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April 8, 2020/Behavioral Health

In the Wake of COVID-19, Taking a Mind-Body Approach to Chronic Neurological Disease Matters More Than Ever

Virtual visits enable continued stress management and wellness care for MS patients


For more than a decade, multidisciplinary care teams in Cleveland Clinic’s Mellen Center for Multiple Sclerosis have been practicing and preaching the centrality of the mind-body connection for health in people with chronic disease, but never have they felt their patients need it more than in the midst of the COVID-19 pandemic.


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“Emphasizing the mind-body connection in multiple sclerosis (MS) and other chronic diseases means putting focus on stress management and wellness practices,” explains clinical health psychologist Amy Sullivan, PsyD, ABPP, Director of Behavioral Medicine at the Mellen Center. “Stress and inflammation are huge factors for many people with chronic disease, particularly at a time like now, and our efforts are aimed at teaching patients how to turn off the sympathetic nervous system response that’s intertwined with fear and stress.”

“Wellness practices matter now more than ever in MS and other chronic diseases because what patients practice day to day can support a healthy immune system and brain health, especially when people are so off their normal schedules,” adds Mary Rensel, MD, a Mellen Center staff neurologist in neuroimmunology who is also board-certified in integrative medicine. “Things like sleeping well, eating healthy, staying connected with others and maintaining movement really matter to people with MS. And they matter particularly during this time of isolation and fear.”

A spike in demand for virtual care

Evidence that they matter to patients themselves comes in the form of explosive demand for virtual visits from Mellen Center patients in the early weeks of the COVID-19 crisis in the U.S. Like the rest of Cleveland Clinic’s Neurological Institute, the Mellen Center has been offering virtual visits for several years, but demand spiked in March and has come mostly from established patients.

“We’re hearing a lot of fear, uncertainty and isolation,” says Dr. Sullivan, who notes that depression is three to four times more likely to develop in people with MS than in the general population. “What’s good is that we have been able to offer virtual visits or telephone visits for all our patients who need to see or hear us, so that none of them are going without care during this uncertain time.”

An explicitly mind-body approach

Much of the care those patients are seeking is an extension of the mind-body approach to MS that has broadly informed the Mellen Center’s comprehensive MS management philosophy over the past three and a half decades — and which has explicitly guided a collaborative mind-body care strategy led by Drs. Rensel and Sullivan for over a decade.

The approach involves a four-session stress management protocol directed by Dr. Sullivan’s team of behavioral health providers run in parallel with a series of shared medical appointments (SMAs) focused on wellness for people with MS directed by Dr. Rensel’s medical team.

In the stress management protocol, patients are connected to biofeedback for assessment of heart rate, respiration rate and saturated oxygen levels. The goal is to see positive change in these metrics over time in response to the stress management skills that are taught.

“We start by teaching diaphragmatic breathing, which is the cornerstone of relaxation techniques,” says Dr. Sullivan. “From there, we figure out what interests the patient on an individual level, exploring everything from visualization to body scanning and mindfulness techniques. The goal for the patient is to come away with several skills that help them manage the negative emotions that often accompany MS or arise from the stress of something like this pandemic.”


The protocol is notable in that it’s directed by a behavioral health team dedicated solely to caring for patients with MS. “Our caregivers understand very well how depression and anxiety typically manifest and are managed in individuals with MS,” she notes.

While they go through the stress protocol, patients also complete the series of wellness SMAs directed by Dr. Rensel and colleagues. “There was a time when people with MS would say, ‘Why does it matter if I eat well or exercise or care about my stress?’,” Dr. Rensel observes. “But over the past decade, evidence has mounted on the importance of general medical health — in terms of blood pressure, cholesterol, vascular health, weight, nutrition, sleep quality — to physical, emotional and even intellectual functioning in people with MS. These things contribute to the brain reserve that’s increasingly recognized as being key to successfully living with MS.”

To that end, Dr. Rensel’s SMAs take a deep dive into practical guidance on best practices in four realms central to wellness:

  • Healthy eating, with a nutritionist instructing patients in a demonstration kitchen
  • Movement, with an exercise physiologist and yoga instructor coming in and teaching practical techniques that can be done in the home or at work
  • Mindfulness and stress reduction, featuring chair yoga, guided imagery, art therapy and more
  • Support for healthy choices, where e-coaches come to the SMA and share healthy living tips as health coaches

In addition to providing a support network among fellow SMA participants with MS, the SMAs serve to introduce patients to wellness techniques and resources at Cleveland Clinic that they can tap into more deeply on their own.


Retaining support — and community — online

While SMAs were not traditionally offered via telemedicine, the Mellen Center has plans to offer virtual wellness SMAs soon, and Dr. Sullivan’s team began offering group behavioral health virtual visits to patients in late March.

“A piece of maintaining brain health is connecting with others,” says Dr. Rensel, “so we are fortunate that the Mellen Center’s telemedicine offerings were well established so that we’ve been able to ramp them up to meet demand produced by the pandemic and now to expand them to virtual group appointments. It’s good to keep a touch point with our patients and know we can still make decisions together via video chat, where I can ask them to maybe jump around the room a bit or touch their nose for their home neurologic examination.”

Dr. Sullivan echoes the importance of continuity of care in both the physical and psychological realms to patients with MS at this time. “With the economic uncertainty and our patients being isolated because of social distancing, it’s a very difficult time for everybody,” she concludes. “We’re aware of that and want to continue making comprehensive mind-body care available to patients in whatever forum necessary.”


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