Telephone-based therapy and exercise appear effective for reducing chronic widespread pain
Telephone-delivered cognitive behavioral therapy and an exercise program, both separately and combined, are associated with short-term positive outcomes for patients with chronic widespread pain, and may offer benefits for patients diagnosed with fibromyalgia, according to a report published Online First by Archives of Internal Medicine, one of the JAMA/Archives journals.
“In the United States, mean [average] per-patient costs (including pain and non-pain-related medication, physician consultations, tests and procedures, and emergency department visits) in the six months following a new diagnosis of fibromyalgia were $3,481,” the authors write as background information in the article. “There is a need to develop clinically effective and cost-effective, acceptable interventions at a primary care level that could potentially be available to a large number of patients.”
John McBeth, M.A., Ph.D., then of the Arthritis Research U.K. Epidemiology Unit, University of Manchester, England, now of the Arthritis Research U.K. Primary Care Centre, Keele University, Staffordshire, England, and colleagues conducted a randomized controlled trial to assess the effects of a telephone-based cognitive behavioral therapy, exercise, or a combined intervention among patients with chronic widespread pain.
The authors randomized 442 patients with chronic widespread pain to receive six months of telephone-delivered cognitive behavioral therapy (TCBT), graded exercise, combined intervention, or treatment as usual (control group). The primary outcome was self-rated score measuring how patients felt their health had changed since the period prior to entering the trial, which was measured using a 7-point scale on a questionnaire or telephone interview conducted by study personnel. A “positive outcome” was defined as feeling “much better” or “very much better.”
After six months (end of the intervention period), 8.1 percent of participants in the control group reported positive outcomes, compared with 29.9 percent of the TCBT group, 34.8 percent of the exercise group and 37.2 percent of the combined intervention group. Results were similar at the nine-month follow-up, with 8.3 percent of participants in the control group, 32.6 percent of the TCBT group, 24.2 percent of the exercise group and 37.1 percent of the combined intervention group reporting positive outcomes.
At the six and nine-month follow-ups, the combined intervention was associated with improvements in the 6-Item Short Form Health Questionnaire physical component score and a reduction in passive coping strategies.
“This trial demonstrates short- to medium-term improvements in patients with chronic widespread pain,” the authors conclude. “Whether improvements continue in the longer term should be established. These results provide encouragement that short-term improvement is possible in a substantial proportion of patients with chronic widespread pain.”
Results from a new clinical trial demonstrate that an eight-week mindfulness-based therapy—Mindfulness-Oriented Recovery Enhancement (MORE)—decreased opioid use and misuse while reducing chronic pain symptoms, with effects lasting as long as nine months. This is the first large-scale clinical trial to demonstrate that a psychological intervention can simultaneously reduce opioid misuse and chronic pain among people who were prescribed opioid pain relievers.
The study, published in the peer-reviewed journal JAMA Internal Medicine, followed 250 adults with chronic pain on long-term opioid therapy who met the criteria of misusing opioids. Most participants took oxycodone or hydrocodone, reported two or more painful conditions and met the clinical criteria for major depression. More than half of participants also had a diagnosable opioid use disorder.
Study participants were randomly assigned to either a standard supportive psychotherapy group, or a MORE group, both engaging in eight weekly two-hour group sessions, as well as 15 minutes of daily homework. The study treatment groups were delivered in doctor’s offices, in the same clinical care setting where patients received their opioid pain management. Researchers measured the participants’ opioid misuse behaviors; symptoms of pain; depression, anxiety and stress; and opioid dose through a nine-month follow-up. Opioid craving was measured at three random times a day, prompted by a text message sent to the participants’ smartphones.
Nine months after the treatment period ended, 45% of participants in the MORE group were no longer misusing opioids, and 36% had cut their opioid use in half or greater. Patients in MORE had more than twice the odds of those in standard psychotherapy to stop misusing opioids by the end of the study. Additionally, participants in the MORE group reported clinically significant improvements in chronic pain symptoms, decreased opioid craving and reduced symptoms of depression to levels below the threshold for major depressive disorder.
“MORE demonstrated one of the most powerful treatment effects I’ve seen,” said Eric Garland, lead author of the study, director of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah and the most prolific author of mindfulness research in the world. “There’s nothing else out there that works this well in alleviating pain and curbing opioid misuse.”
“Remarkably, the effects of MORE seem to get stronger over time,” said Garland, who developed MORE and has been studying it for over a decade. “One possible explanation is that these individuals are integrating the skills they’ve learned through MORE into their everyday lives.” Garland also hypothesized that, based on previous research, the sustained benefits might be related to MORE’s ability to restructure the way the brain processes rewards, helping the participants’ brains shift from valuing drug-related rewards to valuing natural, healthy rewards like a beautiful sunset, the bloom of springtime flowers or the smile on the face of a loved one.
MORE combines meditation, cognitive-behavioral therapy and principles from positive psychology into sequenced training in mindfulness, savoring and reappraisal skills.
Participants are taught to break down the experience of pain or opioid craving into their sensory components, “zooming in” on what they are feeling and breaking it down into different sensations like heat, tightness or tingling. They are trained to notice how those experiences change over time, and to adopt the perspective of an observer. They are also taught to savor pleasant, healthful and life-affirming experiences, amplifying the sense of joy, reward and meaning that can come from positive, everyday events. Finally, participants are taught to reframe stressful events to find a sense of meaning in the face of adversity, to recognize what can be learned from difficult events and how dealing with those experiences might make a person stronger.
Garland explained, “Rather than getting caught up in the pain or craving, we teach people how to step back and observe that experience from the perspective of an objective witness. When they can do that, people begin to recognize that who they truly are is bigger than any one thought or sensation. They are not defined by their experiences of pain or craving; their true nature is something more.”
People experiencing both chronic pain and opioid misuse present a significant treatment challenge, since opioid use disorder has been shown to increase pain sensitivity, which in turn promotes further opioid misuse. By simultaneously reducing pain and opioid use, MORE may offer an effective, economical and lifesaving intervention to help halt the ongoing opioid crisis.
A joint team of Lithuanian researchers and businesses behind the invention – credit KTU
Soon, people working sedentary jobs will be able to take advantage of the innovation created by Lithuanians and prevent troublesome back pain – a joint team of Kaunas University of Technology, Lithuania researchers and JSC Abili created a prototype of an office chair that activates deep muscles and improves trunk stabilisation.
Research shows that many people spend almost 80 per cent of their working day sitting and at least half of that time in the same body position. The prolonged and invariable sitting posture is associated with lower back pain due to impaired musculoskeletal control.
For sedentary workers, it is often suggested to replace their normal work chairs with various unstable surfaces, such as physio balls, balance cushions. While these products activate the deep muscles due to their range of motion, they are not individually tailored to the needs of the user.
A team of scientists, Hominiseat, is developing a personalised sitting device controlled with feedback of trunk muscle activity. Scientific experiments in which muscle, brain activities, and body movements of sedentary workers were analysed confirmed the suitability of the chair in the work environment to prevent musculoskeletal disorders caused by prolonged sitting.
Prolonged sitting is harmful to health
Ieva Aleknaitė-Dambrauskienė, a member of Hominiseat, a physiotherapist, and a researcher at the Biomechatronics Laboratory of the Kaunas University of Technology (KTU) Institute of Mechatronics, states that many people who work in sedentary jobs complain about lower back pain. Often these individuals also rest at home while sitting.
“Sitting is not inherently bad, but a prolonged being in one position, which varies very little throughout the day, eventually causes back pain. This problem exists not only in Lithuania – statistics show that about 37 per cent of Europeans work in sedentary jobs, and the number is even higher in the United States,” says a KTU researcher.
Sitting on the usual non-ergonomic chairs, which can be found in most of the offices around the world, can cause serious health problems.
“Sitting on a regular office chair impairs cognitive function, which reduces productivity,” says the researcher.
Employees who experience back pain due to faulty posture find it difficult to concentrate, make decisions, and absorb textual information. According to the KTU researcher, the muscle-stimulating chair developed by Hominiseat does not allow poor posture because the brain centre responsible for the balance is constantly activated by nerve impulses.
This office chair is exceptional
Compared to other ergonomic chairs, the invention will change the user’s posture by stimulating the deep muscles of the trunk. The seat of other office chairs on the market can move freely around its axis, the degree of instability is not adjustable, and there is no possibility to change the amplitude of motion. The chair, designed by a joint team of scientists, will have these functions, so the ergonomic seat will be able to adapt to the safe level of instability and cater to the needs of each person.
“Although we can already see chairs which work on a similar principle to our seating device, our product is the first of a kind in the world,” says Aleknaitė-Dambrauskienė.
The ergonomic office chair, presented at the virtual exhibition Technorama 2021 organised by KTU, is being developed incorporating the latest technologies. The wireless sensor captures trunk muscle activity, and the seat adjusts the user’s posture based on these parameters. According to the Hominiseat team, the data on the user’s muscle activity and body asymmetry could be used as fitness equipment, yet this will become apparent after the prototype is produced and tested in real conditions.
It is projected that the device could function as both a passive and an active device: the user would be able to adjust the movements of the seat himself, and the invention could move by stimulating the deep muscles of the human trunk. It is no accident that the activation of the lumbar muscles was chosen – the researchers believe that working in a sedentary job has the greatest effect on this group of muscles: the muscles that stabilise the spine undergo atrophy, and the nutrition of the intervertebral discs is disrupted.
“When deep trunk muscles perform a stabilising function, maintains optimal posture, then the forces on the spine and passive structures are not so damaging,” emphasises the physiotherapist.
The researcher emphasises that in the event of a disruption of one deep muscle group, other structures, such as the superficial back muscles, take over the work. Then there is constant tension, followed by back pain and other pathologies.
The prototype is being developed
If this innovation were made available to the general public, people who work sedentary jobs or spend a large part of the day in a static position would be less likely to experience the negative effects of poor posture.
“The benefits for the consumer would be huge – a person working in a sedentary job would have less back pain, he would be more active throughout the day, which would lead to higher work productivity and better results,” believes Aleknaitė-Dambrauskienė.
The researcher points out that the seating device could be mass-produced in Lithuania, but the market demand abroad should be even higher. Although there are enough materials and manpower in the country for the extensive implementation of the project, more attention to the employee’s health and quality work equipment is paid abroad. The prototype of the ergonomic chair project is already being prepared, so the next step is testing.
After winning second place in the Wanted: Life Sciences Innovator competition of the Agency for Science, Innovation and Technology (MITA), the KTU Hominiseat team has expanded. Currently, specialists from the fields of health, design, electronics, biomechanics, and employees of JSC Abili are working on the ergonomic chair project.
“Our team is diverse, as the development of such a product requires various knowledge and experience, and only in this way can we achieve the required results. Each specialist has their tasks which they perform best; constant communication and refinement of ideas allows each team member to focus as much as possible on their specialisation and make fewer mistakes,” says I. Aleknaitė-Dambrauskienė.
Brain activation of the lingual gyrus and parahippocampal gyrus, areas involved in pain perception, was significantly decreased after viewing nostalgic images compared to control images. CREDIT Zhang et al., JNeurosci 2021
Reflecting on fond memories goes a step beyond making you feel warm and fuzzy: nostalgia can reduce pain perception. Nostalgia decreases activity in pain-related brain areas and decreases subjective ratings of thermal pain, according to research recently published in JNeurosci.
Researchers from the Chinese Academy of Sciences measured the brain activity of adults with fMRI while the participants rated the nostalgia levels of images and rated the pain of thermal stimuli. The nostalgic images featured scenes and items from an average childhood, like a popular candy, cartoon TV show, and schoolyard game. Images in the control condition depicted corresponding scenes and items from modern life. Viewing nostalgic images reduced pain ratings compared to viewing control images, with the strongest effect on low-intensity pain.
Viewing nostalgic images also reduced activity in the left lingual gyrus and parahippocampal gyrus, two brain regions implicated in pain perception. Activity in the thalamus, a brain region involved in relaying information between the body and the cortex, was linked to both nostalgia and pain ratings; the thalamus may integrate nostalgia information and transmit it to pain pathways. Nostalgia may be a drug-free way to alleviate low levels of pain, like headaches or mild clinical pain.
Can a diet high in processed fat and sugar and type 2 diabetes cause degeneration of intervertebral discs in the spine? CREDIT Rensselaer Polytechnic Institute
Can a diet high in processed fat and sugar and Type 2 diabetes cause degeneration of intervertebral discs in the spine? If so, what is happening, and can it be prevented? As part of an ongoing collaboration between Rensselaer Polytechnic Institute and the Icahn School of Medicine at Mount Sinai – a partnership that draws upon the expertise of both schools to address significant health problems – researchers hope to answer those questions by investigating the link between diet, obesity-linked Type 2 diabetes, and intervertebral disc degeneration.
Researchers on the project suspect the diet associated with Type 2 diabetes – one high in processed fats and sugars – causes inflammation and modification of disc tissue, triggering a chain of responses, which leads to degeneration. To test this hypothesis, the researchers have set three goals: to establish whether mice fed a diet associated with Type 2 diabetes will develop intervertebral disc degeneration (IDD), isolate the effect of diet causing changes in the tissue, and evaluate how the diet modifies proteins within the disc.
The project is supported by a $3.3 million grant from the National Institutes of Health and is led by Dr. James Iatridis, a professor and vice chair for research in the orthopaedics department at the Icahn School of Medicine.
“Back pain caused by spinal disc degeneration is the number one cause of global disability, so it’s a hugely important problem that needs to be addressed,” said Dr. Iatridis, who has long specialized in spinal disc degeneration.
Deepak Vashishth, a professor of biomedical engineering and the Rensselaer lead on the project, said the partnership makes it possible to tackle a project of this complexity.
“We’re trying to establish the mechanism whereby this diet, and Type 2 diabetes, leads to disc degeneration, and that’s not an easy thing to do because, within the body, various processes are linked and feedback loops are difficult to unravel,” said Vashishth, who is also the director of the Center for Biotechnology and Interdisciplinary Studies. “To investigate this question, you need the mix of experts from different disciplines with different skill sets that the partnership allows.”
At the core of the research project are the effects of advanced glycation endproducts (AGE) – proteins or lipids that have become coated in sugars, which damage their function. Research suggests that a diet high in heat-processed foods, including fried foods, plays a role in AGE formation. Research also indicates the accumulation of AGEs causes structural deterioration, increases inflammation that could lead to disc degeneration, and contributes to a host of degenerative diseases such as diabetes, atherosclerosis, and Alzheimer’s.
In the first part of the project, researchers at Mount Sinai will raise mice – both regular mice and so-called “knock-out” mice that have been genetically modified to reduce the ability of their cells to bind to AGEs – on a diet of foods high in AGEs, accelerating AGE accumulation in the mice, and observing whether the mice develop the various of health conditions associated with Type 2 diabetes, including disc degeneration. This part of the research helps establish the systemic effects of AGEs on the body.
To separate the systemic effects AGEs may have on the body from local effects in specific tissues, researchers will also look at spinal bone and disc tissue in vitro. In that research, bone and disc tissue from both normal and AGE “knock-out” mice fed on a regular diet will be bathed in a high AGE medium, accelerating the exposure of these specific tissues to AGEs. Selected tissue samples will be exposed to a drug that may be able to block AGEs in disc tissue, limiting exposure to bone and disc tissue. In all samples, the researchers will look at changes in indicators of disc and bone health such as the activity of proinflammatory cytokines and AGE formation over time. This research will separate the relative contribution of AGEs to tissue degeneration from systemic damage that may occur as a result of Type 2 diabetes-associated hyperglycemia.
At Rensselaer, researchers will analyze various mouse and human tissue samples, helping to determine how healthy disc tissue in humans and mice differ from the tissue of patients and mice that have developed disc degeneration, as well as mice that have been treated with a drug intended to block the effects of a diet high in AGEs diet on the spine.
In particular, researchers at Rensselaer will analyze proteins within the tissue samples, tracking the type and quantity of post-translational protein modifications – chemical changes on the surface of the protein that are not defined by DNA. Similarities between mice and patients affected by disc degeneration would support a link between diet and disc degeneration.
“We’ll look for a qualitative and a quantitative match,” Vashishth said. “So we’ll want to know if we’re seeing the same modifications in both the mice and humans that present with degenerated discs, how much modification there is based on the diet, and in cases where a drug was used for treatment or prevention, we’ll see whether those modifications are reduced.”
Vashishth, an expert in extracellular bone matrix, has a long-term interest in investigating AGE-accumulation in bone. With his expertise, the team will also look at how changes in bone could be contributing to the degeneration of discs. Vashishth said one aspect of the feedback loop may be causing bone tissue in the spinal vertebrae to stiffen, depriving disc tissue of nutrients that would normally diffuse through the bone to the discs.
At Rensselaer, this research fulfills the vision of The New Polytechnic, a paradigm for higher education which recognizes that global challenges and opportunities are so great they cannot be addressed by the most talented person working alone. Rensselaer serves as a crossroads for collaboration–working with partners across disciplines, sectors, and geographic regions–to address complex global challenges, using the most advanced tools and technologies, many of which are developed at Rensselaer. Research at Rensselaer addresses some of the world’s most pressing technological challenges – from energy security and sustainable development to biotechnology and human health. The New Polytechnic is transformative in three fundamental ways: in the global impact of research, innovative pedagogy, and in the lives of students at Rensselaer.
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