361–7.

[27] Déry C, Campbell NK, Lifshitz M, Raz A. Suggestion overridesautomatic audiovisual integration. Conscious Cogn 2014;24:33–7.

[28] Virot C, Bernard F. Hypnose, douleurs aigues et anesthésie.Amette; 2010.

[29] Gandhi B, Oakley DA. Does "hypnosis'' by any other name smellas sweet? The efficacy of "hypnotic'' inductions depends on thelabel "hypnosis''. Conscious Cogn 2005;14:304–15.

[30] Hylands-White N, Derbyshire S-WG. British Society of Experi-mental & Clinical Hypnosis. Contemporary Hypn 2007;24:143–53.

[31] Thérapeutique antalgiques non médicamenteuses; 2010, http://www.aix-hypnose-therapie.fr/definition_hypnose.html.

[32] Une séance d'hypnose type; 2011, http://www.hypnose-medicale-montpellier.fr/56+une-seance-dhypnose-type.html.

[33] Stern JA, Brown M, Ulett GA, Sletten I. A comparison ofhypnosis, acupuncture, morphine, valium, aspirin, and placeboin the management of experimentally induced pain. Ann N YAcadSci 1977;296:175–93.

[34] Smaga D, Cheseaux N, Forster A, Rentsch D, de Tonnac N,Colombo S. L'hypnose et les troubles anxieux. Rev Med Suisse2010;6:330–3.

[35] Adachi T, Fujino H, Nakae A, Mashimo T, Sasaki J. A meta-analysis of hypnosis for chronic pain problems: a comparisonbetween hypnosis, standard care, and other psychological inter-ventions. Int J Clin Exp Hypn 2014;62:1–28.

[36] McCauley JD, Thelen MH, Frank RG, Willard RR, Callen KE.Hypnosis compared to relaxation in the outpatientmanagement ofchronic low back pain. Arch Phys Med Rehabil 1983;64:548–52.

[37] Domangue BB, Margolis CG, Lieberman D, Kaji H. Biochemicalcorrelates of hypnoanalgesia in arthritic pain patients. J ClinPsychiatry 1985;46:235–8.

[38] Gay MC, Philippot P, Luminet O. Differential effectiveness ofpsychological interventions for reducing osteoarthritis pain: acomparison of Erikson [correction of Erickson] hypnosis andJacobson relaxation. Eur J Pain 2002;6:1–16.

[39] Simon EP, Lewis DM. Medical hypnosis for temporomandibulardisorders: treatment efficacy and medical utilization outcome.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:54–63.

[40] Winocur E, Gavish A, Emodi-Perlman A, Halachmi M, Eli I.Hypnorelaxation as treatment for myofascial pain disorder: acomparative study. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2002;93:429–34.

[41] Ginandes CS, Rosenthal DI. Using hypnosis to accelerate thehealing of bone fractures: a randomized controlled pilot study.Altern Ther Health Med 1999;5(2):67–75.

[42] Liggett DR, Hamada S. Enhancing the visualization of gymnasts.Am J Clin Hypn 1993;35:190–7.

[43] Barker J, Jones M, Greenlees I. Assessing the immediate andmaintained effects of hypnosis on self-efficacy and soccer wall-volley performance. J Sport Exerc Psychol 2010;32:243–52.

[44] Gainer MJ. Hypnotherapy for reflex sympathetic dystrophy. Am JClin Hypn 1992;34:227–32.

[45] Anderson JA, BaskerMA, Dalton R. Migraine and hypnotherapy.Int J Clin Exp Hypn 1975;23:48–58.

[46] Gutfeld G, Rao L. Utilisation de l'hypnose chez des patientssouffrant de maux de tête chroniques, sérieusement résistantsà d'autres traitements. Comme indiqué dans la prévention1992:44, 24-5.

e9

J. Wehbe, Y. SafarFile / Hypnosis

[47] Alladin A. L'hypnose dans le traitement de la migraine sévère. In:Heap M, editor. Hypnose: cliniques actuelles, experimentaleset pratiques de medecine legale.. London: Croom Helm;1988;159–66.

[48] Melis PM, RooimansW, Spierings EL, Hoogduin CA. Treatmentof chronic tension-type headache with hypnotherapy: a single-blind time controlled study. Headache 1991;31:686–9.

[49] Violon A. L'apport de l'hypnose dans le traitement de la migraine.Med Hyg J Inform Med Paramed 2001;1580.

[50] Hammond DC. Review of the efficacy of clinical hypnosiswith headaches and migraines. Int J Clin Exp Hypn 2007;55:207–19.

[51] Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC,Mallee C, Terwiel JP, Hekster GB. Controlled trial of hypnother-apy in the treatment of refractory fibromyalgia. J Rheumatol1991;18:72–5.

[52] Grøndahl JR, Rosvold EO. Hypnosis as a treatment of chronicwidespread pain in general practice: a randomized controlled pilottrial. BMC Muskuloskelet Dis 2008;9:124.

[53] Castel A, Pérez M, Sala J, Padrol A, Rull M. Effect ofhypnotic suggestion on fibromyalgic pain: comparison betweenhypnosis and relaxation. Eur J Pain 2007;11:463–8 [Epub 2006Aug 4].

[54] Oakley DA, Whitman LG, Halligan PW. Hypnotic imagery as atreatment for phantom limb pain: two case reports and a review.Clin Rehabil 2002;16:368–77.

[55] Tan G, Hammond DC, Gurrala J. Hypnosis and irritable bowelsyndrome: a review of efficacy and mechanism of action. Am JClin Hypn 2005;47:161–78.

[56] Shen YH, Nahas R. Complementary and alternative medicine fortreatment of irritable bowel syndrome. Can Fam Physician2009;55:143–8.

e10

[57] Gholamrezaei A, Ardestani SK, Emami MH. Where doeshypnotherapy stand in the management of irritable bowel syn-drome? A systematic review. J Altern Complement Med2006;12:517–27.

[58] Wilson S, Maddison T, Roberts L, Greenfield S, Singh S,Birmingham IBS Research Group. Systematic review: the effec-tiveness of hypnotherapy in the management of irritable bowelsyndrome. Aliment Pharmacol Ther 2006;24:769–80.

[59] Webb AN, Kukuruzovic RH, Catto-Smith AG, Sawyer SM.Hypnotherapy for treatment of irritable bowel syndrome.Cochrane Database Syst Rev 2007;CD005110.

[60] Houghton LA, Heyman DJ, Whorwell PJ. Symptomatology,quality of life and economic features of irritable bowel syn-drome-the effect of hypnotherapy. Aliment Pharmacol Ther1996;10:91–5.

[61] Gonsalkorale WM, Miller V, Afzal A, Whorwell PJ. Long termbenefits of hypnotherapy for irritable bowel syndrome. Gut2003;52:1623–9.

[62] Kippner SC, Pitchford DB. Post-traumatic stress disorder. Healthand Fitness; 2012. p. 177.

[63] Paterson AS, Bracchi F, Black S, Spinelli D, Wigan ER. Paininhibition by means of hypnotic suggestion (physiologic studyutilizing the conditioned reflex method). Cah Anesthesiol1969;17(6):617–22.

[64] Wakeman RJ, Kaplan JZ. An experimental study of hypnoses inpainful burns. Am J Clin Hypn 1978;21.

[65] Patterson DR, Ptacek JT. Baseline pain as a moderator ofhypnotic analgesia for burn injury treatment. J Consult Clin Psy-chol 1997;65:60–7.

[66] Shakibaei F, Harandi AA, Gholamrezaei A, Samoei R, Salehi P.Hypnotherapy in management of pain and reexperiencing oftrauma in burn patients. Int J Clin Exp Hypn 2008;56:185–97.