Chiropractic

Back Clinic Chiropractic. This is a form of alternative treatment that focuses on the diagnosis and treatment of various musculoskeletal injuries and conditions, especially those associated with the spine. Dr. Alex Jimenez discusses how spinal adjustments and manual manipulations regularly can greatly help both improve and eliminate many symptoms that could be causing discomfort to the individual. Chiropractors believe among the main reasons for pain and disease are the vertebrae’s misalignment in the spinal column (this is known as a chiropractic subluxation).

Through the usage of manual detection (or palpation), carefully applied pressure, massage, and manual manipulation of the vertebrae and joints (called adjustments), chiropractors can alleviate pressure and irritation on the nerves, restore joint mobility, and help return the body’s homeostasis. From subluxations, or spinal misalignments, to sciatica, a set of symptoms along the sciatic nerve caused by nerve impingement, chiropractic care can gradually restore the individual’s natural state of being. Dr. Jimenez compiles a group of concepts on chiropractic to best educate individuals on the variety of injuries and conditions affecting the human body.

Maignes Syndrome: 4 Ways Chiropractic Treatment Can Help In El Paso, TX.

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Complex Injuries, Lower Back Pain

Back pain is a daily issue for millions of Americans, with a variety of medial issues being the culprit. The results of lower back pain on the economy as a whole are far reaching, from tons of lost work time to enormous medical costs. Maignes Syndrome is estimated to be the cause of a great deal of the instances of lower back pain.

Never heard of it? Lucky you because those who are diagnosed with Maignes Syndrome suffer pain that sometimes lasts for weeks or even months, and can become quite severe. Discomfort is increased sometimes when the patient twists his torso, or lifts a heavy object.

What Is Maignes Syndrome?

Also called Thoracolumbar Junction Syndrome, Maignes Syndrome is a spinal disorder that is located in the nerves in the upper lumbar region of the back, causing pain to radiate along the nerves from the site. This spinal condition creates difficult to diagnose symptoms, since it often results in pain in a different part of the body than the actual source. It is believed this “condition exists because of the facet joint issues at the junction between the middle spine and lower spine.”. The pain from Maignes Syndrome usually shows up in the hip, lower back, or groin.

If you are experiencing lower back pain, you may suffer from Maignes Syndrome. Schedule a chiropractic visit as soon as possible, because a chiropractor benefits Maignes Syndrome sufferers in four important ways.

Chiropractors Can�

�Help Correctly Diagnose It

Unfortunately, the nature of the pain and location of the condition frequently cause Maignes Syndrome to be misdiagnosed. Sacroiliac joint pain is sometimes the diagnosis they receive, which hinders proper treatment. For this reason, the patient needs to make certain they are working with an experienced chiropractor who understands the subtle differences of the two conditions.

�Adjust The Area Where The Issue Originates

In order to minimize the symptoms of the condition, a chiropractor can administer adjustments on and around the area causing the issue, the thoracolumbar facet joints. Aligning this area correctly, and loosening the area that may have become tight from overcompensation, assists in relieving pain from Maignes Syndrome.

�Offer At Home Exercises To Help With Healing

Fortunately, there are exercises that can aid Maignes Syndrome, both in loosening the tightness of the afflicted area, and building up the surrounding muscle strength so the body can compensate for the issue. A chiropractor who understands this spinal condition can walk you through a step-by-step exercise regimen of the types of exercises that will help your body adapt to and heal from Maignes Syndrome.

�Promote Your Body’s Ability To Heal Itself

Chiropractic care is a broad-based approach to the body’s inner function and balance. Experienced chiropractors understand that all parts fit together for overall health. A patient with Maignes Syndrome benefits from chiropractic care because of this.

Your chiropractor will make a series of adjustments that help the nervous system work at optimum capacity, which promotes healing to the entire body. Attacking Maignes Syndrome directly at the site and through the body as a whole promotes faster healing and increased mobility.

Individuals with Maignes Syndrome unfortunately face an uphill battle that begins with being correctly diagnosed. The complexity of the spinal condition is the primary reason to seek a professional chiropractor’s opinion at the first sign of ongoing lower back pain. Once Maignes Syndrome is correctly pinpointed, the chiropractor will be able to design an in-house and at-home blend of treatment options to minimize your healing time and achieve a pain-free, fully functioning back.

Chiropractic Treatment Helps�Avoid Back Surgery

Mobile Devices Are Wrecking Our Spines In El Paso, TX.

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Conditions Treated, Neck Pain, Neck Pain Treatments, Spine Care

Nearly everyone has a smartphone or mobile device these days, and while there is some merit to this technology by keeping us more connected � at least virtually � it is wreaking havoc on our bodies. When you look at the posture that people assume when texting, reading email, or browsing social media while on their mobile device or smartphone, you will see their head bent forward and rounded shoulders. They typically hold the device either at chest level or waist level meaning that their hands are together, forming an almost crouch position.

This is very bad for the spine but it creates problems for other parts of the body even beyond the spine. Let�s take a look at some of the common issues that come with bad smartphone posture.

Mobile Device Injuries

Text Neck

The more you tilt your head downward (just as you do when looking at a smartphone), the more pounds of pressure you put on your neck and back. Your spine supports the weight of your head. The more it is thrust forward, looking down, the heavier your head gets. Doctors are seeing many young people with this problem, some even as young as 8 years old.

It is characterized by tightness or tension in the neck and shoulders as well as the upper back. Some patients report pain while others feel pressure, and others feel tightness. Sometimes the pain will spread throughout the body or from the neck to the arms and hands.

Forearm & Wrist Pain

Even the way you hold your phone in your hands can cause problems. Since you keep your hand in one position for long periods of time your muscles never have a chance to relax. You have several muscles engaged to do this: the forearms, the wrist, and the neck.

If you are experiencing pain, sometimes shooting, in your elbow or wrist your smartphone use may be the culprit. So put the phones away or leave them at home.

Sore Upper & Lower Back

As your neck struggles to support your head which is rolled forward, it stands to reason that you will experience back pain. In fact, both upper and lower back pain have been attributed to smartphone use.

Think about the muscles that run along your spine. They help stabilize it and help control and support your head. When you hunch over you strain those muscles in your upper back. What you may not realize is that similar strain is being put on the muscles in your lower back as well.

Blackberry Thumb

The muscles in your hand are very small but they can cause you a great deal of pain if you frequently use a mobile device. As you type on the keyboard of your smart phone, it can cause problems with tendons and ligament as well as the muscles.

This repetitive stress of the body is caused daily by people who stay hunched over their small phone screen. The repetitive movement of your thumb as it manipulates the device can cause inflammation in the thumb and hand.

Headaches From Tension In Neck & Back

One of the most common ailments associated with mobile device usage is headaches. These headaches can come from tension in the neck, strained muscled in the back, or overworked muscles through the hand and arm into the shoulder. It can also come from eyestrain caused by staring at the screen for extended amounts of time, looking at tiny text.

There is no doubt that mobile device usage is becoming a serious problem in our society today. While there are the people who text while driving or while walking, posing a significant threat to their own and others� safety, what they are doing to their own bodies is enough to cause alarm.

Chiropractic care can ease the pain and reverse a good portion of the damage that has been done, but if when people continue with the same bad habits the treatment is only temporary. There needs to be a focused effort made to pull people out of their mobile devices, at least a portion of the time, to minimize the structural spinal damage they are doing to themselves.

Chiropractic Treatment For Proper Posture

Effects of Stress Management Treatment for Low Back Pain in El Paso, TX

by spinedoctors | Chiropractic, Physical Rehabilitation, Randomized Controlled Trial, Stress, Treatments

Chiropractic care is a well-known alternative treatment option commonly used for a variety of injuries and/or conditions, including low back pain and sciatica. Of course, not all pain is physical nor does it always have a physical cause. Stress, anxiety and depression affects millions of people each year. While many patients require prescription drug therapy to treat their mental health issues, others may be able to control and treat they symptoms with a holistic approach. Chiropractic care is an effective stress management treatment which can help reduce symptoms associated with stress, such as low back pain and sciatica.

How Does Stress Affect the Body?

There are 3 major categories of stress: bodily, environmental and emotional.

Bodily stress: Caused by lack of sleep, disease, trauma or injury, and an improper nutrition.
Environmental stress: Caused by loud noises (sudden or sustained), pollution and world events, such as war and politics.
Emotional stress: Caused by a variety of life events, such as moving homes, starting a new job and regular personal interactions. In contrast to the other two categories of stress, however, people can have some control over their emotional stress. Such can depend on the individual’s own attitude.

Stress can affect the human body in a variety of ways, both positively and negatively, physically and emotionally. Although short-term stress can be helpful, long-term stress can cause many cumulative health issues on both the mind and body. Stress activates the “fight or flight” response, a defense mechanism triggered by the sympathetic nervous system to prepare the body for perceived danger by increasing heart rate and breathing as well as the senses, by way of instance, eyesight can become more acute. Once the stressor goes away, the central nervous system relays the message to the body and the vitals return to normal.

In several instances, the central nervous system can fail to relay the signal to the body when it is time to return to its relaxed state. Many people also experience persistent, recurrent stress, referred to as chronic stress. Either occurrence takes a toll on the human body. This type of stress can often lead to pain, anxiety, irritability and depression.

Managing Your Stress

Chronic stress can cause painful symptoms, such as low back pain and sciatica, which can then cause more stress. Pain generally contributes to mood issues, such as anxiety and depression, clouded thought processes, and an inability to concentrate. Individuals with chronic stress who experience painful symptoms may feel unable to perform and engage in regular activities.

Stress management treatment can help people improve as well as manage their chronic stress and its associated symptoms. Chiropractic care can help reduce pain and muscle tension, further decreasing stress. The central nervous system can also benefit from the effects of chiropractic treatment. The central nervous system, or CNS, helps regulate mood, as well as full-body health and wellness, meaning that a balanced central nervous system can help enhance overall well-being.

Benefits of Chiropractic Care

Chiropractic care is a holistic treatment approach, designed to return the body to the original state it needs to maintain the muscles and joints functioning properly. Chronic stress can cause muscle tension along the back, which can eventually lead to spinal misalignments. A misalignment of the spine, or a subluxation, can contribute to a variety of symptoms, including nausea and vomiting, headaches and migraines, stress and digestive issues. A chiropractor utilized spinal adjustments and manual manipulations to release pressure and decrease the inflammation around the spine to improve nerve function and allow the body to heal itself naturally. Alleviating pain can ultimately help decrease stress and enhance overall health and wellness. Chiropractic care can also include massage as well as counseling to help control stress, anxiety and depression.

A Holistic Care Approach

Most chiropractors will utilize other treatment methods and techniques, such as physical therapy, exercise, and nutrition advice, to further increase the stress management effects of chiropractic care. These lifestyle changes affect every area of your well-being. Furthermore, the purpose of the article below is to demonstrate the effects of mindfulness-based stress reduction compared to cognitive-behavioral therapy and usual care on stress with associated symptoms of chronic low back pain and sciatica.

Effects of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy and Usual Care on Back Pain and Functional Limitations among Adults with Chronic Low Back Pain: A Randomized Clinical Trial

Name: El Paso Back Clinic | Spine Specialists - El Paso, TX
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Abstract

Importance

Mindfulness-based stress reduction (MBSR) has not been rigorously evaluated for young and middle-aged adults with chronic low back pain.

Objective

To evaluate the effectiveness for chronic low back pain of MBSR versus usual care (UC) and cognitive-behavioral therapy (CBT).

Design, Setting, and Participants

Randomized, interviewer-blind, controlled trial in integrated healthcare system in Washington State of 342 adults aged 20�70 years with CLBP enrolled between September 2012 and April 2014 and randomly assigned to MBSR (n = 116), CBT (n = 113), or UC (n = 113).

Interventions

CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. UC included whatever care participants received.

Main Outcomes and Measures

Co-primary outcomes were the percentages of participants with clinically meaningful (?30%) improvement from baseline in functional limitations (modified Roland Disability Questionnaire [RDQ]; range 0 to 23) and in self-reported back pain bothersomeness (0 to 10 scale) at 26 weeks. Outcomes were also assessed at 4, 8, and 52 weeks.

Results

Among 342 randomized participants (mean age, 49 (range, 20�70); 225 (66%) women; mean duration of back pain, 7.3 years (range 3 months to 50 years), <60% attended 6 or more of the 8 sessions, 294 (86.0%) completed the study at 26 weeks and 290 (84.8%) completed the study 52weeks. In intent-to-treat analyses, at 26 weeks, the percentage of participants with clinically meaningful improvement on the RDQ was higher for MBSR (61%) and CBT (58%) than for UC (44%) (overall P = 0.04; MBSR versus UC: RR [95% CI] = 1.37 [1.06 to 1.77]; MBSR versus CBT: 0.95 [0.77 to 1.18]; CBT versus UC: 1.31 [1.01 to 1.69]. The percentage of participants with clinically meaningful improvement in pain bothersomeness was 44% in MBSR and 45% in CBT, versus 27% in UC (overall P = 0.01; MBSR versus UC: 1.64 [1.15 to 2.34]; MBSR versus CBT: 1.03 [0.78 to 1.36]; CBT versus UC: 1.69 [1.18 to 2.41]). Findings for MBSR persisted with little change at 52 weeks for both primary outcomes.

Conclusions and Relevance

Among adults with chronic low back pain, treatment with MBSR and CBT, compared with UC, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain.

Introduction

Low back pain is a leading cause of disability in the U.S. [1]. Despite numerous treatment options and greatly increased medical care resources devoted to this problem, the functional status of persons with back pain in the U.S. has deteriorated [2, 3]. There is need for treatments with demonstrated effectiveness that are low-risk and have potential for widespread availability.

Psychosocial factors play important roles in pain and associated physical and psychosocial disability [4]. In fact, 4 of the 8 non-pharmacologic treatments recommended for persistent back pain include �mind-body� components [4]. One of these, cognitive-behavioral therapy (CBT), has demonstrated effectiveness for various chronic pain conditions [5�8] and is widely recommended for patients with chronic low back pain (CLBP). However, patient access to CBT is limited. Mindfulness-Based Stress Reduction (MBSR) [9], another �mind-body� approach, focuses on increasing awareness and acceptance of moment-to-moment experiences, including physical discomfort and difficult emotions. MBSR is becoming increasingly popular and available in the U.S. Thus, if demonstrated beneficial for CLBP, MBSR could offer another psychosocial treatment option for the large number of Americans with this condition. MBSR and other mindfulness-based interventions have been found helpful for a range of conditions, including chronic pain [10�12]. However, only one large randomized clinical trial (RCT) has evaluated MBSR for CLBP [13], and that trial was limited to older adults.

This RCT compared MBSR with CBT and usual care (UC). We hypothesized that adults with CLBP randomized to MBSR would show greater short- and long-term improvement in back pain-related functional limitations, back pain bothersomeness, and other outcomes, as compared with those randomized to UC. We also hypothesized that MBSR would be superior to CBT because it includes yoga, which has been found effective for CLBP [14].

Methods

Study Design, Setting, and Participants

We previously published the Mind-Body Approaches to Pain (MAP) trial protocol [15]. The primary source of participants was Group Health (GH), a large integrated healthcare system in Washington State. Letters describing the trial and inviting participation were mailed to GH members who met the electronic medical record (EMR) inclusion/exclusion criteria, and to random samples of residents in communities served by GH. Individuals who responded to the invitations were screened and enrolled by telephone (Figure 1). Potential participants were told that they would be randomized to one of �two different widely-used pain self-management programs that have been found helpful for reducing pain and making it easier to carry out daily activities� or to continued usual care plus $50. Those assigned to MBSR or CBT were not informed of their treatment allocation until they attended the first session. We recruited participants from 6 cities in 10 separate waves.

Figure 1: Flow of participants through trial comparing mindfulness-based stress reduction with cognitive-behavioral therapy and usual care for chronic low back pain.

We recruited individuals 20 to 70 years of age with non-specific low back pain persisting at least 3 months. Persons with back pain associated with a specific diagnosis (e.g., spinal stenosis), with compensation or litigation issues, who would have difficulty participating (e.g., unable to speak English, unable to attend classes at the scheduled time and location), or who rated pain bothersomeness <4 and/or pain interference with activities <3 on 0�10 scales were excluded. Inclusion and exclusion criteria were assessed using EMR data for the previous year (for GH enrollees) and screening interviews. Participants were enrolled between September 2012 and April 2014. Due to slow enrollment, after 99 participants were enrolled, we stopped excluding persons 64�70 years old, GH members without recent visits for back pain, and patients with sciatica. The trial protocol was approved by the GH Human Subjects Review Committee. All participants gave informed consent.

Randomization

Immediately after providing consent and completing the baseline assessment, participants were randomized in equal proportions to MBSR, CBT, or UC. Randomization was stratified by the baseline score (?12 versus ?13, 0�23 scale) of one of the primary outcome measures, the modified Roland Disability Questionnaire (RDQ) [16]. Participants were randomized within these strata in blocks of 3, 6, or 9. The stratified randomization sequence was generated by the study biostatistician using R statistical software [17], and the sequence was stored in the study recruitment database and concealed from study staff until randomization.

Interventions

All participants received any medical care they would normally receive. Those randomized to UC received $50 but no MBSR training or CBT as part of the study and were free to seek whatever treatment, if any, they desired.

The interventions were comparable in format (group), duration (2 hours/week for 8 weeks, although the MBSR program also included an optional 6-hour retreat), frequency (weekly), and number of participants per group [See reference 15 for intervention details]. Each intervention was delivered according to a manualized protocol in which all instructors were trained. Participants in both interventions were given workbooks, audio CDs, and instructions for home practice (e.g., meditation, body scan, and yoga in MBSR; relaxation and imagery in CBT). MBSR was delivered by 8 instructors with 5 to 29 years of MBSR experience. Six of the instructors had received training from the Center for Mindfulness at the University of Massachusetts Medical School. CBT was delivered by 4 licensed Ph.D.-level psychologists experienced in group and individual CBT for chronic pain. Checklists of treatment protocol components were completed by a research assistant at each session and reviewed weekly by a study investigator to ensure all treatment components were delivered. In addition, sessions were audio-recorded and a study investigator monitored instructors� adherence to the protocol in person or via audio-recording for at least one session per group.

MBSR was modelled closely after the original MBSR program [9], with adaptation of the 2009 MBSR instructor�s manual [18] by a senior MBSR instructor. The MBSR program does not focus specifically on a particular condition such as pain. All classes included didactic content and mindfulness practice (body scan, yoga, meditation [attention to thoughts, emotions, and sensations in the present moment without trying to change them, sitting meditation with awareness of breathing, walking meditation]). The CBT protocol included CBT techniques most commonly applied and studied for CLBP [8, 19�22]. The intervention included (1) education about chronic pain, relationships between thoughts and emotional and physical reactions, sleep hygiene, relapse prevention, and maintenance of gains; and (2) instruction and practice in changing dysfunctional thoughts, setting and working towards behavioral goals, relaxation skills (abdominal breathing, progressive muscle relaxation, guided imagery), activity pacing, and pain coping strategies. Between-session activities included reading chapters of The Pain Survival Guide [21]. Mindfulness, meditation, and yoga techniques were proscribed in CBT; methods to challenge dysfunctional thoughts were proscribed in MBSR.

Follow-Up

Trained interviewers masked to treatment group collected data by telephone at baseline (before randomization) and 4 (mid-treatment), 8 (post-treatment), 26 (primary endpoint), and 52 weeks post-randomization. Participants were compensated $20 for each interview.

Measures

Sociodemographic and back pain information was obtained at baseline (Table 1). All primary outcome measures were administered at each time-point; secondary outcomes were assessed at all time-points except 4 weeks.

Table 1: Baseline characteristics of participants by treatment group.

Co�primary Outcomes

Back pain-related functional limitation was assessed by the RDQ [16], modified to 23 (versus the original 24) items and to ask about the past week rather than today only. Higher scores (range 0�23) indicate greater functional limitation. The original RDQ has demonstrated reliability, validity, and sensitivity to clinical change [23]. Back pain bothersomeness in the past week was measured by a 0�10 scale (0 = �not at all bothersome,� 10 = �extremely bothersome�). Our primary analyses examined the percentages of participants with clinically meaningful improvement (?30% improvement from baseline) [24] on each measure. Secondary analyses compared the adjusted mean change from baseline between groups.

Secondary Outcomes

Depressive symptoms were assessed by the Patient Health Questionnaire-8 (PHQ-8; range, 0�24; higher scores indicate greater severity) [25]. Anxiety was measured using the 2-item Generalized Anxiety Disorder scale (GAD-2; range, 0�6; higher scores indicate greater severity) [26]. Characteristic pain intensity was assessed as the mean of three 0�10 ratings (current back pain and worst and average back pain in the previous month; range, 0�10; higher scores indicate greater intensity) from the Graded Chronic Pain Scale [27]. The Patient Global Impression of Change scale [28] asked participants to rate their improvement in pain on a 7-point scale (�completely gone, much better, somewhat better, a little better, about the same, a little worse, and much worse�). Physical and mental general health status were assessed with the 12-item Short-Form Health Survey (SF-12) (0�100 scale; lower scores indicate poorer health status) [29]. Participants were also asked about their use of medications and exercise for back pain during the previous week.

Adverse Experiences

Adverse experiences were identified during intervention sessions and by follow-up interview questions about significant discomfort, pain, or harm caused by the intervention.

Sample Size

A sample size of 264 participants (88 in each group) was chosen to provide adequate power to detect meaningful differences between MBSR and CBT and UC at 26 weeks. Sample size calculations were based on the outcome of clinically meaningful improvement (?30% from baseline) on the RDQ [24]. Estimates of clinically meaningful improvement in the intervention and UC groups were based on unpublished analyses of data from our previous trial of massage for CLBP in a similar population [30]. This sample size provided adequate power for both co-primary outcomes. The planned sample size provided 90% power to detect a 25% difference between MBSR and UC in the proportion with meaningful improvement on the RDQ, and ?80% power to detect a 20% difference between MBSR and CBT, assuming 30% of UC participants and 55% of CBT participants showed meaningful improvement. For meaningful improvement in pain bothersomeness, the planned sample size provided ?80% power to detect a 21.8% difference between MBSR and UC, and a 16.7% difference between MBSR and CBT, assuming 47.5% in UC and 69.3% in CBT showed meaningful improvement.

Allowing for an 11% loss to follow-up, we planned to recruit 297 participants (99 per group). Because observed follow-up rates were lower than expected, an additional wave was recruited. A total of 342 participants were randomized to achieve a target sample size of 264 with complete outcome data at 26 weeks.

Statistical Analysis

Following the pre-specified analysis plan [15], differences among the three groups on each primary outcome were assessed by fitting a regression model that included outcome measures from all four time-points after baseline (4, 8, 26, and 52 weeks). A separate model was fit for each co-primary outcome (RDQ and bothersomeness). Indicators for time-point, randomization group, and the interactions between these variables were included in each model to estimate intervention effects at each time-point. Models were fit using generalized estimating equations (GEE) [31], which accounted for possible correlation within individuals. For binary primary outcomes, we used a modified Poisson regression model with a log link and robust sandwich variance estimator [32] to estimate relative risks. For continuous measures, we used linear regression models to estimate mean change from baseline. Models adjusted for age, sex, education, pain duration (<1 year versus ?1 year since experiencing a week without back pain), and the baseline score on the outcome measure. Evaluation of secondary outcomes followed a similar analytic approach, although models did not include 4-week scores because secondary outcomes were not assessed at 4 weeks.

We evaluated the statistical significance of intervention effects at each time-point separately. We decided a priori to consider MBSR successful only if group differences were significant at the 26-week primary endpoint. To protect against multiple comparisons, we used the Fisher protected least-significant difference approach [33], which requires that pairwise treatment comparisons are made only if the overall omnibus test is statistically significant.

Because our observed follow-up rates differed across intervention groups and were lower than anticipated (Figure 1), we used an imputation method for non-ignorable nonresponse as our primary analysis to account for possible non-response bias. The imputation method used a pattern mixture model framework using a 2-step GEE approach [34]. The first step estimated the GEE model previously outlined with observed outcome data adjusting for covariates, but further adjusting for patterns of non-response. We included the following missing pattern indicator variables: missing one outcome, missing one outcome and assigned CBT, missing one outcome and assigned MBSR, and missing ?2 outcomes (no further interaction with group was included because very few UC participants missed ?2 follow-up time-points). The second step estimated the GEE model previously outlined, but included imputed outcomes from step 1 for those with missing follow-up times. We adjusted the variance estimates to account for using imputed outcome measures for unobserved outcomes.

All analyses followed an intention-to-treat approach. Participants were included in the analysis by randomization assignment, regardless of level of intervention participation. All tests and confidence intervals were 2-sided and statistical significance was defined as a P-value ? 0.05. All analyses were performed using the statistical package R version 3.0.2 [17].

Results

Figure 1 depicts participant flow through the study. Among 1,767 individuals expressing interest in study participation and screened for eligibility, 342 were enrolled and randomized. The main reasons for exclusion were inability to attend treatment sessions, pain lasting <3 months, and minimal pain bothersomeness or interference with activities. All but 7 participants were recruited from GH. Almost 90% of participants randomized to MBSR and CBT attended at least 1 session, but only 51% in MBSR and 57% in CBT attended at least 6 sessions. Only 26% of those randomized to MBSR attended the 6-hour retreat. Overall follow-up response rates ranged from 89.2% at 4 weeks to 84.8% at 52 weeks, and were higher in the UC group.

At baseline, treatment groups were similar in sociodemographic and pain characteristics except for more women in UC and fewer college graduates in MBSR (Table 1). Over 75% reported at least one year since a week without back pain and most reported pain on at least 160 of the previous 180 days. The mean RDQ score (11.4) and pain bothersomeness rating (6.0) indicated moderate levels of severity. Eleven percent reported using opioids for their pain in the past week. Seventeen percent had at least moderate levels of depression (PHQ-8 scores ?10) and 18% had at least moderate levels of anxiety (GAD-2 scores ?3).

Co-Primary Outcomes

At the 26-week primary endpoint, the groups differed significantly (P = 0.04) in percent with clinically meaningful improvement on the RDQ (MBSR 61%, UC 44%, CBT 58%; Table 2a). Participants randomized to MBSR were more likely than those randomized to UC to show meaningful improvement on the RDQ (RR = 1.37; 95% CI, 1.06�1.77), but did not differ significantly from those randomized to CBT. The overall difference among groups in clinically meaningful improvement in pain bothersomeness at 26 weeks was also statistically significant (MBSR 44%, UC 27%, CBT 45%; P = 0.01). Participants randomized to MBSR were more likely to show meaningful improvement when compared with UC (RR = 1.64; 95% CI, 1.15�2.34), but not when compared with CBT (RR = 1.03; 95% CI, 0.78�1.36). The significant differences between MBSR and UC, and non-significant differences between MBSR and CBT, in percent with meaningful function and pain improvement persisted at 52 weeks, with relative risks similar to those at 26 weeks (Table 2a). CBT was superior to UC for both primary outcomes at 26, but not 52, weeks. Treatment effects were not apparent before end of treatment (8 weeks). Generally similar results were found when the primary outcomes were analyzed as continuous variables, although more differences were statistically significant at 8 weeks and the CBT group improved more than the UC group at 52 weeks (Table 2b).

Table 2A: Co-primary outcomes: Percentage of participants with clinically meaningful improvement in chronic low back pain by treatment group and relative risks comparing treatment groups (Adjusted Imputed Analyses).

Table 2B: Co-primary outcomes: Mean (95% CI) change in chronic low back pain by treatment group and mean (95% CI) differences between treatment groups (Adjusted Imputed Analyses).

Secondary Outcomes

Mental health outcomes (depression, anxiety, SF-12 Mental Component) differed significantly across groups at 8 and 26, but not 52, weeks (Table 3). Among these measures and time-points, participants randomized to MBSR improved more than those randomized to UC only on the depression and SF-12 Mental Component measures at 8 weeks. Participants randomized to CBT improved more than those randomized to MBSR on depression at 8 weeks and anxiety at 26 weeks, and more than the UC group at 8 and 26 weeks on all three measures.

Table 3: Secondary outcomes by treatment group and between-group comparisons (Adjusted Imputed Analyses).

The groups differed significantly in improvement in characteristic pain intensity at all three time-points, with greater improvement in MBSR and CBT than in UC and no significant difference between MBSR and CBT. No overall differences in treatment effects were observed for the SF-12 Physical Component score or self-reported use of medications for back pain. Groups differed at 26 and 52 weeks in self-reported global improvement, with both the MBSR and CBT groups reporting greater improvement than the UC group, but not differing significantly from each other.

Adverse Experiences

Thirty of the 103 (29%) participants attending at least 1 MBSR session reported an adverse experience (mostly temporarily increased pain with yoga). Ten of the 100 (10%) participants who attended at least one CBT session reported an adverse experience (mostly temporarily increased pain with progressive muscle relaxation). No serious adverse events were reported.

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Stress management treatment includes a combination of stress management methods and techniques as well as lifestyle changes to help improve and manage stress and its associated symptoms. Because every person responds to stress in a wide variety of ways, treatment for stress will often vary greatly depending on the specific symptoms the individual is experiencing and according to their grade of severity. Chiropractic care is an effective stress management treatment which helps reduce chronic stress and its associated symptoms by reducing pain and muscle tension on the structures surrounding the spine. A spinal misalignment, or subluxation, can create stress and other symptoms, such as low back pain and sciatica. Furthermore, the results of the article above demonstrated that mindfulness-based stress reduction, or MBSR, is an effective stress management treatment for adults with chronic low back pain.

Discussion

Among adults with CLBP, both MBSR and CBT resulted in greater improvement in back pain and functional limitations at 26 and 52 weeks, as compared with UC. There were no meaningful differences in outcomes between MBSR and CBT. The effects were moderate in size, which has been typical of evidence-based treatments recommended for CLBP [4]. These benefits are remarkable given that only 51% of those randomized to MBSR and 57% of those randomized to CBT attended ?6 of the 8 sessions.

Our findings are consistent with the conclusions of a 2011 systematic review [35] that �acceptance-based� interventions such as MBSR have beneficial effects on the physical and mental health of patients with chronic pain, comparable to those of CBT. They are only partially consistent with the only other large RCT of MBSR for CLBP [13], which found that MBSR, as compared with a time- and attention-matched health education control group, provided benefits for function at post-treatment (but not at 6-month follow-up) and for average pain at 6-month follow-up (but not post-treatment). Several differences between our trial and theirs (which was limited to adults ?65 years and had a different comparison condition) could be responsible for differences in findings.

Although our trial lacked a condition controlling for nonspecific effects of instructor attention and group participation, CBT and MBSR have been shown to be more effective than control and active interventions for pain conditions. In addition to the trial of older adults with CLBP [14] that found MBSR to be more effective than a health education control condition, a recent systematic review of CBT for nonspecific low back pain found CBT to be more effective than guideline-based active treatments in improving pain and disability at short- and long-term follow-ups [7]. Further research is needed to identify moderators and mediators of the effects of MBSR on function and pain, evaluate benefits of MBSR beyond one year, and determine its cost-effectiveness. Research is also needed to identify reasons for session non-attendance and ways to increase attendance, and to determine the minimum number of sessions required.

Our finding of increased effectiveness of MBSR at 26�52 weeks relative to post-treatment for both primary outcomes contrasts with findings of our previous studies of acupuncture, massage, and yoga conducted in the same population as the current trial [30, 36, 37]. In those studies, treatment effects decreased between the end of treatment (8 to 12 weeks) and long-term follow-up (26 to 52 weeks). Long-lasting effects of CBT for CLBP have been reported [7, 38, 39]. This suggests that mind-body treatments such as MBSR and CBT may provide patients with long-lasting skills effective for managing pain.

There were more differences between CBT and UC than between MBSR and UC on measures of psychological distress. CBT was superior to MBSR on the depression measure at 8 weeks, but the mean difference between groups was small. Because our sample was not very distressed at baseline, further research is needed to compare MBSR to CBT in a more distressed patient population.

Limitations of this study must be acknowledged. Study participants were enrolled in a single healthcare system and generally highly educated. The generalizability of findings to other settings and populations is unknown. About 20% of participants randomized to MBSR and CBT were lost to follow-up. We attempted to correct for bias from missing data in our analyses by using imputation methods. Finally, the generalizability of our findings to CBT delivered in an individual rather than group format is unknown; CBT may be more effective when delivered individually [40]. Study strengths include a large sample with adequate statistical power to detect clinically meaningful effects, close matching of the MBSR and CBT interventions in format, and long-term follow-up.

Conclusions

Acknowledgments

Funding/Support: Research reported in this publication was supported by the National Center for Complementary & Integrative Health of the National Institutes of Health under Award Number R01AT006226. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Role of sponsor: The study funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Footnotes

Ncbi.nlm.nih.gov/pmc/articles/PMC4914381/

Contributor Information

Daniel C. Cherkin, Group Health Research Institute; Departments of Health Services and Family Medicine, University of Washington.
Karen J. Sherman, Group Health Research Institute; Department of Epidemiology, University of Washington.
Benjamin H. Balderson, Group Health Research Institute, University of Washington.
Andrea J. Cook, Group Health Research Institute; Department of Biostatistics, University of Washington.
Melissa L. Anderson, Group Health Research Institute, University of Washington.
Rene J. Hawkes, Group Health Research Institute, University of Washington.
Kelly E. Hansen, Group Health Research Institute, University of Washington.
Judith A. Turner, Departments of Psychiatry and Behavioral Sciences and Rehabilitation Medicine, University of Washington.

In conclusion,�chiropractic care is recognized as an effective stress management treatment for low back pain and sciatica. Because chronic stress can cause a variety of health issues over time, improving as well as managing stress accordingly is essential towards achieving overall health and wellness. Additionally, as demonstrated in the article above comparing the effects of mindfulness-based stress reduction with cognitive-behavioral therapy and usual care for stress with associated chronic low back pain, mindfulness-based stress reduction, or MBSR, is effective as a stress management treatment. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

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EXTRA IMPORTANT TOPIC: Managing Workplace Stress

Mindfulness Interventions in Chronic Pain Treatment in El Paso, TX

by spinedoctors | Chiropractic, Chronic Pain, Physical Rehabilitation, Stress, Treatments

Stress has become a new standard in today’s society, however, a huge proportion of the United States population has experienced a significant impact on their health due to the stress in their lives. Approximately 77 percent of Americans claim they suffer stress related physical ailments on a regular basis. Also, 73 percent report experiencing stress related emotional symptoms, such as anxiety and depression. Stress management methods and techniques, including chiropractic and mindfulness interventions, are a valuable treatment option for a variety of diseases. Before addressing the symptoms associated with stress, its essential to first understand what stress is, what are the signs and symptoms of stress, and how can stress impact health.

What is Stress?

Stress is a condition of emotional or mental pressure which result from issues, adverse scenarios, or exceptionally demanding circumstances. However, the nature of stress by definition makes it rather subjective. A stressful situation to one person may not be considered stressful to another. This makes it challenging to come up with a universal definition. Stress is much more often used to refer to its symptoms and those symptoms can be as varied as the men and women who experience them.

What are the Signs and Symptoms of Stress?

The signs and symptoms of stress can impact the whole body, both physically and emotionally. Common signs and symptoms of stress include:

Sleep problems
Depression
Anxiety
Muscle tension
Lower back pain
Gastrointestinal problems
Fatigue
Lack of motivation
Irritability
Headache
Restlessness
Chest pain
Feelings of being overwhelmed
Decrease or increase in sex drive
Inability to focus
Undereating or overeating

How can Stress Impact Health?

People can experience different signs and symptoms of stress. Stress itself doesn’t directly impact an individual’s health. Instead, it is a combination of the signs and symptoms of stress as well how the person handles those that adversely impact health.

Ultimately, stress may result in some very serious ailments including: heart disease, hypertension, diabetes, obesity, and even certain cancers. Psychologically, stress can lead to social withdrawal and social phobias. It is also often directly linked to alcohol and drug abuse.

Chiropractic for Stress Management

Mindfulness interventions are common stress management methods and techniques which can help reduce the signs and symptoms of stress. According to several research studies, however, chiropractic care is an effective stress management treatment option, which together with mindfulness interventions, could help improve as well as manage stress.�Because the spine is the root of the nervous system, the health of your spine can determine how you will feel each day, both physically and emotionally. Chiropractic can help restore the balance of the body, aligning the spine, and decreasing pain.

A subluxation, or misalignment of the spine, can interfere with the way the nervous system communicates with the different parts of the body. This can lead to increased signs and symptoms of stress. A subluxation may also result in chronic pain, such as headaches, neck pain or back pain. The stress of a misalignment of the spine can aggravate the signs and symptoms of stress and make a person more susceptible to stress.�Correcting the alignment of the spine can help ease stress.

Regular chiropractic care can help effectively manage stress. Through the use of spinal adjustments and manual manipulations, a chiropractor can gently realign the spine, releasing the pressure being placed on the spinal vertebrae as well as reducing the muscle tension surrounding the spine. Furthermore, a balanced spine also helps boost the immune system, promotes better sleeping habits and helps to improve circulation, all of which are essential towards reducing stress. Finally, chiropractic care can “turn off” the flight or fight response which is commonly associated with stress, allowing the entire body to rest and heal.

Stress should not be ignored. The signs and symptoms of stress aren’t very likely to go away on their own. The purpose of the following article is to demonstrate an evidence-based review on the use of stress management methods and techniques along with mindfulness interventions in chronic pain treatment as well as to discuss the effects of these treatment options towards improving overall health and wellness. Chiropractic, physical rehabilitation and mindfulness interventions are fundamental stress management methods and/or techniques recommended for the improvement and management of stress.

Mindfulness Interventions in Physical Rehabilitation: A Scoping Review

Abstract

A scoping review was conducted to describe how mindfulness is used in physical rehabilitation, identify implications for occupational therapy practice, and guide future research on clinical mindfulness interventions. A systematic search of four literature databases produced 1,524 original abstracts, of which 16 articles were included. Although only 3 Level I or II studies were identified, the literature included suggests that mindfulness interventions are helpful for patients with musculoskeletal and chronic pain disorders and demonstrate trends toward outcome improvements for patients with neurocognitive and neuromotor disorders. Only 2 studies included an occupational therapist as the primary mindfulness provider, but all mindfulness interventions in the selected studies fit within the occupational therapy scope of practice according to the American Occupational Therapy Association�s Occupational Therapy Practice Framework: Domain and Process. Higher-level research is needed to evaluate the effects of mindfulness interventions in physical rehabilitation and to determine best practices for the use of mindfulness by occupational therapy practitioners.

MeSH TERMS: complementary therapies, mindfulness, occupational therapy, rehabilitation, therapeutics

Mindfulness interventions are frequently used in health care to assist patients in managing pain, stress, and anxiety and in targeting additional health, wellness, and quality-of-life outcomes. Although mindfulness practices originate from Buddhism, mindfulness interventions have become largely secular and are based on the philosophy that full and nonjudgmental experience of the present moment creates positive outcomes for mental and physical health (Williams & Kabat-Zinn, 2011). This paradigm assumes that many people experience a high volume of future- or past-focused thoughts that produce anxiety. Hence, mindfulness is the practice of refocusing away from these distractions and toward lived experiences.

The prevalence of mindfulness interventions in health care has grown substantially in recent decades, and several types of mindfulness interventions have emerged. The first and most widely recognized mindfulness intervention is mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982). Initially called the stress reduction and relaxation program, MBSR was developed more than 30 years ago for patients with chronic pain and involves guided sitting meditation, mindful movement, and education on the effect of stress and anxiety on health and wellness. The evidence supporting mindfulness interventions in health care has grown since the inception of MBSR, and modern mindfulness interventions are shown to be effective at reducing pain severity (Reiner, Tibi, & Lipsitz, 2013), reducing anxiety (Shennan, Payne, & Fenlon, 2011), and enhancing well-being (Chiesa & Serretti, 2009).

Mindfulness-based interventions fit well with the strong emphasis on holism within occupational therapy practice (Dale et al., 2002). Specifically, valuing the mind�body whole is a core tenet that distinguishes occupational therapy practitioners from other health care providers (Bing, 1981; Kielhofner, 1995; Wood, 1998). Emerging literature suggests that mindfulness may enhance occupational engagement and be related to flow state (i.e., a state of timelessness within optimal experiences of activity engagement; Elliot, 2011; Reid, 2011). Mindfulness is both the meditative practice, which is an occupation itself, and a means to enhance the experience of occupations (Elliot, 2011). Moreover, a parallel exists between mindfulness practices and the occupational process of doing, being, and becoming (Stroh-Gingrich, 2012; Wilcock, 1999).

Mindfulness-based interventions in health care continue to grow in scope with the description of novel protocols, application of mindfulness to new populations, and targeting of diverse symptoms. The majority of current mindfulness literature focuses on helping people with mental health conditions and improving wellness in people, providing a wealth of evidence for occupational therapy practitioners who work in mental health or health promotion. However, the applicability and effect of mindfulness interventions for clients in rehabilitation for physical dysfunction are not as well established. Current literature that links mindfulness and occupational therapy is largely theoretical, and a translation to practice-based settings has yet to be fully explored. Therefore, the purpose of this review was to describe how mindfulness is currently used in physical rehabilitation, identify the potential applications of mindfulness interventions to occupational therapy practice, and illuminate gaps in knowledge to be explored in future research.

Method

Scoping reviews are rigorous review processes used to present the landscape of the literature on a broad topic, identify gaps in knowledge, and draw implications for further research and clinical application (Arksey & O�Malley, 2005). This type of review differs from a systematic review because it is not intended to answer questions about the efficacy of an intervention or provide specific recommendations for best practice. A scoping review is typically done in place of a systematic review when high-quality literature for a given topic is limited. Although the purpose and outcome of a scoping review differ from those of a systematic review, a systematic process is involved to ensure rigor and minimize bias (Arksey & O�Malley, 2005). A description of the methods used in this study for each of the systematic steps follows.

The question that guided this scoping review was, How is mindfulness being used in physical rehabilitation, and what are the implications for occupational therapy practice and research? Because the purpose of this review was to provide an overview of available literature, an exhaustive search using terms for all potential interventions or diagnoses was not used. Instead, we elected to combine the general key word mindfulness with each of the following major medical subheadings: therapeutics, rehabilitation, and alternative medicine. Searches were conducted in PubMed, CINAHL, SPORTDiscus, and PsycINFO and were limited to articles published in English before October 10, 2014 (i.e., the date the search was conducted). No additional limits were set, and no restrictions were placed on minimum level of evidence or study design.

Abstracts from the searches were compiled, duplicates were eliminated, and two reviewers independently screened all original abstracts. Initial inclusion criteria for abstract screening were a description of a mindfulness intervention, relevance to occupational therapy, and targeting of a disorder addressed in physical rehabilitation. A broad definition of mindfulness intervention was adopted to include any meditative practice, psychological or psychosocial intervention, or other mind�body therapeutic practice that directly mentioned or addressed mindfulness. Abstracts were considered relevant to occupational therapy if the diagnosis being evaluated was within the occupational therapy scope of practice. Disorder addressed in physical rehabilitation was defined as any illness, injury, or disability of the neurological, musculoskeletal, or other body system that could be treated within a medical or rehabilitation setting.

Any abstract identified as relevant by either author was brought to the full-text stage. In large part, these studies were conducted by scientists, psychologists, psychiatrists, or other medical doctors. Additionally, the interventions were often not implemented in settings where physical rehabilitation providers work. Therefore, to most appropriately answer the research question, final inclusion required that the study focus on an applied use of mindfulness in a rehabilitation context. This additional criterion was satisfied if the mindfulness intervention was provided by a rehabilitation professional (e.g., occupational therapist, physical therapist, speech therapist), was an addition or alternative to traditional rehabilitation, or was provided after traditional rehabilitation had failed. The two authors independently reviewed the full texts, and final study inclusion required agreement by both authors. Any disagreement on study selection was settled by deliberation ending in consensus.

For reporting, studies were primarily organized by type of physical disorder being targeted and secondarily sorted and described by type of mindfulness intervention and level of evidence. These data were summarized and are provided in the Results section to answer the first portion of the research question, that is, to describe how mindfulness is being used in physical rehabilitation. The interventions were compared with the �Types of Occupational Therapy Interventions� categories within the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association [AOTA], 2014) to determine how occupational therapy practitioners might use the interventions in clinical practice. Multiple conversations and coediting of this article between the two authors resulted in the final description of implications for occupational therapy practice and research.

Results

Results of the systematic search and review process are shown in Figure 1. The searches produced a total of 1,967 abstracts across the four databases. After 443 duplicates were removed, 1,524 original abstracts were screened, and 188 full texts were evaluated for inclusion. Exclusion at the abstract review phase was largely the result of diagnoses or interventions outside the occupational therapy scope (e.g., therapy for tinnitus) or interventions not targeting a physical disorder (e.g., anxiety disorder). At the study selection stage, full-text articles were excluded if they failed to describe an applied use of mindfulness within a rehabilitation context (n = 82) or failed to meet other initial inclusion criteria (n = 90). Sixteen studies met all criteria and were included in the data extraction and synthesis.

Figure 1: Search and inclusion flow diagram.

As shown in Table 1, 14 studies used experimental or quasi-experimental designs, including pretest�posttest (n = 6), multiple case series (n = 4), randomized trials (n = 2), retrospective cohort (n = 1), and a nonrandomized comparative trial (n = 1). Two expert opinion articles were also included because both added anecdotal evidence for the applied use of mindfulness in physical rehabilitation practice settings. Five of the 16 studies reported the involvement of occupational therapists on the study team, but only 2 of these studies specified that an occupational therapist provided the mindfulness intervention. The remaining 11 studies provided mindfulness interventions to participants either in conjunction with rehabilitation interventions not described as part of the study or after rehabilitation had failed. Mindfulness interventions included MBSR (n = 6), general mindfulness and meditation (n = 5), acceptance and commitment therapy (ACT; n = 2), and other study-specific techniques (n = 3). Physical disorders targeted by mindfulness interventions in the included studies were primarily categorized as musculoskeletal and pain disorders (n = 8), neurocognitive and neuromotor disorders (n = 6), or disorders of other body systems (n = 2).

Table 1: Summary of research on mindfulness interventions for people with musculoskeletal and pain disorders, neurocognitive and neuromotor disorders, and other disorders.

Common Mindfulness Interventions

Mindfulness-Based Stress Reduction. As referenced in Table 1, 3 studies used MBSR, each with an emphasis on meditation provided in a 2-hr group session, once a week for 8 wk. Three additional studies used an adapted MBSR protocol to meet the needs of the target population. Common adaptations of the MBSR protocol were to change the number of weeks the MBSR group met (Azulay, Smart, Mott, & Cicerone, 2013; B�dard et al., 2003, 2005) as well as to reduce the group size and session length (Azulay et al., 2013). The primary goal of MBSR and MBSR-based programs was to enhance trait-level mindfulness within the participants. Sessions included body scans (i.e., bringing attention to various parts of the body and the sensations felt), mindful yoga, guided mindful meditation, or education about stress and health. One or two people with intensive training in MBSR and who were practitioners of mindfulness themselves always facilitated MSBR sessions. Participants were expected to use recordings to meditate at home on a daily basis. Studies that implemented MBSR used it as a primary intervention to enhance mindfulness through mindfulness practices that patients were expected to integrate into their daily lives. This approach cast mindfulness as a new meaningful occupation for participants facilitated by the intervention. Therefore, the description and use of MBSR in these studies match with occupations and activities, education and training, and group interventions within occupational therapy practice (AOTA, 2014).

General Mindfulness. Five studies applied mindfulness principles generally, failed to fully describe the mindfulness portion of their intervention, or used mindfulness components (e.g., body scan only or guided meditation only) within a comprehensive rehabilitation intervention (see Table 1). Interventions varied widely between group or individual formats, in duration and frequency of sessions, and in duration of the full course of treatment. General mindfulness techniques were used as an opening to, as a closing to, or in parallel with traditional rehabilitation treatments. Therefore, the application of mindfulness was individually targeted to meet the specific needs and goals of clients. Examples of these goals included occupational engagement, engagement in therapy, reduced anxiety, awareness of bodily sensations, and nonjudgmental attitude. Given the holistic targets, general mindfulness interventions as used in these studies would be described as activities, education, or preparatory methods and tasks (AOTA, 2014).

Acceptance and Commitment Therapy. ACT is a psychological intervention stemming from clinical behavioral analysis and mindfulness principles. Two studies implemented ACT with different strategies. In 1 study (McCracken & Guti�rrez-Mart�nez, 2011), an intensive intervention was provided to participants in a group setting, 5 days per week, 6 hr per day, over a 4-wk interval. The other study (Mahoney & Hanrahan, 2011) integrated ACT as part of individual routine physical therapy interventions. In both studies, the primary goals of ACT were to improve psychological flexibility and engagement in therapy through pain acceptance and buffering of other psychological experiences. Similar to the integrative use previously described for general mindfulness, ACT was also used in these studies as activities, education, or preparatory methods and tasks (AOTA, 2014).

Targets of Mindfulness Interventions

Musculoskeletal and Pain Disorders. Musculoskeletal and pain disorders targeted by mindfulness interventions included chronic musculoskeletal pain (n = 6), work-related musculoskeletal injury (n = 1), and knee surgery (n = 1). Five of the 6 studies using mindfulness for chronic pain were experimental. In 3 of these studies, a significant reduction in pain severity was found after participation in mindfulness interventions (Kabat-Zinn, Lipworth, & Burney, 1985; McCracken & Guti�rrez-Mart�nez, 2011; Zangi et al., 2012). One randomized trial contrasted with the other studies; Wong et al. (2011) found that pain was reduced over time, but the amount of pain reduction was not significantly different between clients receiving the mindfulness intervention and a control group. The fifth experimental study (Kristj�nsd�ttir et al., 2011) piloted a mindfulness intervention by using a mobile phone application. This study�s sample size was not large enough to evaluate a significant change in the outcome measures; however, the participants reported that the mobile mindfulness intervention was helpful and appropriate for treating their symptoms. Although these studies demonstrated varied results in reducing pain severity, secondary outcomes such as increased acceptance of pain, improved functioning with pain, and decreased distress produced larger effect sizes and were consistently significant.

A retrospective study (Vindholmen, H�igaard, Espnes, & Seiler, 2014) sought to predict treatment outcomes based on the trait-level mindfulness of patients at a vocational rehabilitation center receiving therapeutic interventions for work-related musculoskeletal disorders. The observational facet of trait-level mindfulness was found to significantly predict time until return to work, but only for highly educated patients. The authors noted that mindfulness interventions may moderate quality of life, which was a significant predictor of time until return to work for all participants.

Two studies, 1 with Level IV (i.e., case series; Mahoney & Hanrahan, 2012) and 1 with Level V (i.e., expert opinion; Pike, 2008) evidence, suggested that combining traditional therapeutic rehabilitation interventions with mindfulness for patients with musculoskeletal and pain disorders has benefits. Clients receiving ACT integrated into their physical therapy sessions after knee surgery reported that the mindfulness intervention was helpful to their rehabilitation process and increased their engagement in therapy (Mahoney & Hanrahan, 2012). In his commentary, Pike (2008) argued for implementing mindfulness interventions in combination with physical therapy for patients who suffer from chronic pain, noting that mindfulness is similar to more widely used awareness-based interventions (e.g., Pilates). Similar to the positive reception noted by Mahoney and Hanrahan (2012), Pike noted that integrating mindfulness into his physical therapy practice had proven to be clinically useful and well tolerated by patients. He hypothesized that the mechanism of mindfulness interventions may either directly reduce pain or improve functional outcomes despite pain, concepts validated by the experimental studies previously discussed in this section.

Neurocognitive and Neuromotor Disorders. Studies using mindfulness interventions for people with neurocognitive and neuromotor disorders included participants with diagnoses of aphasia (n = 1), traumatic brain injury (TBI; n = 4), and developmental coordination disorder (n = 1). Orenstein, Basilakos, and Marshall (2012) found no change attributed to a mindfulness intervention on divided attention tasks or symptoms of aphasia when used with 3 clients. However, 3 pretest�posttest studies using mindfulness interventions for patients with TBI showed more promising results. Azulay et al. (2013) reported a trend (p = .07) toward improved cognitive functioning, with moderate effect sizes (d = 0.31 and 0.32). B�dard et al. (2003) found trends toward reduced symptom distress and improved physical health, with small to moderate effect sizes (0.296 < d < 0.32). They also demonstrated significant improvements in secondary measures such as self-efficacy, quality of life, and mental health. Moreover, a 12-mo postintervention follow-up of their 2003 study showed significant maintenance or improvement in patients with TBI across time in vitality, emotional role, and mental health, but fluctuating pain (B�dard et al., 2005). Of note is that although participants reported that they valued the mindfulness intervention, gender played a role in recruitment and retention because most young men either chose to not participate in or dropped out of the study (B�dard et al., 2005).

In Meili and Kabat-Zinn (2004), Meili, a woman who sustained a TBI, recounted that mindfulness was central to her journey of healing. Using Meili�s experience as an example, Kabat-Zinn asserted that helping patients understand, accept, and adjust to their illness or disability through both inner adjustment to new bodily experiences, or mindfulness, and external restoration of physical functioning, or physical rehabilitation, are essential to the healing process. Moreover, Kabat-Zinn stated that occupational therapy practitioners and other rehabilitation professionals are well equipped to implement mindfulness interventions because these interventions complement their existing practice of facilitating the outer work of healing the body. Adding mindfulness interventions would be clinically appropriate to foster the inner work necessary for patients to heal. Jackman (2014) also suggested that mindfulness is appropriate as part of the rehabilitative process. Jackman discussed the use of mindfulness in occupational therapy for children with developmental coordination disorder. Children who participated in mindfulness-enhanced therapy improved on at least one component of motor coordination. This therapy also helped parent�child dyads meet their self-directed goals.

Other Conditions. Two additional studies targeted physical diagnoses that were not explicitly musculoskeletal or neuromotor. In the first, MBSR was provided to women with urge-predominant urinary incontinence by an occupational therapist who had received intensive training in mindfulness (Baker, Costa, & Nygaard, 2012). Seven women who had an average of 4.14 episodes of urinary incontinence per day participated in an 8-wk MBSR group. In contrast to other studies that combined mindfulness with traditional rehabilitation, participants in this study received no other treatment or traditional interventions for urinary incontinence (e.g., pelvic floor muscle exercises, bladder education). At posttest, participants had significantly fewer episodes (p = .005), averaging 1.23 per day. Although limited by a small sample size and lack of a control group, this study demonstrated preliminary support for stand-alone mindfulness interventions provided by occupational therapists for a physical condition.

The second study used mindfulness-based cognitive therapy in the rehabilitation of vestibular dysfunction and dizziness (Naber et al., 2011). In this study, group-based mindfulness components were nested within standard vestibular rehabilitation practices, dialectical behavioral therapy, and cognitive�behavioral therapy over five biweekly sessions. In addition, participants met individually with a physical therapist who provided personalized exercises. Significant improvement in vestibular symptoms, including functional level, impairment, coping, and skill use (p < .0001), was noted.

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Dr. Alex Jimenez’s Insight

Mindfulness interventions, such as mindfulness-based stress reduction, general mindfulness and acceptance and commitment therapy, are prevalent stress management methods and techniques frequently used in health care to help�relieve symptoms of stress, mental health issues and physical pain as well as to address and treat a variety of symptoms and diseases. Mindfulness interventions are believed to increase the outcome measures of alternative and complementary treatment options. Chiropractic care is another popular stress management option which can help improve as well as manage stress. The use of mindfulness interventions and chiropractic care with other treatments, such as physical rehabilitation, has been determined to increase their results. The article above demonstrated evidence-based results on the effectiveness of mindfulness interventions for symptoms of stress, including chronic pain.

Discussion

This scoping review describes how mindfulness is used in physical rehabilitation, identifies implications for occupational therapy, and illuminates gaps in current research. The studies included in the review provide preliminary support that mindfulness interventions can improve urinary incontinence, chronic pain, and vestibular functioning. These studies also show a promising trend toward improved outcomes for cognitive and behavior targets for patients with TBI. Across the studies, the strongest findings were for improvements in adaptation to illness or disability such as self-efficacy for disease management, increased quality of life, and acceptance of pain symptoms. In addition, mindfulness interventions for these outcomes not only were immediately effective but also maintained effectiveness at follow-up at a clinically significant level. This result suggests that adaptation-based outcomes are an important complement to function- and symptom-based outcomes in clinical mindfulness research. Moreover, patient appraisals of mindfulness interventions were positive, and no studies reported adverse or negative effects.

Occupational therapists were the primary providers of mindfulness interventions in 2 studies (Baker et al., 2012; Jackman, 2014). Although these studies showed promising results, both were limited by small sample size and lack of control conditions. In addition, Jackman (2014) failed to report numeric values for the findings, limiting interpretation. In 3 additional studies, occupational therapists had an ancillary role in providing mindfulness interventions (McCracken & Guti�rrez-Mart�nez, 2011; Vindholmen et al., 2014; Zangi et al., 2012). However, because of the complementary nature of the interventions with the occupational therapy scope of practice (AOTA, 2014) and the manner in which they were implemented, occupational therapy practitioners could have been active providers of the mindfulness interventions in these studies, highlighting the feasibility of integrating mindfulness into occupational therapy practice in future research. Moreover, although MBSR was the primary intervention that promoted engagement in mindfulness as an occupation, general mindfulness interventions and ACT also served as appropriate activity-based, preparatory, and educational interventions in these studies. Given the results of these studies and support from additional literature describing the use of mindfulness by occupational therapists (Moll, Tryssenaar, Good, & Detwiler, 2013; Stroh-Gingrich, 2012), further investigation of best practices for integrating mindfulness techniques into physical rehabilitation is warranted.

Although the literature suggests that mindfulness interventions can have positive effects in physical rehabilitation, substantial limitations exist in the current evidence. First, the majority of the positive studies are limited by their study design, being, at best, Level III evidence (i.e., cohort design). In contrast, an appropriately powered randomized controlled trial found a significant pretest�posttest effect of mindfulness interventions on pain reduction but also noted a similar reduction in pain for control group participants (Wong et al., 2011). Second, the wide variability in mindfulness intervention protocols makes it challenging to reach any general conclusions about intervention effectiveness. Finally, many studies overrepresented middle-aged White women, limiting interpretation of the acceptability of mindfulness interventions by or their effects in other demographics. Specifically, B�dard et al. (2005) noted decreased interest and adherence to their mindfulness intervention by male participants.

More information is needed to understand best practices for integration of mindfulness into occupational therapy practice. Specifically, the mindfulness interventions included in this review were generally complex, used a standardized protocol, were not fully integrated with standard rehabilitation interventions, and required intensive training for providers. Thus, further investigation is needed to:

Establish the effectiveness of mindfulness interventions in various settings and patient populations with physical diagnoses in high-level, randomized trials;
Examine the utility of training methods for occupational therapy practitioners in the delivery of mindfulness interventions for physical disorders as part of professional curricula, through continuing education programs or other postprofessional training;
Describe best practices for clinical integration of mindfulness into occupational therapy practice; and
Explore the implications related to reimbursement for and cost-effectiveness of the delivery of mindfulness interventions in occupational therapy practice.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

Mindfulness in physical rehabilitation is primarily used to help clients with chronic pain and TBI adapt to illness and disability, which promotes functional recovery as complementary to symptom remediation.
Mindfulness for physical disorders has yet to be substantiated as an evidence-based intervention within occupational therapy; however, promising preliminary evidence exists, and current mindfulness protocols fit within the occupational therapy scope of practice as preparatory, activity, or occupation-based interventions.
Higher level research is needed to address the substantial limitations in current efficacy studies on mindfulness for physical conditions and to determine best practices for the use of mindfulness in physical rehabilitation by occupational therapy practitioners.

Acknowledgments

Many thanks for the support and guidance received from Dr. Gelya Frank. Work on this review was partially supported by Grant No. K12�HD055929, National Institute of Child Health and Human Development/National Institute of Neurological Disorders and Stroke Rehabilitation Research Career Development Program. The contents of this article are solely the responsibility of the authors and do not necessarily represent the views of the National Institutes of Health. Portions of this work were presented at the 2015 Occupational Therapy Summit of Scholars in Los Angeles, CA.

Footnotes

Indicates studies that were included in the scoping review for this article.

Contributor Information

Ncbi.nlm.nih.gov/pmc/articles/PMC4834757/

In conclusion,�although stress is common in today’s society, stress can lead to a variety of physical and emotional diseases. Stress management methods and techniques are growing as popular treatment options to treat stress and its associated ailments, including chronic pain. Chiropractic care helps reduce stress by correcting subluxations, or spinal misalignments, to release pressure on the vertebrae and reduce muscle tension. The article above also demonstrates the effectiveness of mindfulness interventions in physical rehabilitation, although further research studies are needed. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

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EXTRA IMPORTANT TOPIC: Managing Workplace Stress

Stress Management & Chiropractic Treatment in El Paso, TX

by spinedoctors | Back Pain, Chiropractic, Physical Rehabilitation, Stress, Treatments

Many people utilize chiropractic treatment for stress management. If you haven’t already considered chiropractic to help reduce your stress, then it might still be in your best interest to know if it actually can help manage stress. If that’s the case, how exactly can chiropractic treatment help reduce stress levels? Every individual experiences stress. If chiropractic is so effective for stress management, why isn’t it more well-known? Although the answer to that is complex, the popularity of chiropractic treatment for stress management is growing. The article below discusses how chiropractic can help reduce your stress.

What Causes Stress?

Stress is difficult to define, however, it can be identified as a physical and/or psychological reaction to pressure. Stress may be caused by numerous factors, including environmental, bodily and emotional channels. When we become stressed, the sympathetic nervous system triggers the “fight or flight” response, a defense mechanism which prepares the body for perceived danger. While short-term stress is helpful, long-term stress has been connected to a variety of health issues. For instance, too much stress can create excess tension on the neck, back and low back, which may in turn lead to subluxation or spinal misalingment. This can ultimately also be bad for the heart, digestion, metabolism, and the immune system.

How Can Chiropractic Care Help?

As mentioned above, stress can frequently take a toll on the spine. Tension may continue to build up as a result of chronic stress, eventually resulting in pain and discomfort, among other symptoms, such as back pain and sciatica. Chiropractic care can help in two ways. First, through the use of spinal adjustments and manual manipulations, a chiropractor will carefully correct the misalignment of the spine, or subluxation, releasing tension and stress and relaxing the body to decrease the physical and psychological strain on the body. Second, once the spine is properly realigned, the central nervous system can function effectively.

A doctor of chiropractic will always be happy to speak with you and get you on the path towards a healthy and stress free life. A chiropractor can offer stress management chiropractic treatment to help you feel healthy. The purpose of the following systematic review is to demonstrated how effective mindfulness-based stress reduction methods and techniques can help low back pain.

Mindfulness-Based Stress Reduction for Low Back Pain: A Systematic Review

Abstract

Background

Mindfulness-based stress reduction (MBSR) is frequently used for pain conditions. While systematic reviews on MBSR for chronic pain have been conducted, there are no reviews for specific pain conditions. Therefore a systematic review of the effectiveness of MBSR in low back pain was performed.

Methods

MEDLINE, the Cochrane Library, EMBASE, CAMBASE, and PsycInfo were screened through November 2011. The search strategy combined keywords for MBSR with keywords for low back pain. Randomized controlled trials (RCTs) comparing MBSR to control conditions in patients with low back pain were included. Two authors independently assessed risk of bias using the Cochrane risk of bias tool. Clinical importance of group differences was assessed for the main outcome measures pain intensity and back-specific disability.

Results

Three RCTs with a total of 117 chronic low back pain patients were included. One RCT on failed back surgery syndrome reported significant and clinically important short-term improvements in pain intensity and disability for MBSR compared to no treatment. Two RCTs on older adults (age???65 years) with chronic specific or non-specific low back pain reported no short-term or long-term improvements in pain or disability for MBSR compared to no treatment or health education. Two RCTs reported larger short-term improvements of pain acceptance for MBSR compared to no treatment.

Conclusion

This review found inconclusive evidence of effectiveness of MBSR in improving pain intensity or disability in chronic low back pain patients. However, there is limited evidence that MBSR can improve pain acceptance. Further RCTs with larger sample sizes, adequate control interventions, and longer follow-ups are needed before firm conclusions can be drawn.

Keywords: Low back pain, Mindfulness-based stress reduction, MBSR, Complementary therapies, Review

Background

Low back pain is a major public health problem, with 76 % of the population experiencing low back pain in a given year [1]. It has become the largest category of medical claims, placing a major burden on individuals and health care systems [2]. Low back pain is the most common condition for which complementary therapies are used [3]. In the US, more than half of patients suffering from low back pain use complementary therapies [4].

Mindfulness is the common ground of several complementary therapies. Derived from Buddhist spiritual tradition, mindfulness has been secularized and integrated into behavioral treatment approaches [5]. While mindfulness has been described as the core construct of Buddhist meditation [5], it also comprises a specific state of consciousness that has been characterized as non-elaborative, non-judgmental moment-to moment awareness, a way to accept and trust in one�s own experience [6]. Therefore, mindfulness-based therapies not only include training in so-called formal practice of mindfulness, this is meditation, but also training in so-called informal practice of mindfulness, this is retaining a mindful state of consciousness during routine activities in everyday life [7,8].

The most commonly used mindfulness-based intervention is mindfulness-based stress reduction (MBSR). MBSR has originally been developed in a behavioral medicine setting for patients with chronic pain and stress-related complaints [9,10]. MBSR is a structured 8-week group program of weekly 2.5-hour sessions and 1 all-day (7 to 8-hour) silent retreat. Key components of the program are sitting meditation, walking meditation, hatha yoga and body scan, a sustained mindfulness practice in which attention is sequentially focused on different parts of the body [6]. Another important component is the transition of mindfulness into everyday life.

Mindfulness-based cognitive therapy (MBCT) combines MBSR with cognitive-behavioral techniques [11,12]. It retains the original 8-week group-based approach. Originally developed as a treatment for major depression [11], MBCT is more and more adapted for other specific conditions [12]. Other mindfulness-based interventions include mindful exercise [13] and acceptance and commitment therapy [14] that do not necessarily include formal meditation practice.

Pain has been a key topic of research on MBSR from the beginning [9]. Several trials assessed the effect of MBSR on patients with heterogeneous chronic pain conditions, mainly reporting positive results [15-19]. A recent comprehensive meta-analysis of mindfulness-based interventions for chronic pain conditions found small effects on pain, depression and physical well-being when considering only randomized controlled trials [14]. However, this meta-analysis included only one trial on low back pain.

The aim of this review was to systematically assess and – if possible – meta-analyze the effectiveness of MBSR and MBCT in patients with low back pain.

Methods

PRISMA guidelines for systematic reviews and meta-analyses [20] and the recommendations of the Cochrane Collaboration [21] were followed.

Literature Search

The literature search comprised the following electronical databases from their inception through November 2011: Medline, EMBASE, the Cochrane Library, PsycINFO, and CAMBASE. The complete search strategy for Medline was as follows: (MBSR[Title/Abstract] OR MBCT[Title/Abstract] OR mindful*[Title/Abstract]) AND (low back pain[MeSH Terms] OR low back pain[Title/Abstract] OR lower back pain[Title/Abstract] OR lumbago[Title/Abstract] OR low backache[Title/Abstract] OR low back ache[Title/Abstract] OR sciatica[MeSH Terms] OR sciatica[Title/Abstract]). The search strategy was adapted for each database as necessary. No language restrictions were applied. In addition, reference lists of identified original articles were searched manually. All retrieved articles were read in full to determine eligibility.

Eligibility Criteria

Intervention

Studies that assessed MBSR or MBCT as the main intervention were included. Studies on mindfulness-based interventions that were clearly different from the original MBSR/MBCT programs, such as mindful exercise or acceptance and commitment therapy, were excluded while studies that used variations of the MBSR/MBCT programs, such as variations in program length, frequency or duration were included.

Study Type

Only randomized controlled trials (RCTs) were included, while observational studies or non-randomized trials were excluded. No treatment (�wait-list�), usual care or any active treatment were acceptable as control interventions.

Studies were included only if they were published as full-text articles in peer reviewed scientific journals.

Patients

Studies of patients with a diagnosis of low back pain were included regardless of pain cause, duration and intensity.

Data Extraction

Two reviewers independently extracted data on characteristics of the study (e.g. trial design, randomization, blinding), characteristics of the patient population (e.g. sample size, age, diagnosis), characteristics of the intervention and control condition (e.g. type, program length, frequency and duration), drop-outs, outcome measures, follow-ups, results and safety. Discrepancies were rechecked with a third reviewer and consensus achieved by discussion.

Risk of Bias in Individual Studies

Risk of bias was assessed by two authors independently using the Cochrane risk of bias tool. This tool assesses risk of bias on the following domains: selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias [21]. Discrepancies were rechecked with a third reviewer and consensus achieved by discussion. Trial authors were contacted for further details if necessary.

Data Analysis

Main outcome measures were pain intensity and back-related disability. Safety was defined as secondary outcome measure. Other outcome measures used in the included studies were analyzed exploratively.

Meta-analysis was planned if sufficient homogeneous RCTs were available for statistical pooling. However, as only 3 RCTs were available that were heterogeneous regarding characteristics of patients, interventions, and control conditions, no meta-analysis was performed.

To determine clinical importance of group differences the following criteria were used: 10 mm (or 10 %) difference in post-treatment scores or change scores on a 100 mm visual analog scale of pain intensity [22], and 2�3 points (or 8 %) difference in post-treatment or change scores on the Roland-Morris Disability Questionnaire for back-specific disability [23].

Results

Literature Search

Twenty-five records were retrieved in literature search, 10 of them were duplicates. Three full-text articles with a total of 117 patients were assessed for eligibility and all of them were eligible for qualitative analysis (Figure ?1).

Figure 1: Flowchart of the results of the literature search.

Study Characteristics

Characteristics of the study, patient population, intervention, control condition, outcome measures, follow-ups and results are shown in Table ?1.

Setting and Patient Characteristics

All 3 included RCTs were conducted in the USA. Patients were recruited from a multidisciplinary spine and rehabilitation center [24], an adult pain clinic [25], and by posted flyers and newspaper advertisements [25,26]. Patients in 2 RCTs were older adults (age???65 years) with chronic (duration???3 months) low back pain [25,26]. In one of the two RCTs, minimal pain intensity was not defined [25] while in the other RCT pain had to be of at least moderate intensity on the �pain thermometer� [26]. Patients with non-specific low back pain, as well as specific low back pain, mainly due to osteoarthritis, were included [25,26]. The third RCT included patients of any age with failed back surgery syndrome; this is persistent back pain and/or leg pain of any duration and any intensity that persisted after lumbosacral surgery (within???2 years) [24].

MBSR

All included RCTs used MBSR interventions that were adapted from the original MBSR program developed at the University of Massachusetts. The two trials of older adults [25,26] utilized adapted 8-week programs with weekly 90-minute sessions. Roughly half of each session was dedicated to mindful meditation (body scan, sitting meditation, walking meditation), the other half to education and discussion. The programs did not incorporate yoga or an all-day silent retreat.

Patients in the trial on failed back surgery syndrome [24] participated in a MBSR intervention including 8 weekly 2.5 to 3.5-hour sessions and an additional 6-hour session in the 6th week. Besides education, the program included mindful meditation (sitting meditation, walking meditation) and gentle yoga.

Daily homework of 45 minutes meditation was recommended 6 days a week in all 3 trials [24-26].

In all 3 trials, MBSR was taught by 2 instructors each who completed the MBSR teacher training and had a long-standing meditation practice. In 2 trials, 1 of the instructors was a physician [25,26], while in the other trial 1 instructor was an osteopathic physician and the other 1 held a master�s degree in psychotherapy [24].

Control Conditions

Two RCTs compared MBSR to a waiting list control group [24,25]. Control patients did not receive any specific treatment during the course of the study but were offered the MBSR intervention after the post-treatment assessment. One of the RCTs of older adults [26] compared MBSR to a health education program that controlled for time, group size, and homework. Roughly half of each 90-minute session was dedicated to health-related, mainly back pain-related, education, the other half to mental exercise and discussion. Patients were provided a book and a games console with a “brain training” program as homework.

Co-Interventions

One RCT explicitly allowed patients in both groups to use additional usual medical care including pain medication during the course of the study [24]. The other 2 RCTs did not specify (dis-)allowance or actual use of co-interventions during the course of the study [25,26].

Outcome Measures

All 3 RCTs assessed post-intervention pain intensity using visual analog scales (VAS) [24], the McGill Pain questionnaire (MPQ) total score [25,26] or the MPQ current pain score [26]. Disability was also assessed post-intervention by all 3 RCTs, all using the Roland Morris Disability Questionnaire (RMDQ). Two RCTs [24,25] measured pain acceptance post-treatment using the Chronic Pain Acceptance Questionnaire (CPAQ). Two RCTs assessed quality of life [25,26] with the Medical Outcomes Study 36-item short-form survey (SF-36). One trial assessed analgesic use with an analgesic medication log [24] and sleep quality with the Pittsburgh Sleep Quality Index (PSQI) [24]. Another trial assessed self-efficacy using the Chronic Pain Self-Efficacy Scale (CPSS) [26] and mindfulness using the Mindful Attention Awareness Scale (MAAS) and the Five Facet Mindfulness Questionnaire (FFMQ) [26].

Only one RCT [26] reported group comparisons at longer-term follow-up.

Risk of Bias

Risk of bias for each study is shown in Table ?2. Risk of selection bias was low in all included RCTs. Only 1 study [26] reported blinding of outcome assessment and no study reported blinding of participants and personnel. However, one study [26] used an adequate active comparison group and treatment expectancy was comparably high in intervention and control group at baseline and post-treatment. Therefore it was judged that outcomes in this study were not likely to be influenced by lack of blinding. Risk of attrition bias was high in 2 out of 3 RCTs, while risk of reporting bias and other bias were low in all 3 RCTs.

Table 2: Risk of bias assessment of the included studies using the Cochrane risk of bias tool.

Effectiveness of MBSR Compared to No Treatment for Chronic Low Back Pain

One trial on mixed non-specific and specific chronic low back pain in older adults did not find any differences between MBSR and a wait-listed control group on pain intensity on the MPQ or back-specific disability as assessed with the RMDQ [25]. While disability improved within the MBSR group, group differences were not of clinical importance. This RCT reported MBSR being superior to wait-list in improving physical functioning, but not bodily pain, global health composite, physical health composite, or mental health composite on the SF-36. Pain acceptance on the CPAQ was reported to be significantly higher after MBSR as compared to no treatment. No differences in outcomes within the MBSR group were reported from end of intervention to 1-month follow-up.

One RCT on failed back surgery syndrome reported significant group differences between MBSR and a wait-listed control group in change of pain intensity immediately after the intervention period [24]. The difference in change scores between groups (MBSR: -6.9 cm vs. wait-list: -0.2 cm; sum score of 3 10 cm-VAS) was deemed clinically important. Significant and clinically important group differences after the intervention also were reported for change in disability on the RMDQ (MBSR: -3.6 vs. wait-list +0.1). Further, larger improvements were found for pain acceptance on the CPAQ, medication intake, and sleep quality on the PSQI for the MBSR group. While no group differences were assessed at 40-week follow-up, improvements in the MBSR group were reported to persist at this time point.

Effectiveness of MBSR Compared to Health Education for Chronic Low Back Pain

One RCT on mixed non-specific and specific chronic low back pain in older adults reported no differences between MBSR and health education on pain intensity on the MPQ or back-specific disability on the RMDQ [26]. While disability improved in both groups, group differences did not reach clinical importance. Group differences at short-term follow-up were reported for emotional role functioning on the SF-36, but not for bodily pain on the SF-36, self-efficacy on the CPSS or mindfulness on the MAAS or the FFMQ [26]. No group differences in disability, pain intensity, self-efficacy, quality of life or mindfulness were found at 4-month follow-up.

Safety

One RCT did neither report occurrence (or absence) of adverse events nor reasons for drop-outs [24]. Another RCT reported that no serious adverse events occurred [25]. However, 3 patients dropped out from the MBSR group due to unexpected health or family obligations [25]. The third RCT reported that there were no adverse events or drop-outs due to health obligations [26].

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Dr. Alex Jimenez’s Insight

Chronic stress can lead to prolonged muscle tension and other health issues. Too much tension in the muscles can begin to place unnecessary amounts of pressure on the bony structures of the body, which may lead to the misalignment of the spine, known as a subluxation. Chronic stress can also lead to nerve irritation. Chiropractic treatment is an effective stress management procedure because careful spinal adjustments and manual manipulations release muscle tension and help restore the body to a more balanced and relaxed state. Chiropractic treatment also helps reduce spinal nerve irritation as well as improve blood circulation. A healthy and balanced spine can be the key to effective stress management.

Discussion

This systematic review found only limited evidence that MBSR can provide short-term relief of pain and back-related disability in low back pain patients. Statistical significant and clinically relevant group differences were reported in only 1 out of 3 RCTs. Single studies reported effects on physical or emotional well-being but overall, only little effects on quality of life were reported. These results are only partly in line with a recent meta-analysis on mindfulness-based interventions for chronic pain that found MBSR to be superior to controls in reducing pain intensity and increasing physical wellbeing but not in increasing quality of life [14]. However, this meta-analysis included only 1 of the RCTs included in the present review [25].

Methodological differences between the included RCTs might explain some of the differences in results: firstly, different control groups were chosen; while 1 RCT used an adequate active control group [26], 2 RCTs compared MBSR to no treatment [24,25] and 1 of those was the only study that reported positive intervention effects on most of the study outcomes [24]. Secondly, another source of heterogeneity are differences in inclusion criteria between studies: the study that showed favorable effects of MBSR included a sample of highly chronified specific low back pain patients [24] while the 2 trials that showed little effects included patients with specific or unspecific low back pain [25,26]. Moreover, the 2 RCTs that did not report significant group differences in pain intensity or back-related disability included only older adults [25,26] while no age restriction was posed in the only RCT that reported effectiveness of MBSR for most outcome measures [24]. It has been argued that standard pain measurement instruments might not be suitable for elderly patients [27,28]. Specialized comprehensive approaches might be needed to correctly assess pain intensity in elderly patients [28]. Thirdly, the 2 RCTs that did not report significant group differences did not include yoga or an all-day retreat in their MBSR program [25,26]. Yoga has been reported to increase back-related function and to decrease disability in patients suffering from low back pain [29,30]. As the only RCT that reported favorable effects of MBSR on functional disability actually included yoga in the MBSR program [24], yoga might be crucial for this effect. Further research should include dismantling studies that separately evaluate the effects of different components of MBSR such as mindful meditation and yoga.

Although the use of pain intensity and disability as main outcome measures is in accordance with the IMMPACT recommendations [31], pain relief is not the main aim of MBSR [14]. Instead, patients are guided to accept all varieties of experience, be them pleasant or unpleasant, without elaboration or judgment [5,6]. In accordance with this approach, 2 RCTs reported increased pain acceptance after MBSR interventions [24,25]. Pain acceptance describes patients� attempt to maintain function in spite of their pain as far as possible [32]. Higher pain acceptance has been found to be associated with lower pain intensity and disability [33]. However, whether or not pain acceptance is a mechanism by which MBSR relieves pain in low back pain patients is beyond the scope of this review.

At the moment there is no evidence for longer-term effects of MBSR in low back pain. More RCTs with longer follow-ups are needed.

Generally, adverse events and reasons for drop-outs were poorly reported. This is unsatisfying since safety is a major issue in evaluating therapies. Further trials should put a focus on detailed reporting of safety data.

All included RCTs used MBSR as an intervention. No RCT assessing the effectiveness of MBCT in low back pain patients could be located. This is in line with the aforementioned meta-analysis of chronic pain that could not locate any trials on MBCT either [14].

The evidence found in this review is clearly limited due to several reasons. Firstly, the total number of eligible RCTs was small and clinical heterogeneity was high between RCTs. Thus, no meta-analysis could be performed. This review only included trials that were published in peer reviewed scientific journals. Therefore, some RCTs that were published in �grey literature� or conference proceedings only might have been missed. Secondly, the total number of included patients was low. No study included more than 20 patients in each group. More large RCTs are needed to definitely judge the effects of MBSR in low back pain. Thirdly, the evidence was suspect to high attrition bias. Fourthly, 2 out of 3 RCTs compared MBSR with wait-lists. While there is limited evidence that MBSR is effective in low back pain, more research is needed to evaluate superiority or inferiority of MBSR to other active treatments.

Conclusions

This systematic review found only inconclusive evidence of short-term effectiveness of MBSR in improving pain intensity and disability in patients suffering from low back pain. However, there is limited evidence from 2 wait-list controlled trials that MBSR can improve pain acceptance. Further trials with larger sample size, active control groups and longer follow-up are needed before the evidence for MBSR in low back pain can conclusively be judged.

Competing Interests

All authors disclose any commercial association that might create a conflict of interest in connection with the submitted manuscript. There is especially no competing financial interest for any of the authors.

Authors� Contributions

HC was responsible for conception and design of the review, carried out the literature search, performed data analysis, and drafted the manuscript. HH and RL performed data extraction and assessment of risk of bias, participated in conception and design of the review, and critically revised the manuscript. GD participated in conception and design of the review, and critically revised the manuscript. All authors read and approved the final manuscript.

Pre-Publication History

The pre-publication history for this paper can be accessed here:

www.biomedcentral.com/1472-6882/12/162/prepub

Acknowledgements

This review was partly supported by a grant from the Rut- and Klaus-Bahlsen-Foundation. The founding source had no influence on the design or conduct of the review; the collection, analysis, or interpretation of the data; or in the draft, revision, or approval of the manuscript.

Stress Management: an Exploratory Study of Chiropractic Patients

Abstract

Background

Stress is a recognized variable in the diagnosis, management, and prognosis of musculoskeletal conditions; chiropractic care is reputed to be successful in the management of stress-related visceral conditions. It may be useful for chiropractors to include stress management as a clinical care option.

Objective

To explore screening tools to aid stress self-assessment, investigate patients’ perceptions of stress management as a chiropractic care option, and examine which stress-management strategies chiropractic patients perceive as most useful.

Design

A multiphase qualitative study with purposive sampling of chiropractic clinics to maximize the diversity of the patient population. Convenience sampling of patients was undertaken in a Western Australian case study, an inner city, and a national exploratory study. Data for the case study were collected by semistructured interview. Questionnaires and a self-assessed stress-management task were used to collect data from the inner city and national studies. Data was thematically analyzed, and results were triangulated.

Results

The sample size of chiropractic patients in the West Australian case study was 48, 15 in the Western Australia exploratory study and 36 in the national study. A number of chiropractic patients participating in this study perceive themselves to be stressed and were interested in having stress-management strategies included in their chiropractic care. Individual patients preferred different stress-management options. This qualitative study found little justification for routinely using a stress-assessment technique more complex than asking the patient to rate his or her stress level as absent, minimal, moderate, or severe. Exercise, particularly walking, was found to be a prevalent pasttime among participants in the case study.

Conclusion

This study was too small to warrant statistical analysis; nonetheless, the results of this study are relevant because some patients believe they would benefit from chiropractic care that includes information about stress-management strategies.

In conclusion, chiropractic treatment is growing as a popular stress management option. When we become stressed, the spine can build up continuous tension which can ultimately affect our overall health and wellness. While the research studies above require additional evidence to support the findings, chiropractic treatment has been considered by more individuals as an alternative option for stress management methods and techniques. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

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EXTRA IMPORTANT TOPIC: Managing Workplace Stress!

Chiropractic & Stress Management for Back Pain in El Paso, TX

by spinedoctors | Back Pain, Chiropractic, Randomized Controlled Trial, Treatments

Stress is a reality of contemporary living. In a society where work hours are increasing and the media is constantly overloading our senses with the most regent tragedy, it’s no wonder why so many people experience higher levels of stress on a regular basis. Fortunately, more healthcare professionals are implementing stress management methods and techniques as a part of a patient’s treatment. While stress is a natural response which helps prepare the body for danger, constant stress can have negative effects on the body, causing symptoms of back pain and sciatica. But, why does too much stress negatively affect the human body?

First, it’s important to understand how the body perceives stress. There are three basic “channels” through which we perceive stress: environment, body, and emotions. Environmental stress is rather self-explanatory; if you’re walking down a quiet road and you hear a loud bang nearby, your body will perceive that as an immediate danger. That is an environmental stressor. Pollution could be another example of environmental stress because it externally affects the body the more one is exposed to it.

Stress through the body includes disease, lack of sleep and/or improper nutrition. Emotional stress is a little different, since it involves the way our brains interpret certain things. For instance, if someone you work with is being passive-aggressive, you might become stressed. Thoughts such as, “is he mad at me for some reason” or “they must be having a tough morning”, could be perceived as emotional stress. What is unique about emotional stress, however, is that we have control on just how much of it we experience, much more so than environmental or body stressors.

Now that we understand how the body can perceive stress in a variety of ways, we can discuss what effects constant stress can have on our overall health and wellness. When the body is placed under stress, through any of the above mentioned channels, the body’s fight or flight response is triggered. The sympathetic nervous system, or SNS, becomes stimulated, which in turn makes the heart beats faster and all of the body’s senses become more intense. This is a leftover defense mechanism from prehistoric times; that is the reason we’ve survived to today, instead of all becoming lunch for hungry predators out in the wild.

Unfortunately, the real issue is that in contemporary society, people often become overstressed and the human body is unable to differentiate between an immediate threat and a simple societal issue. Over the years many research studies have been conducted to estimate the effect of chronic stress on the human body, with such effects as hypertension, increased risk for heart disease and damage to muscle tissue as well as symptoms of back pain and sciatica.

According to several other research studies, combining stress management methods and techniques with a variety of treatment options can help more effectively improve symptoms and can promote a faster recovery. Chiropractic care is a well-known alternative treatment option utilized to treat a variety of injuries and/or conditions of the musculoskeletal and nervous systems. Because chiropractic treatment focuses on the spine, the root of the nervous system, chiropractic can also help with stress. Among the effects of stress is strain, which may consequently lead to subluxation or misalignment of the spine. Spinal adjustment and manual manipulations can help ease muscle tension, which in turn eases the strain on specific areas of the spine and helps ease subluxation. A balanced spine is a crucial element of handling personal stress. As mentioned before, proper nutrition and sufficient sleep is also a crucial part of stress management, which is chiropractic care offers lifestyle modification advice to further improve the patient’s stress levels as well as decrease their symptoms.

The purpose of the article below is to demonstrate the research study process developed to compare complementary and alternative medicine with conventional mind-body therapies for chronic back pain. The randomized controlled trial was carefully conducted and the details behind the research study have been recorded below. As with other research studies, further evidence-based information may be required to effectively determine the effect of stress management with treatment for back pain.

Comparison of Complementary and Alternative Medicine with Conventional Mind�Body Therapies for Chronic Back Pain: Protocol for the Mind�Body Approaches to Pain (MAP) Randomized Controlled Trial

Abstract

Background

The self-reported health and functional status of persons with back pain in the United States have declined in recent years, despite greatly increased medical expenditures due to this problem. Although patient psychosocial factors such as pain-related beliefs, thoughts and coping behaviors have been demonstrated to affect how well patients respond to treatments for back pain, few patients receive treatments that address these factors. Cognitive-behavioral therapy (CBT), which addresses psychosocial factors, has been found to be effective for back pain, but access to qualified therapists is limited. Another treatment option with potential for addressing psychosocial issues, mindfulness-based stress reduction (MBSR), is increasingly available. MBSR has been found to be helpful for various mental and physical conditions, but it has not been well-studied for application with chronic back pain patients. In this trial, we will seek to determine whether MBSR is an effective and cost-effective treatment option for persons with chronic back pain, compare its effectiveness and cost-effectiveness compared with CBT and explore the psychosocial variables that may mediate the effects of MBSR and CBT on patient outcomes.

Methods/Design

In this trial, we will randomize 397 adults with nonspecific chronic back pain to CBT, MBSR or usual care arms (99 per group). Both interventions will consist of eight weekly 2-hour group sessions supplemented by home practice. The MBSR protocol also includes an optional 6-hour retreat. Interviewers masked to treatment assignments will assess outcomes 5, 10, 26 and 52 weeks postrandomization. The primary outcomes will be pain-related functional limitations (based on the Roland Disability Questionnaire) and symptom bothersomeness (rated on a 0 to 10 numerical rating scale) at 26 weeks.

Discussion

If MBSR is found to be an effective and cost-effective treatment option for patients with chronic back pain, it will become a valuable addition to the limited treatment options available to patients with significant psychosocial contributors to their pain.

Trial Registration

Clinicaltrials.gov Identifier: NCT01467843.

Keywords: Back pain, Cognitive-behavioral therapy, Mindfulness meditation

Background

Identifying cost-effective treatments for chronic low back pain (CLBP) remains a challenge for clinicians, researchers, payers and patients. About $26 billion is spent annually in the United States in direct costs of medical care for back pain [1]. In 2002, the estimated costs of lost worker productivity due to back pain were $19.8 billion [2]. Despite numerous options for evaluating and treating back pain, as well as the greatly increased medical care resources devoted to this problem, the health and functional status of persons with back pain in the United States has deteriorated [3]. Furthermore, both providers and patients are dissatisfied with the status quo [4-6] and continue to search for better treatment options.

There is substantial evidence that patient psychosocial factors, such as pain-related beliefs, thoughts and coping behaviors, can have a significant impact on the experience of pain and its effects on functioning [7]. This evidence highlights the potential value of treatments for back pain that address both the mind and the body. In fact, four of the eight nonpharmacologic treatments recommended by the American College of Physicians and the American Pain Society guidelines for persistent back pain include �mind�body� components [8]. One of these treatments, cognitive-behavioral therapy (CBT), includes mind�body components such as relaxation training and has been found to be effective for a variety of chronic pain problems, including back pain [9-13]. CBT has become the most widely applied psychosocial treatment for patients with chronic back pain. Another mind�body therapy, mindfulness-based stress reduction (MBSR) [14,15], focuses on teaching techniques to increase mindfulness. MBSR and related mindfulness-based interventions have been found to be helpful for a broad range of mental and physical health conditions, including chronic pain [14-19], but they have not been well-studied for chronic back pain [20-24]. Only a few small pilot trials have evaluated the effectiveness of MBSR for back pain [25,26] and all reported improvements in pain intensity [27] or patients� acceptance of pain [28,29].

Further research on the comparative effectiveness and cost-effectiveness of mind�body therapies should be a priority in back pain research for the following reasons: (1) the large personal and societal impact of chronic back pain, (2) the modest effectiveness of current treatments, (3) the positive results of the few trials in which researchers have evaluated mind�body therapies for back pain and (4) the growing popularity and safety, as well as the relatively low cost, of mind�body therapies. To help fill this knowledge gap, we are conducting a randomized trial to evaluate the effectiveness, comparative effectiveness and cost-effectiveness of MBSR and group CBT, compared with usual medical care only, for patients with chronic back pain.

Specific Aims

Our specific aims and their corresponding hypotheses are outlined below.

1. To determine whether MBSR is an effective adjunct to usual medical care for persons with CLBP
Hypothesis 1: Individuals randomized to the MBSR course will show greater short-term (8 and 26 weeks) and long-term (52 weeks) improvement in pain-related activity limitations, pain bothersomeness and other health-related outcomes than those randomized to continued usual care alone.
2. To compare the effectiveness of MBSR and group CBT in decreasing back pain�related activity limitations and pain bothersomeness
Hypothesis 2: MBSR will be more effective than group CBT in decreasing pain-related activity limitations and pain bothersomeness in both the short term and long term. The rationale for this hypothesis is based on (1) the modest effectiveness of CBT for chronic back pain found in past studies, (2) the positive results of the limited initial research evaluating MBSR for chronic back pain and (3) growing evidence that an integral part of MBSR training (but not CBT training)�yoga�is effective for chronic back pain.
3. To identify the mediators of any observed effects of MBSR and group CBT on pain-related activity limitations and pain bothersomeness
Hypothesis 3a: The effects of MBSR on activity limitations and pain bothersomeness will be mediated by increases in mindfulness and acceptance of pain.
Hypothesis 3b: The effects of CBT on activity limitations and pain bothersomeness will be mediated by changes in pain-related cognition (decreases in catastrophizing, beliefs that one is disabled by pain and beliefs that pain signals harm, as well as increases in perceived control over pain and self-efficacy for managing pain) and changes in coping behaviors (increased use of relaxation, task persistence and coping self-statements and decreased use of rest).
4. To compare the cost-effectiveness of MBSR and group CBT as adjuncts to usual care for persons with chronic back pain
Hypothesis 4: Both MBSR and group CBT will be cost-effective adjuncts to usual care.

We will also explore whether certain patient characteristics predict or moderate treatment effects. For example, we will explore whether patients with higher levels of depression are less likely to improve with both CBT and MBSR or whether such patients are more likely to benefit from CBT than from MBSR (that is, whether depression level is a moderator of treatment effects).

Methods/Design

Overview

We are conducting a randomized clinical trial in which individuals with CLBP are randomly assigned to group CBT, a group MBSR course or usual care alone (Figure 1). Participants will be followed for 52 weeks after randomization. Telephone interviewers masked to participants� treatment assignments will assess outcomes 4, 8, 26 and 52 weeks postrandomization. The primary outcomes we will assess are pain-related activity limitations and pain bothersomeness. Participants will be informed that the study researchers are comparing �two different widely used pain self-management programs that have been found helpful for reducing pain and making it easier to carry out daily activities�.

Figure 1: Flowchart of the trial protocol. CBT, Cognitive-behavioral therapy; MBSR, Mindfulness-based stress reduction.

The protocol for this trial has been approved by the Human Subjects Review Committee of the Group Health Cooperative (250681-22). All participants will be required to give their informed consent before enrollment in this study.

Study Sample and Setting

The primary source of participants for this trial will be the Group Health Cooperative (GHC), a group-model, not-for-profit health-care organization that serves over 600,000 enrollees through its own primary care facilities in Washington state. As needed to achieve recruitment goals, direct mailings will be sent to persons 20 to 70 years of age living in the areas served by the GHC.

Inclusion and Exclusion Criteria

We are recruiting individuals from 20 to 70 years of age whose back pain has persisted for at least 3 months. The inclusion and exclusion criteria were developed to maximize the enrollment of appropriate patients while screening out patients who have low back pain of a specific nature (for example, spinal stenosis) or a complicated nature or who would have difficulty completing the study measures or interventions (for example, psychosis). Reasons for exclusion of GHC members were identified on the basis of (1) automated data recorded (using the International Classification of Diseases, Ninth Revision coding system), during all visits over the course of the previous year and (2) eligibility interviews conducted by telephone. For non-GHC members, reasons for exclusion were identified on the basis of telephone interviews. Tables 1 and ?2 list the inclusion and exclusion criteria, respectively, as well as the rationale for each criterion and the information sources.

In addition, we require that participants be willing and able to attend the CBT or MBSR classes during the 8-week intervention period if assigned to one of those treatments, and to respond to the four follow-up questionnaires so that we can assess outcomes.

Recruitment Procedures

Because the study intervention involves classes, we are recruiting participants in ten cohorts consisting of up to forty-five individuals each. We are recruiting participants from three main sources: (1) GHC members who have made visits to their primary care providers for low back pain and whose pain has persisted for at least 3 months, (2) GHC members who have not made a visit to their primary care provider for back pain but who are between the ages of 20 and 70 years and who respond to our nontargeted GHC mailing or our ad in GHC�s twice-yearly magazine and (3) community residents between the ages of 20 and 70 years who respond to a direct mail recruitment postcard.

For the targeted GHC population, a programmer will use GHC�s administrative and clinical electronic databases to identify potentially eligible members with a visit in the previous 3 to 15 months to a provider that resulted in a diagnosis consistent with nonspecific low back pain. These GHC members are mailed a letter and consent checklist that explains the study and eligibility requirements. Members interested in participating sign and return a statement indicating their willingness to be contacted. A research specialist then calls the potential participant to ask questions; determine eligibility; clarify risks, benefits and expected commitment to the study; and request informed consent. After informed consent has been obtained from the individual, the baseline telephone assessment is conducted.

For the nontargeted GHC population (that is, GHC members without visits with back pain diagnoses received within the previous 3 to 15 months but who could possibly have low back pain), a programmer uses administrative and clinical electronic databases to identify potentially eligible members who were not included in the targeted sample described in the preceding paragraph. This population also includes GHC members who respond to an ad in the GHC magazine. The same methods used for the targeted population are then used to contact and screen the potential participants, obtain their informed consent and collect baseline data.

With regard to community residents, we have purchased lists of the names and addresses of a randomly selected sample of people living within our recruitment area who are between 20 and 70 years of age. The people on the list are sent direct mail postcards describing the study including information regarding how to contact study staff if interested in participating. Once an interested person has contacted the research team the same process detailed above is followed.

To ensure that all initially screened study participants remain eligible at the time the classes begin, those who consent more than 14 days prior to the start of the intervention classes will be recontacted approximately 0 to 14 days prior to the first class to reconfirm their eligibility. The primary concern is to exclude persons who no longer have at least moderate baseline ratings of pain bothersomeness and pain-related interference with activities. Those individuals who remain eligible and give their final informed consent will be administered the baseline questionnaire.

Randomization

After completing the baseline assessment, participants will be randomized in equal proportions to the MBSR, CBT or usual care group. Those randomized to the MBSR or CBT group will not be informed of their type of treatment until they arrive at the first classes, which will occur simultaneously in the same building. The intervention group will be assigned on the basis of a computer-generated sequence of random numbers using a program which ensures that allocation cannot be changed after randomization. To ensure balance on a key baseline prognostic factor, randomization will be stratified based on our primary outcome measurement instrument: the modified version of the Roland Disability Questionnaire (RDQ) [30,31]. We will stratify participants into two activity limitations groups: moderate (RDQ score ?12 on a 0 to 23 scale) and high (RDQ scores ?13). Participants will be randomized within these strata in blocks of varying size (three, six or nine) to ensure a balanced but unpredictable assignment of participants. During recruitment, the study biostatistician will receive aggregated counts of participants randomized to each group to assure that the preprogrammed randomization algorithm is functioning properly.

Study Treatments

Both the group CBT and MBSR class series consist of eight weekly 2-hour sessions supplemented by home activities.

Mindfulness-Based Stress Reduction

Mindfulness-based stress reduction, a 30-year-old treatment program developed by Jon Kabat-Zinn, is well-described in the literature [32-34]. The authors of a recent meta-analysis found that MBSR had moderate effect sizes for improving the physical and mental well-being of patients with a variety of health conditions [16]. Our MBSR program is closely modeled on the original one and includes eight weekly 2-hour classes (summarized in Table 3), a 6-hour retreat between weeks 6 and 7 and up to 45 minutes per day of home practice. Our MBSR protocol was adapted by a senior MBSR instructor from the 2009 MBSR instructor�s manual used at the University of Massachusetts [35]. This manual permits latitude in how instructors introduce mindfulness and its practice to participants. The handouts and home practice materials are standardized for this study.

Table 3 Content of CBT and MBSR Class Sessions

Table 3: Content of cognitive-behavioral therapy and mindfulness-based stress reduction class sessions.

Participants will be given a packet of information during the first class that includes a course outline and instructor contact information; information about mindfulness, meditation, communication skills and effects of stress on the body, emotions and behavior; homework assignments; poems; and a bibliography. All sessions will include mindfulness exercises, and all but the first will include yoga or other forms of mindful movement. Participants will be given audio recordings of the mindfulness and yoga techniques, which will have been recorded by their own instructors. Participants will be asked to practice the techniques discussed in each class daily for up to 45 minutes throughout the intervention period and after classes end. They will also be assigned readings to complete before each class. Time will be devoted in each class to a review of challenges that participants have had in practicing what they learned in previous classes and with their homework. An optional day of practice on the Saturday between the sixth and seventh classes will be offered. This 6-hour �retreat� will be held with the participants in silence and only the instructor speaking. This will provide participants an opportunity to deepen what they have learned in class.

Cognitive-Behavioral Therapy

CBT for chronic pain is well-described in the literature and has been found to be modestly to moderately effective in improving chronic pain problems [9-13]. There is no single, standardized CBT intervention for chronic pain, although all CBT interventions are based on the assumption that both cognition and behavior influence adaptation to chronic pain and that maladaptive cognition and behavior can be identified and changed to improve patient functioning [36]. CBT emphasizes active, structured techniques to teach patients how to identify, monitor and change maladaptive thoughts, feelings and behaviors, with a focus on helping patients to acquire skills that they can apply to a variety of problems and collaboration between the patient and therapist. A variety of techniques are taught, including training in pain coping skills (for example, use of positive coping self-statements, distraction, relaxation and problem-solving). CBT also promotes setting and working toward behavioral goals.

Both individual and group formats have been used in CBT. Group CBT is often an important component of multidisciplinary pain treatment programs. We will use a group CBT format because it has been found to be efficacious [37-40], is more resource-efficient than individual therapy and provides patients with the potential benefits deriving from contact with, and support and encouragement from, others with similar experiences and problems. In addition, using group formats for both MBSR and CBT will eliminate intervention format as a possible explanation for any differences observed between the two therapies.

For this study, we developed a detailed therapist�s manual with content specific for each session, as well as a participant�s workbook containing materials for use in each session. We developed the therapist�s manual and participant�s workbooks based on existing published resources as well as on materials we have used in prior studies [39-47].

The CBT intervention (Table 3) will consist of eight weekly 2-hour sessions that will provide (1) education about the role of maladaptive automatic thoughts (for example, catastrophizing) and beliefs (for example, one�s ability to control pain, hurt equals harm) common in people with depression, anxiety and/or chronic pain and (2) instruction and practice in identifying and challenging negative thoughts, the use of thought-stopping techniques, the use of positive coping self-statements and goal-setting, relaxation techniques and coping with pain flare-ups. The intervention will also include education about activity pacing and scheduling and about relapse prevention and maintenance of gains. Participants will be given audio recordings of relaxation and imagery exercises and asked to set goals regarding their relaxation practice. During each session, participants will complete a personal action plan for activities to be completed between sessions. These plans will be used as logs for setting specific home practice goals and checking off activities completed during the week to be reviewed at the next week�s session.

Usual Care

The usual care group will receive whatever medical care they would normally receive during the study period. To minimize possible disappointment with not being randomized to a mind�body treatment, participants in this group will receive $50 compensation.

Class Sites

The CBT and MBSR classes will be held in facilities close to concentrations of GHC members in Washington state (Bellevue, Bellingham, Olympia, Seattle, Spokane and Tacoma).

Instructors

All MBSR instructors will have received either formal training in teaching MBSR from the Center for Mindfulness at the University of Massachusetts or equivalent training. They will themselves be practitioners of both mindfulness and a body-oriented discipline (for example, yoga), will have taught MBSR previously and will have made mindfulness a core component of their lives. The CBT intervention will be conducted by doctorate-level clinical psychologists with previous experience in providing CBT to patients with chronic pain.

Training and Monitoring of Instructors

All CBT instructors will be trained in the study protocol for the CBT intervention by the study�s clinical psychologist investigators (BHB and JAT), who are very experienced in administering CBT to patients with chronic pain. BHB will supervise the CBT instructors. One of the investigators (KJS) will train the MBSR instructors in the adapted MBSR protocol and supervise them. Each instructor will attend weekly supervision sessions, which will include discussion of positive experiences, adverse events, concerns raised by the instructor or participants and protocol fidelity. Treatment fidelity checklists highlighting the essential components for each session were created for both the CBT and MBSR arms. A trained research specialist will use the fidelity checklist during live observation of every session. The research specialist will provide feedback to the supervisor to facilitate weekly supervision of the instructors. In addition, all sessions will be audio-recorded. The supervisors will listen to a random sample and requested portions of sessions and will monitor them using the fidelity checklist. Feedback will be provided to the instructors during their weekly supervision sessions. Treatment fidelity will be monitored in both intervention groups by KJS and BHB with assistance from research specialists. In addition, they will review and rate on the fidelity checklist a random sample of the recorded sessions.

Participant Retention and Adherence to Home Practice

Participants will receive a reminder call before the first class and whenever they miss a class. They will be asked to record their daily home practice on weekly logs. Questions about their home practice during the prior week will also be included in all follow-up interviews. To maintain interviewer blinding, adherence questions will be asked after all outcome data have been recorded.

Measures

We will assess a variety of participant baseline characteristics, including sociodemographic characteristics, back pain history and expectations of the helpfulness of the mind�body treatments for back pain (Table 4).

We will assess a core set of outcomes for patients with spinal disorders (back-related function, pain, general health status, work disability and patient satisfaction) [48] that are consistent with the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations for clinical trials of chronic pain treatment efficacy and effectiveness [49]. We will measure both short-term outcomes (8 and 26 weeks) and long-term outcomes (52 weeks). We will also include a brief, 4-week, midtreatment assessment to permit analyses of the hypothesized mediators of the effects of MBSR and CBT on the primary outcomes. The primary study endpoint is 26 weeks. Participants will be paid $20 for each follow-up interview completed to maximize response rates.

Co�Primary Outcome Measures

The co�primary outcome measures will be back-related activity limitations and back pain bothersomeness.

Back-related activity limitations will be measured with the modified RDQ, which asks whether 23 specific activities have been limited due to back pain (yes or no) [30]. We have further modified the RDQ to ask a question about the previous week rather than just �today�. The original RDQ has been found to be reliable, valid and sensitive to clinical changes [31,48,50-53], and it is appropriate for telephone administration and use with patients with moderate activity limitations [50].

Back pain bothersomeness will be measured by asking participants to rate how bothersome their back pain has been during the previous week on a 0 to 10 scale (0?=?�not at all bothersome� and 10?=?�extremely bothersome�). On the basis of data compiled from a similar group of GHC members with back pain, we found this bothersomeness measure to be highly correlated with a 0 to 10 measure of pain intensity (r?=?0.8 to 0.9; unpublished data (DCC and KJS) and with measures of function and other outcome measures [54]. The validity of numerical rating scales of pain has been well-documented, and such scales have demonstrated sensitivity in detecting changes in pain after treatment [55].

We will analyze and report these co�primary outcomes in two ways. First, for our primary endpoint analyses, we will compare the percentages of participants in the three treatment groups who achieve clinically meaningful improvement (?30% improvement from baseline) [56,57] at each time point (with 26-week follow-up being the primary endpoint). We will then examine, in a secondary outcome analysis, the adjusted mean differences between groups on these measures at the time of follow-up.

Secondary Outcome Measures

The secondary outcomes that we will measure are depressive symptoms, anxiety, pain-related activity interference, global improvement with treatment, use of medications for back pain, general health status and qualitative outcomes.

Depressive symptoms will be assessed with the Patient Health Questionnaire-8 (PHQ-8) [58]. With the exception of the elimination of a question about suicidal ideation, the PHQ-8 is identical to the PHQ-9, which has been found to be reliable, valid and responsive to change [59,60].

Anxiety will be measured with the 2-item Generalized Anxiety Disorder scale (GAD-2), which has demonstrated high sensitivity and specificity in detecting generalized anxiety disorder in primary care populations [61,62].

Pain-related activity interference with daily activities will be assessed using three items from the Graded Chronic Pain Scale (GCPS). The GCPS has been validated and shown to have good psychometric properties in a large population survey and in large samples of primary care patients with pain [63,64]. Participants will be asked to rate the following three items on a 0 to 10 scale: their current back pain (back pain �right now�), their worst back pain in the previous month and their average pain level over the previous month.

Global improvement with treatment will be measured with the Patient Global Impression of Change scale [65]. This single question asks participants to rate their improvement with treatment on a 7-point scale that ranges from �very much improved� to �very much worse,� with �no change� used as the midpoint. Global ratings of improvement with treatment provide a measure of overall clinical benefit from treatment and are considered one of the core outcome domains in pain clinical trials [49].

Use of medications and exercise for back pain during the previous week will be assessed with the 8-, 26- and 52-week questionnaires.

General health status will be assessed with the 12-item Short Form Health Survey (SF-12) [66], a widely used instrument that yields summary scores for physical and mental health status. The SF-12 will also be used to calculate quality-adjusted life-years (QALYs) using the Short Form Health Survey in 6 dimensions in the cost-effectiveness analyses [67].

Qualitative outcomes will be measured with open-ended questions. We have included open-ended questions in our previous trials and found that they yield valuable insights into participants� feelings about the value of specific components of the interventions and the impact of the interventions on their lives. We therefore will include open-ended questions about these issues at the end of the 8-, 26- and 52-week follow-up interviews.

Measures Used in Mediator Analyses

In the MBSR arm, we will evaluate the mediating effects of increased mindfulness (measured with the Nonreactivity, Observing, Acting with Awareness, and Nonjudging subscales of the Five Facet Mindfulness Questionnaire short form [68-70]) and increased pain acceptance (measured with the Chronic Pain Acceptance Questionnaire [71,72]) on the primary outcomes. In the CBT arm, we will evaluate the mediating effects of improvements in pain beliefs and/or appraisals (measured with the Patient Self-Efficacy Questionnaire [73]; the Survey of Pain Attitudes 2-item Control, Disability, and Harm scales [74-76]; and the Pain Catastrophizing Scale [77-80]) and changes in the use of pain coping strategies (measured with the Chronic Pain Coping Inventory 2-item Relaxation scale and the complete Activity Pacing scale [81,82]) on the primary outcomes. Although we expect the effects of MBSR and CBT on outcomes to be mediated by different variables, we will explore the effects of all potential mediators on outcomes in both treatment groups.

Measures Used in the Cost-Effectiveness Analyses

Direct costs will be estimated using cost data extracted from the electronic medical records for back-related services provided or paid by GHC and from patient reports of care not covered by GHC. Indirect costs will be estimated using the Work Productivity and Activity Impairment questionnaire [83]. The effectiveness of the intervention will be derived from the SF-12 general health status measure [84].

Data Collection, Quality Control and Confidentiality

Data will be collected from participants by trained telephone interviewers using a computer-assisted telephone interview (CATI) version of the questionnaires to minimize errors and missing data. Questions about experiences with specific aspects of the interventions (for example, yoga, meditation, instruction in coping strategies) that would unmask interviewers to treatment groups will be asked at each time point after all other outcomes have been assessed. We will attempt to obtain outcome data from all participants in the trial, including those who never attend or drop out of the classes, those who discontinue enrollment in the health plan and those who move away. Participants who do not respond to repeated attempts to obtain follow-up data by telephone will be mailed a questionnaire including only the two primary outcome measures and offered $10 for responding.

We are will collect information at every stage of recruitment, randomization and treatment so that we can report patient flow according to the CONSORT (Consolidated Standards of Reporting Trials) guidelines [85]. To maintain the confidentiality of patient-related information in the database, unique participant study numbers will be used to identify patient outcomes and treatment data. Study procedures are in place to ensure that all masked personnel will remain masked to treatment group.

Protection of Human Participants and Assessment of Safety

Protection of Human Participants

The GHC Institutional Review Board (IRB) approved this study.

Safety Monitoring

This trial will be monitored for safety by an independent Data and Safety Monitoring Board (DSMB) composed of a primary care physician experienced in mindfulness, a biostatistician and a clinical psychologist with experience in treating patients with chronic pain.

Adverse Experiences

We will collect data on adverse experiences (AEs) from several sources: (1) reports from the CBT and MBSR instructors of any participants� experiences of concern to them; (2) the 8-, 26- and 52-week CATI follow-up interviews in which the participants are asked about any harm they felt during the CBT or MBSR treatment and any serious health problems they had had during the respective time periods; and (3) spontaneous reports from participants. The project coinvestigators and a GHC primary care internist will review AE reports from all sources weekly. Any serious AEs will be reported promptly to the GHC IRB and the DSMB. AEs that are not serious will be recorded and included in regular DSMB reports. Any identified deaths of participants will be reported to the DSMB chair within 7 days of discovery, regardless of attribution.

Stopping Rules

The trial will be stopped only if the DSMB believes that there is an unacceptable risk of serious AEs in one or more of the treatment arms. In this case, the DSMB can decide to terminate one of the arms of the trial or the entire trial.

Statistical Issues

Sample Size and Detectable Differences

Our sample size was chosen to ensure adequate power to detect a statistically significant difference between each of the two mind�body treatment groups and the usual care group, as well as power to detect a statistically significant difference between the two mind�body treatment groups. Because we considered patient activity limitations to be the more consequential of our two co�primary outcome measures, we based our sample size calculations on the modified RDQ [30]. We specified our sample size on the basis of the expected percentage of patients with a clinically meaningful improvement measured with the RDQ at the 26-week assessment (that is, at least 30% relative to baseline) [57].

Because of multiple comparisons, we will use Fisher�s protected least significant difference test [86], first analyzing if there is any significant difference among all three groups (using the omnibus ?2 likelihood ratio test) for each outcome and each time point. If we find a difference, we will then test for pairwise differences between groups. We will need 264 participants (88 in each group) to achieve 90% power to find either mind�body treatment different from usual care on the RDQ. This assumes that 30% of the usual care group and 55% of each mind�body treatment group will have clinically meaningful improvement on the RDQ at 26 weeks, rates of improvement that are similar to those we observed in a similar back pain population in an evaluation of complementary and alternative treatments for back pain [87]. We will have at least 80% power to detect a significant difference between MBSR and CBT on the RDQ if MBSR is at least 20 percentage points more effective than CBT (that is, 75% of the MBSR group versus 55% of the CBT group).

Our other co�primary outcome is the pain bothersomeness rating. With a total sample size of 264 participants, we will have 80% power to detect a difference between a mind�body treatment group and usual care on the bothersomeness rating scale, assuming that 47.5% of usual care and 69.3% of each mind�body treatment group have 30% or more improvement from baseline on the pain bothersomeness rating scale. We will have at least 80% power to detect a significant difference between MBSR and CBT on the bothersomeness rating scale if MBSR is at least 16.7 percentage points more effective than CBT (that is, 87% of the MBSR group versus 69.3% of the CBT group).

When analyzing the primary outcomes as continuous measures, we will have 90% power to detect a 2.4-point difference between usual care and either mind�body treatment on the modified RDQ scale scores and a 1.1-point difference between usual care and either mind�body treatment on the pain bothersomeness rating scale (assumes normal approximation to compare two independent means with equal variances and a two-sided P?=?0.05 significance level with standard deviations of 5.2 and 2.4 for RDQ and pain bothersomeness measures, respectively [88]. Assuming an 11% loss to follow-up (slightly higher than that found in our previous back pain trials), we plan to recruit a sample of 297 participants (99 per group).

Both of the co�primary outcomes will be tested at the P?<?0.05 level at each time point because they address separate scientific questions. Analyses of both outcomes at all follow-up time points will be reported, imposing a more stringent requirement than simply reporting a sole significant outcome.

Statistical Analyses

Primary Analyses

In our comparisons of treatments based on the outcome measures, we will analyze outcomes assessed at all follow-up time points in a single model, adjusting for possible correlation within individuals and treatment group cohorts using generalized estimating equations [89]. Because we cannot reasonably make an assumption regarding constant or linear group differences over time, we will include an interaction term between treatment groups and time points. We plan to adjust for baseline outcome values, sex and age, as well as other baseline characteristics found to differ significantly by treatment group or follow-up outcomes, to improve precision and power of our statistical tests. We will conduct the following set of analyses for both the continuous outcome score and the binary outcome (clinically significant change from baseline), including all follow-up time points (4, 8, 26 and 52 weeks). The MBSR treatment will be deemed successful only if the 26-week time point comparisons are significant. The other time points will be considered secondary evaluations.

We will use an intent-to-treat approach in all analyses; that is, the assessment of individuals will be analyzed by randomized group, regardless of participation in any classes. This analysis minimizes biases that often occur when participants who do not receive the assigned treatments are excluded from analysis. The regression model will be in the following general form:

Regression Model General Form

where yt is the response at follow-up time t, baseline is the prerandomization value of the outcome measure, treatment includes dummy variables for the MBSR and CBT groups, time is a series of dummy variables indicating the follow-up times and z is a vector of covariates representing other variables adjusted for. (Note that ?1, ?2, ?3 and ?4 are vectors.) The referent group in this model is the usual care group. For binary and continuous outcomes, we will use appropriate link functions (for example, logit for binary). For each follow-up time point at which the omnibus ?2 test is statistically significant, we will go on to test whether there is a difference between MBSR and usual care to address aim 1 and a difference between MBSR and CBT to address aim 2. We will also report the comparison of CBT to usual care. When determining whether MBSR is an effective treatment for back pain, we will require that aim 1, the comparison of MBSR to usual care, must be observed.

On the basis of our previous back pain trials, we expect at least an 89% follow-up and, if that holds true, our primary analysis will be a complete case analysis, including all observed follow-up outcomes. However, we will adjust for all baseline covariates that are predictive of outcome, their probability of being missing and differences between treatment groups. By adjusting for these baseline covariates, we assume that the missing outcome data in our model are missing at random (given that baseline data are predictive of missing data patterns) instead of missing completely at random. We will also conduct sensitivity analysis using an imputation method for nonignorable nonresponses to evaluate whether our results are robust enough to compensate for different missing data assumptions [90].

Mediator Analyses If MBSR or CBT is found to be effective (relative to usual care and/or to each other) in improving either primary outcome at 26 or 52 weeks, we will move to aim 3 to identify the mediators of the effects of MBSR and group CBT on the RDQ and pain bothersomeness scale. We will perform the series of mediation analyses separately for the two primary outcomes (RDQ and pain bothersomeness scale scores) and for each separate treatment comparator of interest (usual care versus CBT, usual care versus MBSR and CBT versus MBSR). We will conduct separate mediator analyses for the 26- and 52-week outcomes (if MBSR or CBT is found to be effective at those time points).

Next, we describe in detail the mediator analysis for the 26-week time point. A similar analysis will be conducted for the 52-week time point. We will apply the framework of the widely used approach of Baron and Kenny [91]. Once we have demonstrated the association between the treatment and the outcome variable (the �total effect� of the treatment on the outcome), the second step will be to demonstrate the association between the treatment and each putative mediator. We will construct a regression model for each mediator with the 4- or 8-week score of the mediator as the dependent variable and the baseline score of the mediator and treatment indicator as independent variables. We will conduct this analysis for each potential mediator and will include as potential mediators in the following step only those that have a P-value ?0.10 for the relationship with the treatment. The third step will be to demonstrate the reduction of the treatment effect on the outcome after removing the effect of the mediators. We will construct a multimediator inverse probability weighted (IPW) regression model [92]. This approach will allow us to estimate the direct effects of treatment after rebalancing the treatment groups with respect to the mediators. Specifically, we will first model the probability of the treatment effects, given the mediators (that is, all mediators that were found to be associated with treatment in step 2), using logistic regression and adjusting for potential baseline confounders. Using this model, we will obtain the estimated probability that each person received the observed treatment, given the observed mediator value. We will then use an IPW regression analysis to model the primary outcomes on treatment status while adjusting for the baseline levels of the outcome and mediator. Comparing the weighted model with the unweighted model will allow us to estimate how much of the direct effect of treatment on the associated outcome can be explained by each potential mediator. The inclusion in step 3 of all mediators found to be significant in step 2 will enable us to examine whether the specific variables that we hypothesized would differentially mediate the effects of MBSR versus CBT in fact mediate the effects of each treatment independently of the effects of the other �process variables�.

Cost-Effectiveness Analyses

A societal perspective cost�utility analysis (CUA) will be performed to compare the incremental societal costs revealed for each treatment arm (direct medical costs paid by GHC and the participant plus productivity costs) to incremental effectiveness in terms of change in participants� QALYs [93]. This analysis will be possible only for study participants recruited from GHC. This CUA can be used by policymakers concerned with the broad allocation of health-related resources [94,95]. For the payer perspective, direct medical costs (including intervention costs) will be compared to changes in QALYs. This CUA will help us to determine whether it makes economic sense for MBSR to be a reimbursed service among this population. A bootstrap methodology will be used to estimate confidence intervals [96]. In secondary analyses conducted to assess the sensitivity of the results to different cost outcome definitions, such as varying assumptions of wage rates used to value productivity and the inclusion of non-back-related health-care resource utilization [97] in the total cost amounts, will also be considered. In cost-effectiveness analyses, we will use intention to treat and adjust for health-care utilization costs in the one calendar year prior to enrollment and for baseline variables that might be associated with treatment group or outcome, such as medication use, to control for potential confounders. We expect there will be minimal missing data, but sensitivity analyses (as described above for the primary outcomes) will also be performed to assess cost measures.

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Stress is the body’s response to physical or psychological pressure. Several factors can trigger stress, which in turn activates the “fight or flight” response, a defense mechanism which prepares the body for perceived danger. When stressed, the sympathetic nervous system becomes stimulated and secretes a complex combination of hormones and chemicals. Short-term stress can be helpful, however long-term stress has been connected to a variety of health issues, including back pain and sciatica symptoms. According to research studies, stress management has become an essential addition for many treatment options because stress reduction may help improve treatment outcome measures. Chiropractic care uses spinal adjustments and manual manipulations together with lifestyle modifications to treat the spine, the root of the nervous system, as well as to promote decreased stress levels through proper nutrition, fitness and sleep.

Discussion

In this trial, we will seek to determine whether an increasingly popular approach for dealing with stress�mindfulness-based stress reduction�is an effective and cost-effective treatment option for persons with chronic back pain. Because of its focus on the mind as well as the body, MBSR has the potential to address some of the psychosocial factors that are important predictors of poor outcomes. In this trial, we will compare the effectiveness and cost-effectiveness of MBSR with that of CBT, which has been found to be effective for back pain but is not widely available. The study will also explore psychosocial variables that may mediate the effects of MBSR and CBT on patient outcomes. If MBSR is found to be an effective and cost-effective treatment option for persons with chronic back pain, it will be a valuable addition to the treatment options available for patients with significant psychosocial contributors to this problem.

Trial Status

Recruitment started in August 2012 and was completed in April 2014.

Abbreviations

AE: Adverse event; CAM: Complementary and alternative medicine; CATI: Computer-assisted telephone interview; CBT: Cognitive-behavioral therapy; CLBP: Chronic low back pain; CUA: Cost�utility analysis; DSMB: Data and Safety Monitoring Board; GHC: Group Health Cooperative; ICD-9: International Classification of Diseases Ninth Revision; IPW: Inverse probability weighting; IRB: Institutional Review Board; MBSR: Mindfulness-based stress reduction; NCCAM: National Center for Complementary and Alternative Medicine; QALY: Quality-adjusted life-year.

Competing Interests

The authors declare that they have no competing interests.

Authors� Contributions

DC and KS conceived of the trial. DC, KS, BB, JT, AC, BS, PH, RD and RH participated in refining the study design and implementation logistics and in the selection of outcome measures. AC developed plans for the statistical analyses. JT and AC developed plans for the mediator analyses. BS, BB and JT developed the materials for the CBT intervention. PH developed plans for the cost-effectiveness analyses. DC drafted the manuscript. All authors participated in the writing of the manuscript and read and approved the final manuscript.

Acknowledgements

The National Center for Complementary and Alternative Medicine (NCCAM) provided funding for this trial (grant R01 AT006226). The design of this trial was reviewed and approved by NCCAM�s Office of Clinical and Regulatory Affairs.

In conclusion, environmental, bodily and emotional stressors can trigger the “fight or flight response” in charge of preparing the the human body for danger. Although stress is essential to increase our performance, chronic stress can have a negative impact in the long-run, manifesting symptoms associated with back pain and sciatica. Chiropractic care utilizes a variety of treatment procedures, along with stress management methods and techniques, to help reduce stress as well as improve and manage symptoms associated with injuries and/or conditions of the musculoskeletal and nervous systems.�Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

Dance Injuries: Chiropractic Treatment Can Help | El Paso, TX.

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Complex Injuries, Injury Care

Do You Want To Dance?

Most people love hearing these words, and wholeheartedly jump to the dance floor to twist and shout with the best of them. Some even take classes to learn to swing, tap, or ballroom dance. Others even train and compete. It’s big fun, and provides social interaction and exercise.

And Sometimes Pain:

While some don’t view it this way, dancing is a sport. As such, dance moves can put pressure on your body that causes injury.

Common dancing injuries include foot and ankle sprains, pulled knees, and stress fractures. If you have shimmied your back out, or do-si-do’d your knee into a stiff, painful mess, it’s time to call the best dance partner you have ever had: your chiropractor!

Chiropractic care helps dancers prevent and cope with injuries in a variety of ways.

Before:

Dancing requires coordination and balance that comes from strong muscles, bones, and ligaments. If your body is tight and ill-prepared for exercise, you could end up busting a move in the wrong way on the dance floor.

Chiropractic care can, over time, help strengthen your muscles and align your spine so your body is in prime condition for physical activity, with minimal risk of injury. Chiropractic visits work wonders from the neck to the feet in putting the body back in its top performing form. In addition, your chiropractor can offer an at-home regimen of stretching exercises that serves to further promote healthy joints, tendons and muscles.

During:

For those who dance regularly, painful feet, ankles and knees may be viewed as part of the package of doing something they love. This doesn’t have to be the case. By committing to regular chiropractic care, dancers improve their range of motion, and keep muscles and joints loose and functioning correctly. Chiropractic care during a regular routine of dancing plays into staying healthy and mobile.

After:

Dancing requires a body to move, turn, and stretch in ways that it may not be accustomed. If you ignored proper preparation, or ended up taking precautions and suffered an injury anyway, you may experience pain and loss of mobility. Make an appointment with your chiropractor as soon as possible.

Many common bodily injuries can be dramatically improved by a regimen of chiropractic care. From sprains to strains to misalignment, a few visits to your chiropractor offers multiple benefits.

The first is pain management, often without drugs. The second is injury improvement by performing manual manipulations, known as adjustments, that stretch the injured area and promote healing. The third is increased mobility. Finally, chiropractic care assists the body in knitting itself back together so well that it minimizes the chances of future injury.

If you have been dancing on and off or regularly for years, or if you are thinking about taking up dancing, know there are many great benefits from incorporating it into your routine. However, you need to take proper precautions to reduce the risk of suffering an injury as you move.

Make sure to choose a nutritious diet and stay hydrated while you dance, and wear properly fitting clothing and shoes. Strive to practice the moves correctly, as well as maintain correct posture. Don’t overdo it, because pushing your body past its limits is a surefire way to cause an injury. Also remember to always stretch out and warm up before dancing.

By following these simple suggestions, you can hit the floor when the music starts and dance until you wear out, enjoying the health benefits dancing brings, while avoiding the injuries.

Chiropractic Treatment Helps With Stress

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What Is Maignes Syndrome?

Chiropractors Can�

�Help Correctly Diagnose It

�Adjust The Area Where The Issue Originates

�Offer At Home Exercises To Help With Healing

�Promote Your Body’s Ability To Heal Itself

Chiropractic Treatment Helps�Avoid Back Surgery

Mobile Device Injuries

Text Neck

Forearm & Wrist Pain

Sore Upper & Lower Back

Blackberry Thumb

Headaches From Tension In Neck & Back

Chiropractic Treatment For Proper Posture

How Does Stress Affect the Body?

Managing Your Stress

Benefits of Chiropractic Care

A Holistic Care Approach

Effects of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy and Usual Care on Back Pain and Functional Limitations among Adults with Chronic Low Back Pain: A Randomized Clinical Trial

Abstract

Importance

Objective

Design, Setting, and Participants

Interventions

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Study Design, Setting, and Participants

Randomization

Interventions

Follow-Up

Measures

Co�primary Outcomes

Secondary Outcomes

Adverse Experiences

Sample Size

Statistical Analysis

Results

Co-Primary Outcomes

Secondary Outcomes

Adverse Experiences

Dr. Alex Jimenez’s Insight

Discussion

Conclusions

Acknowledgments

Footnotes

Contributor Information

Additional Topics: Back Pain

Blank

References

Close Accordion

What is Stress?

What are the Signs and Symptoms of Stress?

How can Stress Impact Health?

Chiropractic for Stress Management

Mindfulness Interventions in Physical Rehabilitation: A Scoping Review

Abstract

Method

Results

Common Mindfulness Interventions

Targets of Mindfulness Interventions

Dr. Alex Jimenez’s Insight

Discussion

Implications for Occupational Therapy Practice

Acknowledgments

Footnotes

Contributor Information

Additional Topics: Back Pain

Blank

References

Close Accordion

What Causes Stress?

How Can Chiropractic Care Help?

Mindfulness-Based Stress Reduction for Low Back Pain: A Systematic Review

Abstract