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Stress

Back Clinic Stress And Anxiety Chiropractic Functional Medicine Team. People experience stress and anxiety from time to time. Stress is any demand placed on our brain or physical body. People can report feeling stressed with multiple demands placed on them. It can be triggered by an event that makes one feel frustrated or nervous. Anxiety is a feeling of fear, worry, or unease. This can be a reaction, and it can also happen in people who cannot identify significant stressors and are not sure of what to do.

Stress and anxiety are not always bad. They help overcome challenges or dangerous situations. Examples of everyday anxiety include worrying about finding a job, feeling nervous before a big test, or being embarrassed in certain social situations. If there were no anxiety, there would be no motivation to do certain things that need to be done ( i.e., studying for a big test).

However, if stress and anxiety start to interfere with one’s daily life, it may indicate a much more serious issue. For example, if avoiding situations due to irrational fears, constantly worrying, or experiencing severe anxiety about traumatic event/s weeks after it happened, it may be time to seek help.

Mindfulness for Headache and Cervical Disc Herniation in El Paso, TX

Mindfulness for Headache and Cervical Disc Herniation in El Paso, TX

by | Conditions Treated, Herniated Disc, Randomized Controlled Trial, Stress, Treatments

Stress is a result of the human body’s “fight or flight” response, a prehistoric defense mechanism triggered by the sympathetic nervous system (SNS). Stress is an essential component of survival. When stressors activate the fight or flight response, a mixture of chemicals and hormones are secreted into the blood flow, which prepare the body for perceived danger. Although short-term stress is helpful, however, long-term stress can lead to a variety of health issues. Furthermore, stressors in modern society have changed and it’s become more difficult for people to manage their stress and maintain mindfulness.

 

How Does Stress Affect the Body?

 

Stress can be experienced through three different channels: emotion; body and environment. Emotional stress involves adverse situations which affect our mind and decision making. Bodily stress includes improper nutrition and a lack of sleep. And finally, environmental stress occurs based on external experiences. When you experience any of these types of stressors, the sympathetic nervous system will trigger the “fight or flight” response, releasing adrenaline and cortisol to increase heart rate and heighten our senses to make us more alert in order to face the situation ahead of us.

 

However, if perceived stressors are always present, the SNS’s fight or flight response can remain active. Chronic stress can then lead to a variety of health issues, such as anxiety, depression, muscle tension, neck and back pain, digestive problems, weight gain and sleep problems as well as impaired memory and concentration. In addition, muscle tension along the spine due to stress can cause a spinal misalignment, or subluxation, which may in turn lead to disc herniation.

 

Headache and Disc Herniation from Stress

 

A herniated disc occurs when the soft, gel-like center of an intervertebral disc pushes through a tear in its outer, cartilage ring, irritating and compressing the spinal cord and/or the nerve roots. Disc herniation commonly occurs in the cervical spine, or neck, and in the lumbar spine, or low back. Symptoms of herniated discs depend on the location of the compression along the spine. Neck pain and back pain accompanied by numbness, tingling sensations and weakness along the upper and lower extremities are some of the most common symptoms associated with disc herniation. Headache and migraine are also common symptoms associated with stress and herniated discs along the cervical spine, as a result of muscle tension and spinal misalignment.

 

Mindfulness Interventions for Stress Management

 

Stress management is essential towards improving as well as maintaining overall health and wellness. According to research studies, mindfulness interventions, such as chiropractic care and mindfulness-based stress reduction (MBSR), among others, can safely and effectively help reduce stress. Chiropractic care utilizes spinal adjustments and manual manipulations to carefully restore the original alignment of the spine, relieving pain and discomfort as well as easing muscle tension. Additionally, a chiropractor may include lifestyle modifications to help further improve symptoms of stress.�A balanced spine can help the nervous system respond to stress more effectively. MBSR can also help reduce stress, anxiety and depression.

 

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If you are experiencing symptoms of stress with headache or migraine as well as neck and back pain associated with disc herniation, mindfulness interventions such as chiropractic care can be a safe and effective treatment for your stress. Dr. Alex Jimenez’s stress management services can help you achieve overall health and wellness. Seeking the proper mindfulness interventions can get you the relief you deserve. The purpose of the following article is to demonstrate the effects of mindfulness-based stress reduction in patients with tension headache. Don’t just treat the symptoms, get to the source of the issue.

 

Effects of Mindfulness-Based Stress Reduction on Perceived Stress and Psychological Health in Patients with Tension Headache

 

Abstract

 

Background: Programs for improving health status of patients with illness related to pain, such as headache, are often still in their infancy. Mindfulness-based stress reduction (MBSR) is a new psychotherapy that appears to be effective in treating chronic pain and stress. This study evaluated efficacy of MBSR in treatment of perceived stress and mental health of client who has tension headache.

 

Materials and Methods: This study is a randomized clinical trial. Sixty patients with tension type headache according to the International Headache Classification Subcommittee were randomly assigned to the Treatment As Usual (TAU) group or experimental group (MBSR). The MBSR group received eight weekly classmates with 12-min sessions. The sessions were based on MBSR protocol. The Brief Symptom Inventory (BSI) and Perceived Stress Scale (PSS) were administered in the pre- and posttreatment period and at 3 months follow-up for both the groups.

 

Results: The mean of total score of the BSI (global severity index; GSI) in MBSR group was 1.63 � 0.56 before the intervention that was significantly reduced to 0.73 � 0.46 and 0.93 � 0.34 after the intervention and at the follow-up sessions, respectively (P < 0.001). In addition, the MBSR group showed lower scores in perceived stress in comparison with the control group at posttest evaluation. The mean of perceived stress before the intervention was 16.96 � 2.53 and was changed to 12.7 � 2.69 and 13.5 � 2.33 after the intervention and at the follow-up sessions, respectively (P < 0.001). On the other hand, the mean of GSI in the TAU group was 1.77 � 0.50 at pretest that was significantly reduced to 1.59 � 0.52 and 1.78 � 0.47 at posttest and follow-up, respectively (P < 0.001). Also, the mean of perceived stress in the TAU group at pretest was 15.9 � 2.86 and that was changed to 16.13 � 2.44 and 15.76 � 2.22 at posttest and follow-up, respectively (P < 0.001).

 

Conclusion: MBSR could reduce stress and improve general mental health in patients with tension headache.

 

Keywords: Mental health, tension headache, mindfulness-based stress reduction (MBSR), perceived stress, treatment as usual (TAU)

 

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Dr. Alex Jimenez’s Insight

Chiropractic care is an effective stress management treatment because it focuses on the spine, which is the base of the nervous system. Chiropractic utilizes spinal adjustments and manual manipulations to carefully restore the alignment of the spine in order to allow the body to naturally heal itself. A spinal misalignment, or subluxation, can create muscle tension along the spine and lead to a variety of health issues, including headache and migraine, as well as disc herniation and sciatica. Chiropractic care can also include lifestyle modifications, such as nutritional advice and exercise recommendations, to further enhance its effects. Mindfulness-based stress reduction can also effectively help with stress management and symptoms.

 

Introduction

 

Tension headache constitutes 90% of total headaches. About 3% of the population are suffering from chronic tension headache.[1] Tension headaches are often associated with lower quality of life and high levels of psychological discomforts.[2] In recent years, several meta-analyses evaluating the established pain treatments used today have shown that medical treatments, which may be effective in acute pain, are not effective with chronic pain and may, in fact, be causing further problems. Most of the pain treatments are designed for and useful for acute pain but if used in the long run may create more problems such as substance abuse and avoidance of important activities.[3] A common element in most of the pain treatments is that they emphasize on either avoiding pain or fighting to reduce pain. The pain in tension headache can be intolerable. Painkillers and pain management strategies can increase intolerance and sensitivity to pain. Therefore, the treatments that increase acceptance and tolerance to pain, especially chronic pain, are effective. Mindfulness-based stress reduction (MBSR) is a new psychotherapy that appears to be effective in improving physical performance and psychological well-being in patients with chronic pain.[4,5,6,7,8] In the past two decades, Kabat-Zinn et al. in the US successfully used mindfulness for the relief of pain and illness related to pain.[9] Recent studies on acceptance-based methods, such as mindfulness, show improved performance in patients with chronic pain. Mindfulness modulates the pain using nonelaborative awareness of thoughts, feelings and sensations, and an emotionally distanced relationship with internal and external experience.[10] Studies found that MBSR program can significantly alleviate medical illness related to chronic pains such as fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, chronic low back pain, and multiple sclerosis.[7,11,12,13] MBSR has significant changes in pain intensity, anxiety, depression, somatic complaints, well-being, adaptation, quality of sleep, fatigue, and physical functioning.[6,14,15,16,17] But the programs for improving health status of patients with illness related to pain, such as tension headache, are often still in their infancy. Therefore, the study was conducted to assess the effects of MBSR on perceived stress and general mental health in patients with tension headache.

 

Materials and Methods

 

This randomized controlled clinical trial was performed in 2012 in Shahid Beheshti Hospital in Kashan City. The Research Ethics Committee of the Kashan University of Medical Sciences approved this study (IRCT No: 2014061618106N1). The participants of the study included adults with tension headache who were referred by the psychiatrists and neurologists in Kashan. The inclusion criteria were as follows: Having tension headache according to the International Headache Classification Subcommittee, willing to participate in the study, not having a medical diagnosis of organic brain disorder or psychotic disorder, and not having a history of psychological treatment during the preceding 6 months. The patients who did not complete the intervention and missed more than two sessions were excluded from the study. The participants, who signed an informed consent form, completed the measures as a pretest. For estimating the sample size, we referred to another study in which changes in mean of scores of fatigue was 62 � 9.5 in the pretreatment period and 54.5 � 11.5 in the posttreatment period.[18] Then, by utilizing the sample size calculation, 33 participants (with attrition risk) in each group with ? = 0.95 and 1 � ? = 0.9 were segregated. After sample size calculation, 66 patients with tension headache were selected via convenient sampling according to the inclusion criteria. Then, the patients were called and invited to participate in the study. If a patient agreed to participate, then he/she was invited to attend the study-briefing session and if not another patient was selected similarly. Then using a random number table, they were assigned either to the experimental group (MBSR) or to the control group that treated as usual. Finally, 3 patients were excluded from each group and 60 patients were included (30 patients in each group). The TAU group was treated only by antidepressant medication and clinical management. The MBSR group received MBSR training in addition to TAU. The patients in MBSR group were trained for 8 weeks by a clinical psychologist with PhD degree. The Brief Symptom Inventory (BSI) and Perceived Stress Scale (PSS) were administered before the first treatment session in the MBSR group, after the eighth session (posttest), and 3 months after the test (follow-up) in both groups. The TAU group was invited to Shahid Beheshti Hospital to fill out the questionnaires. Figure 1 shows a Consolidated Standards of Reporting Trials (CONSORT) diagram depicting the flow of study participants.

 

Figure 1 CONSORT Diagram Depicting Flow of Study Participants

Figure 1: CONSORT diagram depicting flow of study participants.

 

Intervention

 

The intervention group (MBSR) was trained in Shahid Beheshti Hospital. The eight weekly sessions (120 min) were held according to the standard MBSR protocol as developed by Kabat-Zinn.[11] Additional sessions were held for the participants who had missed one or two sessions. At the end of the training and 3 months later (follow-up), both MBSR and TAU groups were invited to Shahid Beheshti Hospital (the place of MBSR trial) and were instructed to complete the questionnaires. During the MBSR sessions, the participants were trained to be aware of their thoughts, feelings, and physical sensations nonjudgmentally. Mindfulness exercises are taught as two forms of meditation practices � formal and informal. Formal type exercises include trained sitting meditation, body scan, and mindful yoga. In informal meditation, attention and awareness are focused not only on daily activities, but also on thoughts, feelings, and physical sensation even they are problematic and painful. The overall content of the sessions were mentioned in Table 1.

 

Table 1 Agendas for Sessions of MBSR

Table 1: Agendas for sessions of mindfulness-based stress reduction.

 

Measurement Tools

 

International Headache Classification Subcommittee Diary Scale for Headache

 

Headache was measured by diary scale for headache.[19] The patients were asked to record the pain severity diary on a 0-10 rating scale. Absence of pain and the most intense disabling headache were characterized by 0 and 10, respectively. The mean of headache severity in a week was calculated by dividing the sum of the severity scores by 7. Moreover, the mean of headache severity in a month was calculated by dividing the sum of the severity scores by 30. The minimum and maximum scores of headache severity were 0 and 10, respectively. Headache diary was given to five patients and a neurologist and a psychiatrist confirmed the content validity of the instrument.[20] The reliability coefficient of Persian version of this scale was calculated as 0.88.[20]

 

Brief symptom Inventory (BSI)

 

Psychological symptoms were assessed with the BSI.[21] The inventory consist 53 items and 9 subscales that assess psychological symptoms. Each item scores between 0 and 4 (for example: I have nausea or upset in my stomach). BSI has a global severity index (GSI) achieved a total score of 53 items. The reliability of the test has reported a score of 0.89.[22] In our study, GSI test�retest estimate was .90 based on a sample of 60 patients with tension headache who completed the BSI.

 

Perceived Stress Scale (PSS)

 

Perceived stress was assessed using the PSS,[21,23] a 10-item scale that assesses the degree of uncontrollable and unpredictable situations of life during the past month (for example: Felt that you were unable to control the important things in your life?). Respondents report the prevalence of an item within the last month on a 5-point scale, ranging from 0 (never) to 4 (very often). Scoring is completed by reverse scoring of four positively worded items[4,5,7,8] and summing all item scores. The scale scores range from 0-40. Higher scores indicate higher levels of stress. It assumes that people depending on their coping resources evaluate level of threatening or challenging events. A higher score indicates a greater degree of perceived stress. Adequate test�retest reliability and convergent and discriminate validity have also been reported.[19] In our study, Cronbach’s alpha coefficients for assessing internal consistency of this scale were calculated to be 0.88.

 

The repeated measures analysis of variance was performed to compare the MBSR and TAU groups on measures of perceived stress and GSI at pretreatment, posttreatment, and 3-month follow-up. Also, Chi-square test was used to compare the demographics in the two groups. P value less than 0.05 was considered significant in all tests.

 

Results

 

Among 66 subjects, 2 participants from the MBSR group were excluded because of missing more than 2 sessions. Also, three participants were excluded because of did not complete the questionnaires in post-test or follow-up who one of them were from MBSR group and three participants from TAU group. Table 2 showed demographic characteristics of the subjects and results of the randomization check. The results of t-test for differences between the MBSR and TAU groups in age variable and Chi-square test in other variables showed that there was no significant difference between demographic variables in two groups and the subjects were randomly assigned to two groups.

 

Table 2 Demographic Characteristics of the Subjects

Table 2: Demographic characteristics of the subjects a,b.

 

Table 3 provides the mean scores and standard deviations of the dependent variables (perceived stress and GSI) and comparison of outcome measures at pretreatment period, post-treatment period, and 3-month follow-up.

 

Table 3 Means, Standard Deviations and Comparison of Outcome Measures

Table 3: Means, standard deviations, and comparison of outcome measures at pretreatment, posttreatment, and follow-up stages in the MBSR and TAU groups a,b.

 

Table 3 shows the more reduction in received stress and GSI in the intervention group (MBSR) compared to TAU group, while the reduction in received stress and GSI were not observed in the TAU group. The results revealed the significant effect of time and interaction between time and type of treatment on the changes of scores (P < 0.001).

 

Figures ?2 and ?3 present mean received stress and GSI scores for MBSR and TAU groups at posttest and follow-up stages.

 

Figure 2 CONSORT Diagram Depicting Flow of Study Participants

Figure 2: CONSORT diagram depicting flow of study participants.

 

Figure 3 Mean of Perceived Stress in MBSR and Control Groups

Figure 3: Mean of perceived stress in MBSR and control groups in pretest, posttest, and follow-up.

 

Discussion

 

This study compared efficacy of MBSR and Treatment As Usual (TAU) in perceived stress and mental health of patients with tension headache. Although MBSR is recognized as an effective treatment for stress symptoms and pain, there is a need to examine its efficacy for the treatment of mental health problems in patients with tension headache, which is one of the common complaints in the population.

 

The findings of our study demonstrate enhanced general mental health in the GSI index of BSI. In some study, significant improvements by MBSR intervention were reported on all indexes of the 36-item Short Form Health Survey (SF-36).[20,24] Studies showed significant reduction in psychological problems in the Symptom Checklist-90-Revised (SCL-90-R) subscale such as anxiety and depression by MBSR after intervention and 1-year follow-up.[5] Reibel et al. showed MBSR in patients with chronic pain reported a decrease in medical symptoms such as anxiety, depression, and pain.[5] It has been shown that tension headache and anxiety are accompanied with deficits in controlled cognitive processing such as sustained attention and working memory.[25] Negative emotions may amplify suffering associated with pain perception.

 

MBSR implements the following mechanisms to improve the patient’s mental status: First, mindfulness leads to increased awareness for what is happening in each moment, with an accepting attitude, without getting caught up in habitual thoughts, emotions, and behavior patterns. The increased awareness then gives rise to new ways to respond and cope in relation to oneself and the world around.[3] Mindfulness establishes a sense of self that is greater than one’s thoughts, feelings, and bodily sensation such as pain. Mindfulness exercises, learned clients develop an �observer�self�. With this ability, they can observe their thoughts and feelings in a nonreactive and nonjudgmental way that previously avoided, that previously avoided thoughts and feelings be observed in a nonreactive and nonjudgmental way. The clients learn to notice thoughts without necessarily acting on them, being controlled by them, or believing them.[3]

 

Second, mindfulness helps the client develop persistence in taking steps in valued directions that are important to them. Most clients with chronic pain want to become pain free rather than living the vital lives of their choice. But the MBSR program trained them to engage in valued action despite the the pain. Studies have shown attention and emotional reaction to pain has an important role in becoming persistent the pain.[26] Emotional and cognitive components can modulate attention to pain and worry about it that could intensify pain and disrupt the patients activities.[27,28]

 

Third, findings from some studies indicate that MBSR can alter the function of the brain that is responsible for affect regulation and the areas that govern how we react to stressful impulses, and this in turn may normalize body functions such as breathing, heart rate, and immune function.[29,30] Mindfulness practice reduces reactivity to distressing thoughts and feelings that comorbid and strengthen pain perception.[31] Also mindfulness may lessen psychophysiological activation related to stress and mood dysfunction by strengthening positive reappraisal and emotion regulation skills.[32]

 

The strength of this study is the use of a new effective psychotherapy in reducing the stress on a complaint that is less studied, but it is a common medical problem. The implications of our study are using a simple psychotherapy that does not make too much cognitive demand and is readily usable as a coping skill for the patient with tension headache. Therefore, the health-care professionals related to this complaint and the patient will be able to use this treatment. Also, MBSR will change the patient’s lifestyle who would be exacerbated by his/her problem. The main limitation of this study was the lack of comparison between MBSR and the gold standard psychotherapies such as cognitive behavior therapy (CBT). It is suggested that future studies need to compare the efficacy of MBSR and other traditional and newer cognitive behavioral therapies in patients with tension headache.

 

Conclusion

 

Our study supports the hypothesis that patients suffering from tension headache can enhance their general mental health by participating in the MBSR program. In summary, the results of the present study suggest that MBSR can reduce pain-related anxiety and interference in daily activities in the short term. The unique features of mindfulness exercises are easy training and no need to complex cognitive abilities.

 

Financial support and sponsorship: Nil.

 

Conflicts of interest: There are no conflicts of interest.

 

Author’s Contribution

 

AO contributed in the conception of the work, conducting the study, and agreed for all aspects of the work. FZ contributed in the conception of the work, revising the draft, approval of the final version of the manuscript and agreed for all aspects of the work.

 

Acknowledgments

 

Authors are grateful to the staff of Shahid Beheshti Hospital and participants. Authors also express their gratitude to Kabat-Zinn from the Center for Mindfulness (CFM) at the University of Massachusetts who graciously provided electronic copies of the MBSR guidelines.

 

In conclusion,�while short-term stress is helpful, long-term stress can eventually lead to a variety of health issues, including anxiety and depression as well as neck and back pain, headache and disc herniation. Fortunately, mindfulness interventions, such as chiropractic care and mindfulness-based stress reduction (MBSR) are safe and effective stress management alternative treatment options. Finally, the article above demonstrated evidence-based results that MBSR could reduce stress and improve general mental health in patients with tension headache. 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

 

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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

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor

 

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Cognitive-Behavioral Therapy for Auto Accident Injuries in El Paso, TX

Cognitive-Behavioral Therapy for Auto Accident Injuries in El Paso, TX

by | Back Pain, Chronic Pain, Conditions Treated, Herniated Disc, Neck Pain, Physical Rehabilitation, Randomized Controlled Trial, Research Studies, Stress, Treatments

Being involved in an automobile accident is an undesirable situation which can result in a variety of physical trauma or injury as well as lead to the development of a number of aggravating conditions. Auto accident injuries, such as whiplash, can be characterized by painful symptoms, including chronic neck pain, however, recent research studies have found that emotional distress resulting from an auto collision could manifest into physical symptoms. Stress, anxiety, depression and post traumatic stress disorder, or PTSD, are common psychological issues which may occur as a result of an automobile accident.

 

The researchers of the research studies also determined that cognitive-behavioral therapy may be an effective treatment for emotional distress and psychological issues which may have developed as a result of the auto accident injuries. Additionally, auto accident injuries may also cause stress, anxiety, depression and even PTSD if left untreated for an extended amount of time. The purpose of the article below is to demonstrate the effects of cognitive-behavioral therapy, together with alternative treatment options like chiropractic care and physical therapy. for auto accident injuries, such as whiplash.

 

Neck Exercises, Physical and Cognitive Behavioural-Graded Activity as a Treatment for Adult Whiplash Patients with Chronic Neck Pain: Design of a Randomised Controlled Trial

 

Abstract

 

Background

 

Many patients suffer from chronic neck pain following a whiplash injury. A combination of cognitive, behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders. The objective is to present the design of a randomised controlled trial (RCT) aimed at evaluating the effectiveness of a combined individual physical and cognitive behavioural-graded activity program on self-reported general physical function, in addition to neck function, pain, disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline.

 

Methods/Design

 

The design is a two-centre, RCT-study with a parallel group design. Included are whiplash patients with chronic neck pain for more than 6 months, recruited from physiotherapy clinics and an out-patient hospital department in Denmark. Patients will be randomised to either a pain management (control) group or a combined pain management and training (intervention)group. The control group will receive four educational sessions on pain management, whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months, including guidance in specific neck exercises and an aerobic training programme. Patients and physiotherapists are aware of the allocation and the treatment, while outcome assessors and data analysts are blinded. The primary outcome measures will be Medical Outcomes Study Short Form 36 (SF36), Physical Component Summary (PCS). Secondary outcomes will be Global Perceived Effect (-5 to +5), Neck Disability Index (0-50), Patient Specific Functioning Scale (0-10), numeric rating scale for pain bothersomeness (0-10), SF-36 Mental Component Summary (MCS), TAMPA scale of Kinesiophobia (17-68), Impact of Event Scale (0-45), EuroQol (0-1), craniocervical flexion test (22 mmHg – 30 mmHg), joint position error test and cervical range of movement. The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a standard deviation of 10.

 

Discussion

 

The perspectives of this study are discussed, in addition to the strengths and weaknesses.

 

Trial registration

 

The study is registered in www.ClinicalTrials.gov identifier NCT01431261.

 

Background

 

The Danish National Board of Health estimates that 5-6,000 subjects per year in Denmark are involved in a traffic accident evoking whiplash-induced neck pain. About 43% of those will still have physical impairment and symptoms 6 months after the accident [1]. For Swedish society, including Swedish insurance companies, the economic burden is approximately 320 million Euros [2], and this burden is likely to be comparable to that of Denmark. Most studies suggest that patients with Whiplash-Associated Disorders (WAD) report chronic neck symptoms one year after the injury [3]. The main problems in whiplash patients with chronic neck pain are cervical dysfunction and abnormal sensory processing, reduced neck mobility and stability, impaired cervicocephalic kinaesthetic sense, in addition to local and possibly generalised pain [4,5]. Cervical dysfunction is characterised by reduced function of the deep stabilising muscles of the neck.

 

Besides chronic neck pain, patients with WAD may suffer from physical inactivity as a consequence of prolonged pain [6,7]. This influences physical function and general health and can result in a poor quality of life. In addition, WAD patients may develop chronic pain followed by sensitisation of the nervous system [8,9], a lowering of the threshold for different sensory inputs (pressure, cold, warm, vibration and electrical impulses) [10]. This can be caused by an impaired central pain inhibition [11] – a cortical reorganisation [12]. Besides central sensitisation, the group with WAD may have poorer coping strategies and cognitive functions, compared with patients with chronic neck pain in general [13-15].

 

Studies have shown that physical training, including specific exercises targeting the deep postural muscles of the cervical spine, is effective in reducing neck pain [16-18] for patients with chronic neck pain, albeit there is a variability in the response to training with not every patient showing a major change. Physical behavioural-graded activity is a treatment approach with a focus on increasing general physical fitness, reducing fear of movement and increasing psychological function [19,20]. There is insufficient evidence for the long-term effect of treatment of physical and cognitive behavioural-graded activity, especially in chronic neck pain patients. Educational sessions, where the focus is on understanding complex chronic pain mechanisms and development of appropriate pain coping and/or cognitive behavioural strategies, have shown reduced general pain [6,21-26]. A review indicated that interventions with a combination of cognitive, behavioural therapy with physiotherapy including neck exercises is effective in the management of WAD patients with chronic neck pain [27], as also recommended by the Dutch clinical guidelines for WAD [28]. However, the conclusions regarding the guidelines are largely based on studies performed on patients with either acute or sub-acute WAD [29]. A more strict conclusion was drawn for WAD patients with chronic pain in the Bone and Joint Decade 2000-2010 Task Force, stating, that ‘because of conflicting evidence and few high-quality studies, no firm conclusions could be drawn about the most effective non-invasive interventions for patients with chronic WAD” [29,30]. The concept of combined treatment for WAD patients with chronic pain has been used in a former randomised controlled trial [31]. The results indicated that a combination of non-specific aerobic exercises and advice containing standardised pain education and reassurance and encouragement to resume light activity, produced better outcomes than advice alone for patients with WAD 3 months after the accident. The patients showed improvements in pain intensity, pain bothersomeness and functions in daily activities in the group receiving exercise and advice, compared with advice alone. However, the improvements were small and only apparent in the short term.

 

This project is formulated on the expectation that rehabilitation of WAD patients with chronic neck pain must target cervical dysfunctions, training of physical function and the understanding and management of chronic pain in a combined therapy approach. Each single intervention is based upon former studies that have shown effectiveness [6,18,20,32]. This study is the first to also include the long-term effect of the combined approach in patients with chronic neck pain after whiplash trauma. As illustrated in Figure ?Figure1,1, the conceptual model in this study is based upon the hypothesis that training (including both individually-guided specific neck exercises and graded aerobic training) and education in pain management (based on a cognitive behavioural approach) is better for increasing the patients’ physical quality of life, compared with education in pain management alone. Increasing the physical quality of life includes increasing the general physical function and level of physical activity, decreasing fear of movement, reducing post-traumatic stress symptoms, reducing neck pain and increasing neck function. The effect is anticipated to be found immediately after the treatment (i.e. 4 months; short-term effect) as well as after one year (long-term effect).

 

Figure 1 Hypothesis of the Intervention Effect

Figure 1: Hypothesis of the intervention effect for patients with chronic neck pain after a whiplash accident.

 

Using a randomised controlled trial (RCT) design, the aim of this study is to evaluate the effectiveness of: graded physical training, including specific neck exercises and general aerobic training, combined with education in pain management (based on a cognitive behavioural approach) versus education in pain management (based on a cognitive behavioural approach), measured on physical quality of life’, physical function, neck pain and neck functions, fear of movement, post-traumatic symptoms and mental quality of life, in patients with chronic neck pain after whiplash injury.

 

Methods/Design

 

Trial Design

 

The study is conducted in Denmark as an RCT with a parallel group design. It will be a two-centre study, stratified by recruitment location. Patients will be randomised to either the Pain Management group (control) or the Pain Management and Training group (intervention). As illustrated in Figure ?Figure2,2, the study is designed to include a secondary data assessment 12 months after baseline; the primary outcome assessment will be performed immediately after the intervention program 4 months after baseline. The study utilises an allocation concealment process, ensuring that the group to which the patient is allocated is not known before the patient is entered into the study. The outcome assessors and data analysts will be kept blinded to the allocation to intervention or control group.

 

Figure 2 Flowchart of the Patients in the Study

Figure 2: Flowchart of the patients in the study.

 

Settings

 

The participants will be recruited from physiotherapy clinics in Denmark and from The Spine Centre of Southern Denmark, Hospital Lilleb�lt via an announcement at the clinics and the Hospital. Using physiotherapy clinics spread across Denmark, the patients will receive the intervention locally. The physiotherapy clinics in Denmark receive patients via referral from their general practitioners. The Spine Centre, a unit specialising in treating patients with musculoskeletal dysfunctions and only treating out-patients, receives patients referred from general practitioners and/or chiropractors.

 

Study Population

 

Two hundred adults with a minimum age of 18 years, receiving physiotherapy treatment or having been referred for physiotherapy treatment will be recruited. For patients to be eligible, they must have: chronic neck pain for at least 6 months following a whiplash injury, reduced physical neck function (Neck Disability Index score, NDI, of a minimum of 10), pain primarily in the neck region, finished any medical /radiological examinations, the ability to read and understand Danish and the ability to participate in the exercise program. The exclusion criteria include: neuropathies/ radiculopathies (clinically tested by: positive Spurling, cervical traction and plexus brachialis tests) [33], neurological deficits (tested as in normal clinical practice through a process of examining for unknown pathology), engagement in experimental medical treatment, being in an unstable social and/or working situation, pregnancy, known fractures, depression according to the Beck Depression Index (score > 29) [18,34,35], or other known coexisting medical conditions which could severely restrict participation in the exercise program. The participants will be asked not to seek other physiotherapy or cognitive treatment during the study period.

 

Intervention

 

Control

 

The Pain Management (control) group will receive education in pain management strategies. There will be 4 sessions of 11/2 hours, covering topics regarding pain mechanisms, acceptance of pain, coping strategies, and goal-setting, based upon pain management and cognitive therapy concepts [21,26,36].

 

Intervention

 

The Pain Management plus Training (intervention) group will receive the same education in pain management as those in the control group plus 8 treatment sessions (instruction in neck exercises and aerobic training) with the same period of 4 months length. If the treating physiotherapist estimates additional treatments are needed, the treatment can be extended with 2 more sessions. Neck training: The treatment of neck-specific exercises will be progressed through different phases, which are defined by set levels of neck function. At the first treatment session, patients are tested for cervical neuromuscular function to identify the specific level at which to start neck training. A specific individually tailored exercise program will be used to target the neck flexor and extensor muscles. The ability to activate the deep cervical neck flexor muscles of the upper cervical region to increase their strength, endurance and stability function is trained progressively via the craniocervical training method using a biopressure feedback transducer [18,37]. Exercises for neck-eye coordination, neck joint positioning, balance and endurance training of the neck muscles will be included as well, since it has been shown to reduce pain and improve sensorimotor control in patients with insidious neck pain [17,38]. Aerobic training: The large trunk and leg muscles will be trained with a gradually increasing physical training program. Patients will be allowed to select activities such as walking, cycling, stick walking, swimming, and jogging. The baseline for training duration is set by exercising 3 times at a comfortable level, that does not exacerbate pain and aims at a rated perceived exertion (RPE) level of between 11 and 14 on a Borg scale [39]. The initial duration of training is set 20% below the average time of the three trials. Training sessions are carried out every second day with a prerequisite that pain is not worsened, and that RPE is between 9 and 14. A training diary is used. If patients do not experience a relapse, and report an average RPE value of 14 or less, the exercise duration for the following period (1 or 2 weeks) is increased by 2-5 minutes, up to a maximum of 30 minutes. If the RPE level is 15 or higher, the exercise duration will be reduced to an average RPE score of 11 to 14 every fortnight [20,40]. By using these pacing principles, the training will be graded individually by the patient, with a focus on perceived exertion – with the aim of increasing the patient’ s general physical activity level and fitness.

 

Patients’ compliance will be administered by registration of their participation in the control and intervention group. The patients in the control group will be considered to have completed the pain management if they have attended 3 out of 4 sessions. The patiesnts in the intervention group will be considered to have completed if the patient has attended a minimum of 3 out of 4 pain management sessions and a minimum of 5 out of 8 trainings sessions. Each patient’s home training with neck exercises and aerobic training will be registered by him/her in a logbook. Compliance with 75% of the planned home training will be considered as having completed the intervention.

 

Physiotherapists

 

The participating physiotherapists will be recruited via an announcement in the Danish Physiotherapy Journal. The inclusion criteria consist of: being a qualified physiotherapist, working at a clinic and having at least two years of working experience as a physiotherapist, having attended a course in the described intervention and passed the related exam.

 

Outcome Measures

 

At baseline the participants’ information on age, gender, height and weight, type of accident, medication, development of symptoms over the last two months (status quo, improving, worsening), expectation of treatment, employment and educational status will be registered. As a primary outcome measure, Medical Outcomes Study Short Form 36 (SF36) – Physical Component Summary (PCS) will be used [41,42]. The PCS scales are scored using norm-based methods [43,44] with a mean score of 50 with a standard deviation of 10. The primary outcome with respect to having an effect, will be calculated as a change from baseline [45]. Secondary outcomes contain data on both clinical tests and patient-reported outcomes. Table ?Table11 presents clinical tests for measuring the intervention effect on neuromuscular control of the cervical muscles, cervical function and mechanical allodynia. Table ?Table22 presents the patient-related outcomes from questionnaires used to test for perceived effect of the treatment, neck pain and function, pain bothersomeness, fear of movement, post-traumatic stress and quality of life and potential treatment modifiers.

 

Table 1 Clinical Outcomes Used for Measurement of Treatment Effect

Table 1: Clinical outcomes used for measurement of treatment effect on muscle strategy, function and treatment modifiers.

 

Table 2 Patient Reported Outcomes Used for Measured of Treatment Effect

Table 2: Patient reported outcomes used for measured of treatment effect on pain and function.

 

Patients will be tested at baseline, 4 and 12 months after baseline, except for GPE, which will only be measured 4 and 12 months after baseline.

 

Power and Sample Size Estimation

 

The power and sample size calculation is based on the primary outcome, being SF36-PCS 4 months after baseline. For a two-sample pooled t-test of a normal mean difference with a two-sided significance level of 0.05, assuming a common SD of 10, a sample size of 86 per group is required to obtain a power of at least 90% to detect a group mean difference of 5 PCS points [45]; the actual power is 90.3%, and the fractional sample size that achieves a power of exactly 90% is 85.03 per group. In order to adjust for an estimated 15% withdrawal during the study period of 4 months, we will include 100 patients in each group. For sensitivity, three scenarios were applied: firstly, anticipating that all 2 � 100 patients complete the trial, we will have sufficient power (> 80%) to detect a group mean difference as low as 4 PCS points; secondly, we will be able to detect a statistically significant group mean difference of 5 PCS points with sufficient power (> 80%) even with a pooled SD of 12 PCS points. Thirdly and finally, if we aim for a group mean difference of 5 PCS points, with a pooled SD of 10, we will have sufficient power (> 80%) with only 64 patients in each group. However, for logistical reasons, new patients will no longer be included in the study 24 months after the first patient has been included.

 

Randomisation, Allocation and Blinding Procedures

 

After the baseline assessment, the participants are randomly assigned to either the control group or the intervention group. The randomisation sequence is created using SAS (SAS 9.2 TS level 1 M0) statistical software and is stratified by centre with a 1:1 allocation using random block sizes of 2, 4, and 6. The allocation sequence will be concealed from the researcher enrolling and assessing participants in sequentially numbered, opaque, sealed and stapled envelopes. Aluminium foil inside the envelope will be used to render the envelope impermeable to intense light. After revealing the content of the envelope, both patients and physiotherapists are aware of the allocation and the corresponding treatment. Outcome assessors and data analysts are however kept blinded. Prior to the outcome assessments, the patients will be asked by the research assistant not to mention the treatment to which they have been allocated.

 

Statistical Analysis

 

All the primary data analyses will be carried out according to a pre-established analysis plan; all analyses will be done applying SAS software (v. 9.2 Service Pack 4; SAS Institute Inc., Cary, NC, USA). All descriptive statistics and tests are reported in accordance with the recommendations of the ‘Enhancing the QUAlity and Transparency Of health Research’ (EQUATOR) network; i.e., various forms of the CONSORT statement [46]. Data will be analysed using a two-factor Analysis of Covariance (ANCOVA), with a factor for Group and a factor for Gender, using the baseline value as covariate to reduce the random variation, and increase the statistical power. Unless stated otherwise, results will be expressed as the difference between the group means with 95% confidence intervals (CIs) and associated p-values, based on a General Linear Model (GLM) procedure. All the analyses will be performed using the Statistical Package for Social Sciences (version 19.0.0, IBM, USA) as well as the SAS system (v. 9.2; SAS Institute Inc., Cary, NC, USA). A two-way analysis of variance (ANOVA) with repeated measures (Mixed model) will be performed to test the difference over time between the intervention and the control groups; interaction: Group � Time. An alpha-level of 0.05 will be considered as being statistically significant (p < 0.05, two- sided). The data analysts will be blinded to the allocated interventions for primary analyses.

 

The baseline scores for the primary and secondary outcomes will be used to compare the control and intervention groups. The statistical analyses will be performed on the basis of the intention-to-treat principle, i.e. patients will be analysed in the treatment group to which they were randomly allocated. In the primary analyses, missing data will be replaced with the feasible and transparent ‘Baseline Observation Carried Forward’ (BOCF) technique, and for sensitivity also a multiple imputation technique will apply.

 

Secondarily, to relate the results to compliance, a ‘per protocol’ analysis will be used as well. The ‘per protocol’ population he patients who have ‘completed’ the intervention to which they were allocated, according to the principles described in the intervention section above.

 

Ethical Considerations

 

The Regional Scientific Ethical Committee of Southern Denmark approved the study (S-20100069). The study conformed to The Declaration of Helsinki 2008 [47] by fulfilling all general ethical recommendations.

 

All subjects will receive information about the purpose and content of the project and give their oral and written consent to participate, with the possibility to drop out of the project at any time.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Managing stress, anxiety, depression and symptoms of post traumatic stress disorder, or PTSD, after being involved in an automobile accident can be difficult, especially if the incident caused physical trauma and injuries or aggravated a previously existing condition. In many cases, the emotional distress and the psychological issues caused by the incident may be the source of the painful symptoms. In El Paso, TX, many veterans with PTSD visit my clinic after manifesting worsening symptoms from a previous auto accident injury. Chiropractic care can provide patients the proper stress management environment they need to improve their physical and emotional symptoms. Chiropractic care can also treat a variety of auto accident injuries, including whiplash, head and neck injuries, herniated disc and back injuries.

 

Discussion

 

This study will contribute to a better understanding of treating patients with chronic neck pain following a whiplash accident. The knowledge from this study can be implemented into clinical practice, as the study is based on a multimodal approach, mirroring the approach, which in spite of the current lack of evidence, is often used in a clinical physiotherapy setting. The study may also be included in systematic reviews thereby contributing to updating the knowledge about this population and to enhancing evidence-based treatment.

 

Publishing the design of a study before the study is performed and the results obtained has several advantages. It allows the design to be finalised without its being influenced by the outcomes. This can assist in preventing bias as deviations from the original design can be identified. Other research projects will have the opportunity to follow a similar approach with respect to population, interventions, controls and outcome measurements. The challenges of this study are related to standardising the interventions, treating a non-homogeneous population, defining and standardising relevant outcome measures on a population with long-lasting symptoms and having a population from two different clinical settings. Standardisation of the interventions is obtained by teaching the involved physiotherapists in an instructional course. Population homogeneity will be handled by strict inclusion and exclusion criteria and by monitoring the baseline characteristics of the patients, and differences between groups based on other influences than the intervention/control will be possible to analyse statistically. This research design is composed as an ‘add-on’ design: both groups receive pain education; the intervention group receives additional physical training, including specific neck exercises and general training. Today there is insufficient evidence for the effect of treatment for patients with chronic neck pain following a whiplash accident. All participating patients will be referred for a treatment (control or intervention), as we consider it unethical not to offer some form of treatment, i.e. randomising the control group to a waiting list. The add-on design is chosen as a pragmatic workable solution in such a situation [48].

 

For whiplash patients with chronic pain, the most responsive disability measures (for the individual patient, not for the group as a whole) are considered to be the Patient Specific Functional Scale and the numerical rating scale of pain bothersomeness [49]. By using these and NDI (the most often used neck disability measure) as secondary outcome measures, it is anticipated that patient-relevant changes in pain and disability can be evaluated. The population will be recruited from and treated at two different clinical settings: the out-patient clinic of The Spine Centre, Hospital Lilleb�lt and several private physiotherapy clinics. To avoid any influence of the different settings on the outcome measures, the population will be block randomised related to the settings, securing equal distribution of participants from each setting to the two intervention groups.

 

Competing Interests

 

The authors declare that they have no competing interests.

 

Authors’ Contributions

 

IRH drafted the manuscript. IRH, BJK and KS participated in the design of the study. All contributed to the design. RC, IRH; BJK and KS participated in the power and sample size calculation and in describing the statistical analysis as well as the allocation and randomization procedure. All authors read and approved the final manuscript. Suzanne Capell provided writing assistance and linguistic corrections.

 

Pre-Publication History

 

The pre-publication history for this paper can be accessed here: www.biomedcentral.com/1471-2474/12/274/prepub

 

Acknowledgements

 

This study has received funding from the Research Fund for the Region of Southern Denmark, the Danish Rheumatism Association, the Research Foundation of the Danish Association of Physiotherapy, the Fund for Physiotherapy in Private Practice, and the Danish Society of Polio and Accident Victims (PTU). The Musculoskeletal Statistics Unit at the Parker Institute is supported by grants from the Oak Foundation. Suzanne Capell provided writing assistance and linguistic correction.

 

The trial is registered in www.ClinicalTrials.gov identifier NCT01431261.

 

A Randomized Controlled Trial of Cognitive-Behavioral Therapy for the Treatment of PTSD in the context of Chronic Whiplash

 

Abstract

 

Objectives

 

Whiplash-associated disorders (WAD) are common and involve both physical and psychological impairments. Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes. Trauma-focused cognitive-behavioral therapy (TF-CBT) has shown moderate effectiveness in chronic pain samples. However, to date, there have been no clinical trials within WAD. Thus, this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder (PTSD).

 

Method

 

Twenty-six participants were randomly assigned to either TF-CBT or a waitlist control, and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview, self-report questionnaires, and measures of physiological arousal and sensory pain thresholds.

 

Results

 

Clinically significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at postassessment, with further gains noted at the follow-up. The treatment of PTSD was also associated with clinically significant improvements in neck disability, physical, emotional, and social functioning and physiological reactivity to trauma cues, whereas limited changes were found in sensory pain thresholds.

 

Discussion

 

This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD. The finding that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD. Clinical implications of the findings and future research directions are discussed.

 

In conclusion, being involved in an automobile accident is an undesirable situation which can result in a variety of physical trauma or injury as well as lead to the development of a number of aggravating conditions. However, stress, anxiety, depression and post traumatic stress disorder, or PTSD, are common psychological issues which may occur as a result of an automobile accident. According to research studies, physical symptoms and emotional distress may be closely connected and treating both physical and emotional injuries could help patients achieve overall health and wellness. 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

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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

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor

 

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Mindfulness Interventions for Auto Accident Injuries in El Paso, TX

Mindfulness Interventions for Auto Accident Injuries in El Paso, TX

by | Back Pain, Chiropractic, Neck Pain, Physical Rehabilitation, Randomized Controlled Trial, Stress, Treatments

When you’ve been involved in a car crash, the auto accident injuries resulting from the incident may not always have a physical cause. The emotional distress due to trauma or injury from the impact of an automobile accident may often be so immense, it can lead to a variety of painful symptoms. If such stress is not treated immediately, it could result in the development of psychological conditions. Stress, anxiety, depression and in severe cases, PTSD, or post traumatic stress disorder, are some of the most common psychological issues you may end up encountering after a traumatic auto accident.

 

Anxiety and Irrational Fears

 

In several cases, the victim of an automobile accident may develop irrational fears as a result of the incident. As a matter of fact, many of these individuals report experiencing anxiety about getting behind the wheel again. For them, the fear of being in another accident may ultimately cause them to avoid driving altogether. For many other individuals still, the irrational fear of suffering a panic attack while on the road may be the cause for them to avert driving entirely. If the anxiety and irrational fears caused by the emotional distress of an auto accident worsen, it may permanently�discourage a person from driving again.

 

Depression

 

It is also possible for people who’ve been involved in an auto accident to develop depression following the incident. In the end, you wind up experiencing psychological trauma as a result of physical trauma. There are numerous symptoms of depression which you might readily recognize. These include problems with sleep, losing your appetite, and headaches. As it becomes worse, however, you might end up feeling sad or hopeless all of the time, which could lead to worsening symptoms.

 

Post Traumatic Stress Disorder (PTSD)

 

It’s highly possible for individuals involved in an automobile accident to suffer from post traumatic stress disorder, or PTSD. According to the National Center For PTSD, as much as 9 percent of people who experience auto accident injuries end up suffering from PTSD. Moreover, at least 14 percent of car crash survivors who seek mental health care are experiencing PTSD.

 

A new research study demonstrated that mindfulness interventions might be just as essential to your health as traditional treatment, especially if you’ve got post traumatic stress disorder, or PTSD. Researchers have demonstrated that chiropractic care can lead to a substantial advancement in the mind-body stress component of a patient’s overall health and wellness.

 

 

Chiropractic Care for Auto Accident Injuries

 

Addressing automobile accident injuries, such as whiplash, which also result in anxiety and irrational fears, depression and especially PTSD, demands a multi-disciplinary strategy. Chiropractic is an alternative treatment option which focuses on injuries and/or conditions of the musculoskeletal and nervous system. A chiropractor commonly utilizes spinal adjustments and manual manipulations to carefully correct spinal misalignments, or subluxations, which could be causing pain and discomfort. By releasing pressure and muscle tension, a doctor of chiropractic, or chiropractor, can help reduce stress and emotional distress which could be causing the individual’s anxiety, irrational fears, depression and PTSD. If further help is required, the chiropractor can recommend patients to the best healthcare specialist to help them with their symptoms. The purpose of the following article is to demonstrate the prevalence of PTSD on individuals involved in a traffic collision as well as to show how mindfulness interventions can ultimately help improve as well as manage the stress symptoms people may experience after a car crash.

 

Prediction of Post Traumatic Stress Disorder by Immediate Reactions to Trauma: a Prospective Study in Road Traffic Accident Victims

 

Abstract

 

Road traffic accidents often cause serious physical and psychological sequelae. Specialists of various medical faculties are involved in the treatment of accident victims. Little is known about the factors which might predict psychiatric disorders, e.g. Posttraumatic Stress Disorder (PTSD) after accidents and how psychological problems influence physical treatment. In a prospective study 179 unselected, consecutively admitted road traffic accident victims were assessed a few days after the accident for psychiatric diagnoses, severity of injury and psychopathology. All were inpatients and had to be treated for bone fractures. At 6-months follow-up assessment 152 (85%) of the patients were interviewed again. Of the patients, 18.4% fulfilled the criteria for Posttraumatic Stress Disorder (DSM-III-R) within 6 months after the accident. Patients who developed PTSD were injured more severely and showed more symptoms of anxiety, depression and PTSD a few days after the accident than patients with no psychiatric diagnosis. Patients with PTSD stayed significantly longer in the hospital than the other patients. Multiple regression analysis revealed that the length of hospitalization was due mainly to a diversity of factors such as severity of injury, severity of accident, premorbid personality and psychopathology. Posttraumatic stress disorder is common after road traffic accidents. Patients with PTSD at follow-up can be identified by findings from early assessment. Untreated psychological sequelae such as PTSD cause longer hospitalization and therefore more costs than in non-PTSD patients.

 

 

Trauma-Focused Cognitive Behavior Therapy and Exercise for Chronic Whiplash: Protocol of a Randomized Controlled Trial

 

Abstract

 

  • Introduction:�As a consequence of a road traffic crash, persistent pain and disability following whiplash injury are common and incur substantial personal and economic costs. Up to 50% of people who experience a whiplash injury will never fully recover and up to 30% will remain moderately to severely disabled by the condition. The reason as to why symptoms persist past the acute to sub-acute stage and become chronic is unclear, but likely results from complex interactions between structural injury, physical impairments, and psychological and psychosocial factors. Psychological responses related to the traumatic event itself are becoming an increasingly recognised factor in the whiplash condition. Despite this recognition, there is limited knowledge regarding the effectiveness of psychological interventions, either delivered alone or in combination with physiotherapy, in reducing the physical and pain-related psychological factors of chronic whiplash. Pilot study results have shown positive results for the use of trauma-focused cognitive behaviour therapy to treat psychological factors, pain and disability in individuals with chronic whiplash. The results have indicated that a combined approach could not only reduce psychological symptoms, but also pain and disability.
  • Aims:�The primary aim of this randomised, controlled trial is to investigate the effectiveness of combined trauma-focused cognitive behavioural therapy, delivered by a psychologist, and physiotherapy exercise to decrease pain and disability of individuals with chronic whiplash and post-traumatic stress disorder (PTSD). The trial also aims to investigate the effectiveness of the combined therapy in decreasing post-traumatic stress symptoms, anxiety and depression.
  • Participants and Setting:�A total of 108 participants with chronic whiplash-associated disorder (WAD) grade II of > 3 months and < 5 years duration and PTSD (diagnosed with the Clinician Administered PTSD Scale (CAPS) according to the DSM-5) will be recruited for the study. Participants will be assessed via phone screening and in person at a university research laboratory. Interventions will take place in southeast Queensland, Australia and southern Denmark.
  • Intervention:�Psychological therapy will be delivered once a week over 10 weeks, with participants randomly assigned to either trauma-focused cognitive behavioural therapy or supportive therapy, both delivered by a clinical psychologist. Participants will then receive ten sessions of evidence-based physiotherapy exercise delivered over a 6-week period.
  • Outcome Measures:�The primary outcome measure is neck disability (Neck Disability Index). Secondary outcomes focus on: pain intensity; presence and severity of PTSD (CAPS V and PTSD Checklist 5); psychological distress (Depression, Anxiety Stress Scale 21); patient perceived functionality (SF-12, Tampa Scale of Kinesiophobia, and Patient-Specific Functional Scale); and pain-specific self-efficacy and catastrophising (Pain Self-Efficacy Questionnaire and Pain Catastrophizing Scale). After psychotherapy (10 weeks after randomisation) and physiotherapy (16 weeks after randomisation), as well as at the 6-month and 12-month follow-ups, a blind assessor will measure the outcomes.
  • Analysis:�All analyses will be conducted on an intention-to-treat basis. The primary and secondary outcomes that are measured will be analysed using linear mixed and logistic regression models. Any effect of site (Australia or Denmark) will be evaluated by including a site-by-treatment group-by-time interaction term in the mixed models analyses. Effect modification will only be assessed for the primary outcome of the Neck Disability Index.
  • Discussion:�This study will provide a definitive evaluation of the effects of adding trauma-focused cognitive behaviour therapy to physiotherapy exercise for individuals with chronic WAD and PTSD. This study is likely to influence the clinical management of whiplash injury and will have immediate clinical applicability in Australia, Denmark and the wider international community. The study will also have implications for both health and insurance policy makers in their decision-making regarding treatment options and funding.

 

Introduction

 

Persistent pain and disability following whiplash injury as a consequence of a road traffic crash (RTC) is common and incurs substantial personal and economic costs. Up to 50% of people who experience a whiplash injury will never fully recover and up to 30% will remain moderately to severely disabled by the condition [1-3]. Less recognised are the mental health issues that accompany this condition. The prevalence of psychiatric disorders has been shown to be 25% for PTSD, 31% for Major Depressive Episode and 20% for Generalised Anxiety Disorder [4-6]. Whiplash injury accounts for the vast majority of any submitted claims as well as the greatest incurred costs in Queensland compulsory third party scheme [7]. In Australia, Whiplash injuries comprise approximately 75% of all survivable RTC injuries [8] with total costs of more than $950 M per annum [9], exceeding costs for both spinal cord and traumatic brain injury [7]. In Denmark, whiplash costs an estimated 300 million USD per annum if loss of work is included [10].

 

Neck pain is the cardinal symptom of individuals following whiplash injury. It is now generally accepted that there is an initial peripheral injury of some kind to the neck [11] although the specific injured structure in individual patients is difficult to clinically identify with current imaging techniques. The reason as to why symptoms persist past the acute to sub-acute stage and become chronic is not clear but likely results from complex interactions between structural injury, physical impairments, psychological and psychosocial factors [12]. However it is clear that chronic WAD is a heterogeneous and complex condition involving physical impairments such as movement loss, disturbed movement patterns and sensory disturbances [13] as well as pain related psychological responses such as catastrophizing [14, 15], kinesiophobia [16], activity avoidance and poor self-efficacy for pain control [17]. In addition recent studies have shown that posttraumatic stress symptoms or event related distress is common [18-20]. Thus it would seem logical that interventions targeting both the physical and psychological manifestations of the whiplash condition would be of benefit.

 

In contrast to many common musculoskeletal pain conditions (e.g. low back pain, non-specific neck pain) whiplash related neck pain usually occurs following a traumatic event, namely a motor vehicle crash. Psychological responses related to the traumatic event itself, posttraumatic stress symptoms, are emerging as an important additional psychological factor in the whiplash condition. Recent data indicates that post-traumatic stress symptoms are prevalent in individuals who have sustained whiplash injuries following motor vehicle accidents [18, 20, 21]. The early presence of posttraumatic stress symptoms have been shown to be associated with poor functional recovery from the injury [13, 18]. Recent data from our laboratory have shown that following whiplash injury 17% of individuals will follow a trajectory of initial moderate/severe posttraumatic stress symptoms that persist for at least 12 months and 43% will follow a trajectory of moderate initial symptoms that decrease but remain at mild to moderate (sub-clinical) levels for at least 12 months (the duration of the study) [4]. See Figure 1. These figures are significant as they are similar to the prevalence of PTSD in individuals admitted to hospital following �more severe� motor vehicle injuries [22].

 

Figure 1 Data from Whiplash Injured Participants

Figure 1: Data from 155 whiplash injured participants measured at 1, 3, 6 & 12 months post-accident. The Posttraumatic Stress Diagnostic Scale (PDS) was measured at each time point. Group based trajectory modelling identified 3 distinct clinical pathways (trajectories). 1. Chronic moderate/severe (17%) 2. Recovering: initial moderate levels of posttraumatic stress decreasing to mild/ moderate levels. 3. Resilient: negligible symptoms throughout2. PDS symptom score Cut-offs: 1�10 mild, 11�20 moderate, 21�35.

 

Although chronic WAD is a considerable health problem the number of published randomized controlled trials (RCTs) is very limited [23]. A recent systematic review concluded that there is evidence to suggest that exercise programs are modestly effective in relieving whiplash-related pain, at least over the short term [23]. For example, Stewart et al [24] showed only a 2 point (on a 10 point scale) decrease in pain levels immediately after a 6 week functional exercise management intervention that adhered to pain-related CBT principals but with no significant sustained effects at more long term follow-ups of 6 and 12 months. In a preliminary RCT conducted in our laboratory (published in 2007), a more neck specific exercise approach also delivered only modest effects, in that pain and disability scores decreased by just clinically relevant amounts (8�14% on the Neck disability Index) when compared to a single advice session [25].

 

The systematic review also concluded that there is conflicting evidence regarding the effectiveness of psychological interventions either delivered alone or in combination with physiotherapy [23]. The studies included in the review were of variable quality and mostly utilized CBT in some format to address pain related cognitions and distress [26, 27]. No study specifically targeted PTSD symptoms.

 

Thus the seemingly logical proposal of interventions to target the physical and pain�related psychological factors of chronic WAD is not working as well as would be anticipated. This expectation is based on more favourable outcomes with such approaches for other musculoskeletal pain conditions such as low back [28].

 

In an endeavour to understand why exercise rehabilitation approaches are not very effective for chronic WAD, we undertook a NHMRC (570884) funded randomized controlled trial that included effect modifiers of PTSD symptoms and sensory disturbances. In this larger (n=186) multicentre trial, preliminary analysis indicate that only 30% of patients with chronic WAD and a PTSD diagnosis had a clinically relevant change in Neck Disability Index scores (>10% change) compared to 70% of WAD patients without PTSD following an exercise rehabilitation program. All included participants reported moderate or greater levels of pain and disability indicating that the co-morbid presence of PTSD prevents a good response to physical rehabilitation. We could find no modifying effect of any sensory changes. The results of this study lead us to propose that first treating PTSD and then instituting physical rehabilitation will be a more effective intervention to improve health outcomes for chronic WAD.

 

Trauma-focused CBT is a highly effective treatment for PTSD symptoms [29] and the Australian Guidelines for Treatment of Acute Stress Disorder and PTSD recommend that individually delivered trauma-focused CBT should be provided to people with these conditions [30]. There is data available to indicate that trauma-focused CBT may potentially have an effect not only on PTSD symptoms but also on pain and disability. The results of a recent empirical examination explored directional relationships between PTSD and chronic pain in 323 survivors of accidents [31]. The results indicated a mutual maintenance of pain intensity and posttraumatic stress symptoms at 5 days post injury but by 6 months post injury (chronic stage), PTSD symptoms impacted significantly on pain but not vice versa. Whilst this study did not specifically focus on whiplash injury, it provides indication that addressing PTSD symptoms in the chronic stage of WAD may allow for a decrease in levels of pain thus facilitating the potential effects of more pain/disability focused approaches to management such as exercise and pain-focused CBT.

 

Based on our findings of the co-occurrence of PTSD and WAD, we conducted a small pilot study with the aim being to test the effects of trauma-focused CBT on psychological factors, pain and disability in individuals with chronic WAD [32]. Twenty-six participants with chronic WAD and a diagnosis of PTSD were randomly assigned to treatment (n = 13) or no-Intervention (n = 13) control. The treatment group underwent 10 weekly sessions of trauma-focused CBT for PTSD. Assessments of PTSD diagnosis, psychological symptoms, disability, and pain symptoms were made at baseline and post-assessment (10-12 weeks). Following the treatment intervention, there was not only a significant reduction in psychological symptoms (PTSD symptom severity; numbers meeting the diagnostic criteria for PTSD; depression, anxiety and stress scores) but also a significant decrease in pain and disability and improvements in physical function, bodily pain and role physical items of the SF36 (Table 1).

 

Table 1. Results of pilot randomised control trial

Trauma-focused CBT No-intervention Control
Neck Disability Index (0-100)*
Baseline 43.7 (15) 42.8 (14.3)
Post intervention 38.7 (12.6) 43.9 (12.9)
SF-36 Physical Function �
Baseline 55.8 (25.9) 55.4 (28.2)
Post intervention 61.5 (20.1) 51.1 (26.3)
SF -36 Bodily Pain �
Baseline 31.2 (17.2) 22.6 (15.5)
Post intervention 41.8 (18) 28.2 (15.8)
Posttraumatic Stress Disorder Diagnosis (SCID-IV)
Baseline N= 13 (100%) N= 13 (100%)
Post intervention N= 5 (39.5%) N= 12 (92.3%)

* higher score=worse; �higher scores=better

 

The results of this study indicate that trauma-focused CBT provided to individuals with chronic WAD has positive effects, not only on psychological status but also on pain and disability the cardinal symptoms of this condition. Whilst the mean change of 5% was marginal in terms of a clinical relevance [33], the effect size for change of the NDI was moderate (d=0.4) and shows promise for a greater effect in a larger sample size [34]. Nevertheless our pilot trial findings suggest that trauma-focused CBT alone will not be enough for successful management of chronic WAD and for this reason our proposed trial will combine this approach with exercise. These findings are potentially ground breaking in the area of whiplash management and it is imperative that they are now tested in a full randomised controlled design.

 

In summary, we have already shown that individuals with chronic WAD and moderate PTSD symptoms do not respond as well to a physical rehabilitation based intervention as those without PTSD symptoms [25]. Our recent pilot study indicates that trauma-focused CBT has a beneficial effect on both psychological status and pain and disability. We propose that by pre-treating the PTSD, PTSD symptoms and pain related disability will decrease allowing the exercise intervention to be more effective than has been seen to date [24, 25]. Therefore our proposed research will address this identified gap in knowledge by being the first to evaluate the efficacy of a combined trauma-focused CBT intervention followed by exercise for chronic WAD.

 

The primary aim of this project is to investigate the effectiveness of combined trauma-focused CBT and exercise to decrease pain and disability of individuals with chronic whiplash and PTSD. The secondary aims are to investigate the effectiveness of combined trauma-focused CBT and exercise to decrease posttraumatic stress symptoms, anxiety and depression, and to investigate the effectiveness of trauma-focused CBT alone on posttraumatic stress symptoms and pain/disability.

 

This trial is expected to commence in June 2015 and completed by December 2018.

 

Design

 

This study will be a randomised controlled multi-centre trial evaluating 10 weeks of trauma-focused CBT compared with 10 weeks of supported therapy, each followed by a 6 week exercise program. Outcomes will be measured at 10 weeks, 16 weeks, 6 and 12 months post randomisation. A total of 108 people with chronic whiplash disorder (>3 months, <5 years duration) and PTSD (DSM-5 diagnosed with CAPS) will be enrolled in the study. The assessors measuring outcomes will be blinded to the assigned treatment group allocation. The protocol conforms to CONSORT guidelines.

 

Figure 2 Study Design

 

Methods

 

Participants

 

A total of 108 participants with chronic whiplash associated disorder (WAD) grade II (symptom duration >3 months and <5 years) and PTSD will be recruited from Southeast Queensland and Zealand, Denmark. Participants will be recruited via:

 

  1. Advertisements (the Danish national health register, newspaper, newsletter and internet): potential participants will be invited to make contact with project staff.
  2. Physiotherapy and General Medical Practices: the study will be promoted in physiotherapy and medical clinics where project staff already have a relationship. Patients deemed to be appropriate for inclusion will be given an information sheet about the project and invited to contact project staff directly.

 

There is a two-step process to determining inclusion to this study: initial online/telephone interview followed by a screening clinical examination. The initial interview will identify duration of whiplash injury (inclusion criteria) and moderate pain based on NDI scores, and potential exclusion criteria. Likelihood of PTSD will be based on conservative PCL-5 scores, requiring at least one moderate score per symptom and a minimum score of 30 overall. A description of the project will be provided to all volunteers at the point of initial contact. Volunteers deemed likely to be eligible will be invited to attend a screening clinical examination. If more than four weeks passes between the phone interview and clinical screening than the NDI and PCL-5 measures are to be re-administered.

 

Prior to undertaking the screening clinical examination, volunteers will be provided with participant information and asked to complete informed consent documentation. During the screening examination, participants who have significant co-morbidity such as serious spinal pathology will be identified and excluded from participation. To screen for serious pathology, a diagnostic triage will be conducted following the Motor Accident Authority of NSW Whiplash Guidelines [35]. The screening examination will also include a clinical interview by a research assistant who will administer the Clinician Administered PTSD scale 5 (CAPS 5) to determine the presence and severity of PTSD [36]. The research assistant will also confirm the absence of exclusion criteria such as past history or current presentation of psychosis, bipolar disorder, organic brain disorder and severe depression substance abuse. If participants report a diagnosis of an exclusion criteria the relevant section of SCID-I will be utilised to clarify diagnosis.

 

During the initial screen or during treatment, if a participant is identified as being at high risk of self-harm or suicide, they will be referred to appropriate care in accordance with the professional standards of psychologists. Participants who meet the inclusion criteria (NDI >30% and PTSD diagnosis) will then be evaluated on all outcome measures for baseline results. It is possible that volunteers invited to attend the screening clinical examination will not meet the inclusion criteria (NDI >30% and PTSD diagnosis) and will therefore be excluded from further participation. Volunteers will be informed of this possibility during the telephone interview and also during the informed consent process. The Interview will be recorded and a random selection will be assessed for consistency

 

Inclusion Criteria

 

  • Chronic WAD Grade II (no neurological deficit or fracture) [37] of at least 3 months duration but less than 5 years duration
  • At least moderate pain and disability (>30% on the NDI)
  • A diagnosis of PTSD (DSM-5, APA, 2013) using the CAPS 5
  • Aged between 18 and 70 years old
  • Proficient in written English or Danish (depending on country of participation)

 

Exclusion Criteria

 

  • Known or suspected serious spinal pathology (e.g. metastatic, inflammatory or infective diseases of the spine)
  • Confirmed fracture or dislocation at the time of injury (WAD Grade IV)
  • Nerve root compromise (at least 2 of the following signs: weakness/reflex changes/sensory loss associated with the same spinal nerve)
  • Spinal surgery in the last 12 months
  • A history or current presentation of psychosis, bipolar disorder, organic brain disorder or severe depression.

 

Sample Size

 

We are interested in detecting a clinically important difference between the two interventions, given that baseline values for each group are statistically equivalent as a result of the randomisation. Based on a two-sided t-test a sample of 86 (43 per group) will provide 80% power to detect a significant difference at alpha 0.05 between the group means of 10 points on the 100 point NDI (assuming a SD of 16, based on our pilot data and data from recent trials ). Effects smaller than this are unlikely to be considered clinically worthwhile. Allowing for a 20% loss to follow up by 12 months, we would require 54 participants per treatment group.

 

Intervention

 

Randomisation

 

Participants will be randomly allocated to treatment group. The randomisation schedule will be generated by the study biostatistician. Randomisation will be by random permuted blocks of 4 to 8. Consecutively numbered, sealed, opaque envelopes will be used to conceal randomisation. Group allocation will be performed immediately following completion of baseline measures by an independent (non-blinded) research assistant . This same research assistant will arrange all appointment times with the treating practitioners and the blinded assessor for all outcome measures. Participants will be instructed not to reveal details about their treatment to the examiner in order to assist with blinding. Patients will be scheduled to receive their first treatment within one week of randomisation.

 

Intervention group – Trauma-focused Cognitive-behavioural therapy (CBT)

 

A psychological intervention that targets PTSD symptoms will consist of 10 weekly 60-90 minute sessions of individually delivered trauma-focused CBT based on the Australian Guidelines for the treatment of Adults with Acute Stress Disorder and PTSD [38] (see Table 2). Session one will focus on providing psycho-education regarding the common symptoms of PTSD, maintaining factors and providing a rationale for various treatment components. Sessions two and three will continue to develop patient�s knowledge of PTSD symptoms and teach anxiety management strategies including deep breathing and progressive muscle relaxation. Cognitive restructuring which involves challenging unhelpful and irrational thoughts and beliefs will commence in session three and continue throughout treatment. Participants will start prolonged exposure in session four which will be paired with relaxation and cognitive challenging. Session six will introduce graded in-vivo exposure. Relapse prevention will also be included in the final two sessions [12]. Participants will be asked to complete a home practice over the course of their sessions which will be recorded and brought to the next session. Treatment will be delivered by registered psychologists with postgraduate clinical training and experience delivering trauma-focused CBT interventions.

 

Table 2. Overview of CBT program

Session Overview
1 Introduction and rationale
2 Relaxation training
3 Relaxation training and cognitive challenging
4 and 5 Cognitive challenging and prolonged exposure
6 Prolonged exposure and in vivo exposure
7 and 8 Prolonged exposure and in-vivo exposure
9 Relapse prevention
10 Relapse prevention and end of treatment

 

 

Control group – Supportive Therapy

 

The first session will involve education about trauma and an explanation of the nature of supportive therapy. The following sessions will include discussions of current problems and general problem-solving skills. Home practice will involve diary keeping of current problems and mood states. Supportive therapy will specifically avoid exposure, cognitive restructuring or anxiety management techniques. If the results of the trial are favourable and participants randomised to this intervention still have a PTSD diagnosis at the 12 month follow-up, they will be offered a referral to a clinical psychologist.

 

Exercise Program

 

Following the 10 week psychological therapy sessions (intervention or control), All participants will participate in the same exercise program. The 6-week exercise program will be carried out under supervision from a physiotherapist (2 sessions in each of the first four weeks; and 1 session in week 5 and week 6) and will comprise specific exercises to improve the movement and control of the neck and shoulder girdles as well as proprioceptive and co-ordination exercises (see Table 3). The exercises will be tailored by the physiotherapist for each individual participant.

 

The program begins with a clinical examination of the cervical muscles and the axio-scapular-girdle muscles and includes tests that assess ability to recruit the muscles in a coordinated manner, tests of balance, cervical kinaesthesia and eye movement control and tests of muscle endurance at low levels of maximum voluntary contraction. The specific impairments that are identified are then addressed with an exercise program that is supervised and progressed by the physiotherapist. This specific treatment program has been described in detail [15] and focuses on activating and improving the co-ordination and endurance capacity of the neck flexor, extensor and scapular muscles in specific exercises and functional tasks, and a graded program directed to the postural control system, including balance exercises, head relocation exercises and exercises for eye movement control.

 

Participants will also perform the exercises at home, once a day. A log book will be completed by participants to record compliance with the exercises. At the same time, the physiotherapist will guide the subject�s return to normal activities.

 

Physiotherapists will adhere to cognitive-behavioural principles during training and supervision of all exercises [26]. The cognitive behavioural therapy principles include the encouragement of skill acquisition by modelling, setting progressive goals, self-monitoring of progress, and positive reinforcement of progress. Self-reliance will be fostered by encouraging subjects to engage in problem-solving to deal with difficulties rather than seeking reassurance and advice, by encouraging relevant and realistic activity goals, and by encouraging self-reinforcement. Daily physical activity at home will be encouraged and monitored using a diary. Written and illustrated exercise instructions will be provided.

 

Table 3. Overview of the exercise program

Week Sessions per week Components
1 2 ������� Baseline & follow-up assessments to guide initial prescription & progression of program

������� Exercise to improve cervical and scapular muscle control, kinaesthesia & balance

������� Education and advice

������� Daily home program including exercise & graded increase of physical activities

������� CBT principles such as goal setting, reinforcement used by physiotherapists

������� Discharge session to reinforce progress and plan for continued activity
2 2
3 2
4 2
5 1
6 1

 

 

Outcome Measures

 

At the baseline assessment, personal characteristics such as age, gender, level of education, compensation status, accident date and information about symptoms of whiplash will be collected. The following outcome measures will be assessed by a blind assessor at baseline, 10 weeks, 16 weeks, 6 months and 12 months post randomisation.

 

The Neck Disability Index (NDI) will be the primary outcome measure [21]. The NDI is a valid measure and reliable measure of neck pain related disability [21] and is recommended for use by the Bone and Joint Decade Neck Pain Task Force [7] and at the recent International Whiplash Summit [11, 16].

 

Secondary outcome measures include:

 

  1. Average pain intensity over last week (0-10 scale) [39]
  2. Average pain intensity over last 24 hours (0-10 scale) [39]
  3. Patient�s global impression of recovery (-5 to +5 scale) [39]
  4. Clinician administered PTSD scale 5 (CAPS 5) [40].
  5. The PTSD Checklist (PCL-5) [41]
  6. Depression Anxiety Stress Scale-21 (DASS-21) [42]
  7. Generic measure of health status (SF-12) [43]
  8. Patient-generated measure of disability (Patient-Specific Functional Scale) [44]
  9. Physical measures (cervical range of movement, pressure pain threshold, cold pain threshold)
  10. Pain Catastrophizing Scale (PCS) [45]
  11. Pain Self Efficacy Questionnaire (PSEQ) [46]
  12. Tampa Scale of Kinesiophobia (TSK) [47]

 

Expectations of a beneficial treatment effect will be measured with the Credibility Expectancy Questionnaire (CEQ) [48] at the first and last week of each treatment. Working alliance as reported by the client and the therapist (psych or physio) will also be measured at the first and last week of each treatment using the Working Alliance Inventory (WAI) [49].

 

Monitoring of Treatment Sites

 

Treatment sites will be located in areas easily accessible by public transport. Attempts will be made to have both the psychology and exercise sessions held at the same site. Prior to commencement of the trial, psychologists and physiotherapists at each treatment site will be provided with the appropriate therapist protocol. Psychologists will be trained to implement the CBT program and the supported therapy by senior investigators at a one day workshops. Physiotherapists will be trained by senior investigators to implement the exercise program at a one day workshop.

 

Prior to starting the trial, the different treatment provider sites and therapists will be provided with a copy of the trial and treatment protocols. Both psychological therapies will be conducted according to a procedural manual. Therapists will be required to record each session as well as complete a checklist of adherence to the protocol. A random sample of these recordings and checklists will be evaluated and ongoing supervision provided by a psychologist on the research team. Physiotherapy exercises will be based on a previous exercise trial for chronic WAD [25]. An audit of the physiotherapy sessions will be conducted twice during the intervention by a senior investigator expert in this area. A handover will occur between psychologist and physiotherapist to maintain continuity of care.

 

Adverse Events

 

Apart from the usual ethics committee based provisions for reporting of adverse effects, practitioners will be requested to report any adverse event to the Chief Investigators. Also at the 16 week follow-up, information about adverse effects of treatment will be sought from all subjects using open-ended questioning. At 6 and 12 months follow-up, data relating to the number of recurrences of neck pain, and the number of health care contacts will also be collected.

 

Statistical Analysis

 

The study biostatistician will analyse the data in a blinded manner. All analyses will be conducted on an intention to treat basis. The primary and secondary outcomes measured at 10 weeks, 16 weeks, 6 months, and 12 months will be analysed using linear mixed and logistic regression models that will include their respective baseline scores as a covariate, subjects as a random effect and treatment conditions as fixed factors. Diagnostics will be used to examine assumptions, including homogeneity of variances. Effect sizes will be calculated for all measures with an effect size of 0.2 considered small, 0.5 medium and 0.8 large. Alpha will be set at 0.05. Any effect of site (Qld or Denmark) will be evaluated by including a site-by-treatment group-by-time interaction term to the mixed models analyses. Effect modification will only be assessed for the primary outcome of NDI.

 

Funding

 

  • The trial is funded by a NHMRC Project grant 1059310.
  • The Council of the Danish Victims Fund Project grant 14-910-00013

 

Potential Significance

 

This project addresses a problem of major importance to human health. Whiplash is an enormous health burden for both Australia and all countries where there are motor vehicles. Current conservative approaches to the management of chronic WAD have been shown to be only marginally effective. One reason for this may be due to the lack of attention of current practice to the psychological status of whiplash injured patients. This study will provide a definitive evaluation of the effects of adding trauma-focused CBT to exercise for individuals with chronic WAD and PTSD.

 

This study is likely to influence the clinical management of whiplash injury and will have immediate clinical applicability. Any intervention that may improve health outcomes for individuals with chronic whiplash will have far reaching effects in both Australia and internationally. Our study will also have implications for both health and insurance policy makers in their decision making regarding treatment options and funding. A search of the WHO International Clinical Trials Registry Platform Search Portal on 2/3/13 revealed no planned or completed trial that would duplicate our work.

 

Conflict of Interest Declaration

 

The authors declare no conflict of interest.

 

Role of Psychosocial Stress in Recovery from Common Whiplash

 

Abstract

 

It is widely accepted that psychosocial factors are related to illness behaviour and there is some evidence that they may influence the rate of recovery from post-traumatic disorders. The abilities of psychosocial stress, somatic symptoms, and subjectively assessed cognitive impairment to predict delayed recovery from common whiplash were investigated in a follow-up study. 78 consecutive patients referred 7.2 (SD 4.5) days after they had sustained common whiplash in car accidents were assessed for psychosocial stress, negative affectivity, personality traits, somatic complaints, and cognitive impairment by semistructured interview and by several standardised tests. On examination 6 months later 57 patients were fully recovered and 21 had persisting symptoms. The groups’ scores for the independent variables assessed at the baseline examination were compared. Stepwise regression analysis showed that psychosocial factors, negative affectivity, and personality traits were not significant in predicting the outcome. However, initial neck pain intensity, injury-related cognitive impairment, and age were significant factors predicting illness behaviour. This study, which was based on a random sample and which considered many other possible predictive factors as well as psychosocial status, does not support previous findings that psychosocial factors predict illness behaviour in post-trauma patients.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Being involved in an automobile accident can be a traumatic experience for anyone. From physical injuries and financial problems, to emotional distress, an auto accident can place a heavy burden on those individuals who’ve experienced it, especially if the auto accident injuries begin to take a toll on the mind. Many patients visit my chiropractic office with anxiety, irrational fears, depression and PTSD after being involved in an automobile accident. Learning to trust again to receive chiropractic care can be challenging, but through careful and effective spinal adjustments and manual manipulations, our staff can provide patients with the sense of safety they need to continue treatment and achieve overall health and wellness.

 

In conclusion,�automobile accidents can cause a variety of physical injuries and conditions, such as whiplash, back pain and headaches, as well as financial issues, however, auto accident injuries and complications can also lead to emotional distress. According to evidence-based research studies, like the one above, emotional distress has been connected to chronic pain symptoms. Fortunately, researchers have conducted numerous research studies to demonstrate how mindfulness interventions, like chiropractic care, can help reduce emotional distress and improve painful symptoms. 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

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

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.

 

blog picture of cartoon paperboy big news

 

EXTRA IMPORTANT TOPIC: Managing Workplace Stress

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor

 

 

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Effectiveness of Mindfulness on Herniated Discs & Sciatica in El Paso, TX

Effectiveness of Mindfulness on Herniated Discs & Sciatica in El Paso, TX

by | Conditions Treated, Herniated Disc, Physical Rehabilitation, Randomized Controlled Trial, Spinal Decompression Treatments, Stress, Treatments

Chronic low back pain is the second most common cause of disability in the United States. Approximately 80 percent of the population will experience back pain at least once throughout their lifetime. The most prevalent causes of chronic low back pain include: herniated discs, sciatica, injuries from lifting heavy objects or any other non-specific spine injury. However, people will often react differently to their symptoms. These differing responses are due to people’s psychological attitudes and outlooks.

 

Chronic Low Back Pain and the Mind

 

Stress has been associated with increased pain but your own personal health beliefs and coping strategies can influence your own perception of pain as well. That’s because psychological vulnerabilities can alter your brain and intensify the pain. Additionally, the pain itself can rewire the brain.�When pain first occurs, it impacts the pain-sensitivity brain circuits. When pain becomes persistent, the associated brain activity switches from the pain circuits to circuits that process emotions. That’s why it’s believed that stress, anxiety and depression can cause as well as worsen chronic low back pain.

 

Managing the Scourge of Chronic Low Back Pain

 

Fortunately, several stress management methods and techniques can help improve chronic low back pain. Mindfulness is the most common treatment with the best supporting evidence towards improving and managing chronic pain.�A recent study demonstrated that mindfulness-based stress reduction, or MBSR, including mindfulness meditation and other mindfulness interventions, can help reduce back pain and enhance psychological control by increasing brain blood flow to the frontal lobe. Practicing mindfulness involves activating a brain relaxation pathway by intentionally ignoring mental “chatter” and focusing on your breathing.�Cognitive behavioral therapy, or CBT can also be helpful for chronic low back pain. Cognitive behavioral therapy can prevent an acute injury from progressing to chronic low back pain. Hypnosis may also help relieve chronic low back pain. However, CBT and hypnosis have weaker evidence to support their effectiveness on back pain.

 

Mind Over Matter

 

So while it may seem that chronic low back pain is all “in your head”, research studies have demonstrated that stress can influence painful symptoms.��Mind� includes �matter,� especially when you consider that the physical �matter� of the brain plays a major role in mindset changes. This is especially true when it comes to the brain-based changes related to low back pain. The purpose of the article below is to demonstrate the effectiveness of mindfulness meditation on chronic low back pain.

 

Effectiveness of Mindfulness Meditation on Pain and Quality of Life of Patients with Chronic Low Back Pain

 

Abstract

 

  • Background and aim: Recovery of patients with chronic low back pain (LBP) is depended on several physical and psychological factors. Therefore, the authors aimed to examine the efficacy of mindfulness based stress reduction (MBSR) as a mind-body intervention on quality of life and pain severity of female patients with nonspecific chronic LBP (NSCLBP).
  • Methods: Eighty-eight patients diagnosed as NSCLBP by physician and randomly assigned to experimental (MBSR+ usual medical care) and the control group (usual medical care only). The subjects assessed in 3 times frames; before, after and 4 weeks after intervention by Mac Gil pain and standard brief quality of life scales. Data obtained from the final sample analyzed by ANCOVA using SPSS software.
  • Results: The findings showed MBSR was effective in reduction of pain severity and the patients who practiced 8 sessions meditation reported significantly lower pain than patients who only received usual medical care. There was a significant effect of the between subject factor group (F [1, 45] = 16.45, P < 0.001) and (F [1, 45] = 21.51, P < 0.001) for physical quality of life and (F [1, 45] = 13.80, P < 0.001) and (F [1, 45] = 25.07, P < 0.001) mental quality of life respectively.
  • Conclusion: MBSR as a mind-body therapy including body scan, sitting and walking meditation was effective intervention on reduction of pain severity and improvement of physical and mental quality of life of female patients with NSCLBP.
  • Keywords: Chronic low back pain, mindfulness based stress reduction, pain, quality of life, SF-12

 

Introduction

 

In nonspecific low back pain (NSLBP) the pain is not related to conditions such as fractures, spondylitis, direct trauma, or neoplastic, infectious, vascular, metabolic, or endocrine-related although it is a cause of limitation in daily activities due to actual pain or fear of pain.[1] Unfortunately, the majority of LBP patients (80�90%) suffers from nonspecific LBP which leads to considerable pain-related disability and limitation in daily activities.[1,2] Chronic LBP is not only prevalent, but is also a source of great physical disability, role impairment, and diminished psychological well-being and quality of life.[1]

 

Prior to the current accepted biopsychosocial model, the biomedical model dominated all illness conceptualizations for almost 300 years and still dominates in the popular imagination. First proposed by Engel (1977) the biopsychosocial model acknowledges biological processes but also highlights the importance of experiential and psychological factors in pain. The famous gate control theory of pain[3] also proposed that the brain plays a dynamic role in pain perception as opposed to being a passive recipient of pain signals. They suggested psychological factors can inhibit or enhance sensory flow of pain signals and thus influence the way brain ultimately responds to painful stimulation.[4] If mind processes can change the way the brain processes pain then this holds tremendous potential for psychological intervention to produce reduced pain signals from the brain.

 

Kabat-Zinn’s et al. (1986) described the process of pain reduction in his paper on mindfulness and meditation. The process of pain reduction occurred by �an attitude of detached observation toward a sensation when it becomes prominent in the field of awareness and to observe with similar detachment the accompanying but independent cognitive processes which lead to evaluation and labeling of the sensation as painful, as hurt.� Thus, by �uncoupling� the physical sensation, from the emotional and cognitive experience of pain, the patient is able to reduce the pain.[5] The patients� descriptions of distraction from pain, identifying maladaptive coping strategies toward pain and heightened awareness of pain sensation leading to behavioral changes are examples of how pain is unassociated with emotion, cognition, and sensation [Figure 1]. Therefore recently these theories attracted several researchers who are working on pain.

 

Figure 1 Consort Diagram

Figure 1: Consort diagram.

 

Mindfulness meditation has roots in Buddhist Vipassana philosophy and practice and has been independently adopted within clinical psychology in Western societies.[6,7,8,9] Recently in Netherlands Veehof et al. conducted a systematic review of controlled and noncontrolled studies on effectiveness of acceptance-based interventions such as mindfulness-based stress reduction program, acceptance and commitment therapy for chronic pain. Primary outcomes measured were pain intensity and depression. Secondary outcomes measured were anxiety, physical well-being and quality of life.[10] Twenty-two studies randomized controlled studies clinical controlled studies without randomization and noncontrolled studies were included totaling 1235 patients with chronic pain. An effect size on pain of (0.37) was found in the controlled studies. The effect on depression was (0.32). The authors concluded that ACT and mindfulness interventions had similar effects to other cognitive-behavioral therapy interventions and that these types of interventions may be a useful alternative or adjunct to current therapies. Chiesa and Serretti also conducted another systematic review on 10 mindfulness interventions.[11] The main findings were that these interventions produced small nonspecific effects in terms of reducing chronic pain and symptoms of depression. When compared to active control groups (support and education) no additional significant effects were noted.

 

In summary, there is a need for further studies into the specific effects of mindfulness studies on chronic pain. Regarding as the researcher knowledge efficacy of mindfulness has not been explored on quality of life of chronic pain patients in Iran. The authors aimed to examine the impact of mindfulness based stress reduction (MBSR) protocol designed for pain management on quality of life and pain of a homogeneous sample of females with nonspecific chronic LBP (NSCLBP) in comparison of the usual medical care group.

 

Methods

 

Sampling

 

Out of initial female samples aged 30�45 (n = 155) who diagnosed as chronic NSLBP by physicians in physiotherapy centers of Ardebil-Iran at least 6 months before. Only 88 met inclusion criteria and gave consent to participate in the research program. Patients were randomly assigned in small groups to receive MBSR plus medical usual care (experimental group) and medical usual care (control group). Some patients dropped during and after the treatment. The final sample of the study comprised of 48 females.

 

Inclusion Criteria

 

  • Age 30�45 years
  • Being under medical treatments like physiotherapy and medicine
  • Medical problem-history of NSCLBP and persisting pain for at least 6 months
  • Language – Persian
  • Gender – female
  • Qualification – educated at least up to high school
  • Consent and willingness to alternative and complementary therapies for pain management.

 

Exclusion Criteria

 

  • History of spine surgery
  • Combination with other chronic disease
  • Psychotherapy in the last 2 years excluded
  • Unavailability in next 3 months.

 

The proposal of study approved by the scientific committee of �Panjab University,� psychology department and all patients signed consent to participate in the present study. The study approved in India (in the university which researcher done her PhD), but conducted in Iran because researcher is from Iran originally and there was language and culture difference problem. Approval from Institutional Ethics Committee of physiotherapy center of Ardebil was obtained in Iran also to carry out the research.

 

Design

 

The study made use of the pre-post quasi time series experimental design to assess the efficacy of MBSR in 3 times frames (before-after-4 weeks after the program). A MBSR program administered one session per week for explaining techniques, practice, and feedback and share their experience for 8 weeks beside 30�45 min� daily home practice [Table 1]. The intervention was conducted in three groups included 7�9 participants in each group. The process of framing the program was based on the quid lines provided by Kabat-Zinn, Morone (2008a, 2008b and 2007)[6,12,13,14] and some adaptation done for the patients involved in the study. The control group was not offered any type of intervention in the research project. Consequently, they underwent the normal routines in healthcare including physiotherapy and medicine.

 

Table 1 Content of MBSR Sessions

Table 1: Content of MBSR sessions.

 

Intervention

 

The sessions conducted in a private physiatrist clinic near to physiotherapy centers. Sessions took 8 weeks, and each session lasted for 90 min. Meditation transformed the patients� awareness through the techniques of breathing and mindfulness. The intervention was conducted in small groups included 7�9 participants in each group. Table 1 for details of session’s content which prepared according books and previous studies.[6,12,13,14]

 

Assessments

 

The questionnaire completed by patients before the intervention, after intervention and 4 weeks after the interventions. The receptor of physiotherapy centers conducted the assessment. The receptors trained before conducting the assessment, and they were blind for the hypothesis of the study. The following are used for assessment of participants:

 

McGill Pain Questionnaire

 

The main component of this scale consists of 15 descriptive adjectives, 11 sensory including: Throbbing, Shooting, Stabbing, Sharp, Cramping, Gnawing, Hot-burning, Aching, Heavy, Tender, Splitting, and four affective including: Tiring-exhausting, Sickening, Fearful, Punishing-cruel, which are rated by the patients according to their severity on a four point scale (0 = none, 1 = mild, 2 = moderate, 3 = severe), yielding three scores. The sensory and affective scores are calculated by adding sensory and affective item values separately, and the total score is the sum of the two above-mentioned scores. In this study, we just used pain rating index with total scores. Adelmanesh et al.,[15] translated and validated Iran version of this questionnaire.

 

Quality of Life (SF-12)

 

The quality of life assessed by the validated SF-12 Health Survey.[16] It was developed as a shorter, quicker-to-complete alternative to the SF-36v2 Health Survey and measures the same eight health constructs. The constructs are: Physical functioning; role physical; bodily pain; general health; vitality; social functioning; role emotional; and mental health. Items have five response choices (for example: All of the time, most of the time, some of the time, a little of the time, none of the time), apart from two questions for which there are three response choices (for the physical functioning domain). Four items are reverse scored. Summed raw scores in the eight domains are transformed to convert the lowest possible score to zero and the highest possible score to 100. Higher scores represent better health and well-being. The standard form SF-12 uses a time frame of the past 4 weeks.[16]

 

The Iranian version of SF-12 in Montazeri et al. (2011) study showed satisfactory internal consistency for both summary measures, that are the Physical Component Summary (PCS) and the Mental Component Summary (MCS); Cronbach’s ? for PCS-12 and MCS-12 was 0.73 and 0.72, respectively. The known – group comparison showed that the SF-12 discriminated well between men and women and those who differed in age and educational status (P < 0.001) 2.5.[17]

 

Statistical Analysis

 

The SPSS 20 (Armonk, NY: IBM Corp) was used to analysis of data. For descriptive analysis mean, standard deviation (SD) used. For performing ANCOVA, the pretest scores were used as covariates.

 

Results

 

The mean age was 40.3, SD = 8.2. 45% of females were working and the rest were a house wife. 38% had two children, 55% one child and the rest did have children. All were married and from middle-income families. 9.8% of patients reported very low physical quality of life, and the rest were low (54.8%) and moderate (36.4%). This was 12.4%, 40% and 47.6% very low, low and medium levels of mental quality of life in patients participated in our study (n = 48). The mean and SD of patients in MBSR and control group showed a decrease in pain and increase in mental and physical quality of life [Table 2].

 

Table 2 Mean and SD of Patients

Table 2: Mean and SD of patients in pain, mental and physical quality of life in baseline, after intervention and 4 weeks after intervention.

 

Comparative Results

 

Pain. The results indicated that after adjusting for pretest scores, there was a significant effect of the between subject factor group (F [1, 45] =110.4, P < 0.001) and (F [1, 45] =115.8, P < 0.001). Adjusted post-test scores suggest that the intervention had an effect on increasing the pain scores of the NSCLBP patients who received the MBSR as compared to those who were in the control group and did not receive any mind-body therapy [Table 3].

 

Table 3 The Result of Comparison of Pain and Quality of Life

Table 3: The result of comparison of pain and quality of life of MBSR and control group after intervention (time 1) and 4 weeks after intervention (time 2).

 

Quality of life. The results shows that after adjusting for pretest scores, there was a significant effect of the between subject factor group (F [1, 45] =16.45, P < 0.001) and (F [1, 45] =21.51, P < 0.001). Adjusted post-test scores suggest that the intervention had an effect on increasing the physical quality of life scores of the NSCLBP patients who received the MBSR as compared to those who were in the control group and did not receive any mind-body therapy [Table 3].

 

The results also showed that after adjusting for pretest scores, there was a significant effect of the between subject factor group (F [1, 45] =13.80, P < 0.001) and (F [1, 45] =25.07, P < 0.001). Adjusted post-test scores suggest that the intervention had an effect on increasing the mental quality of life scores of the NSCLBP patients who received the MBSR as compared to those who were in the control group and did not receive any psychological therapy [Table 3].

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Mindfulness is the psychological process which involves�activating a brain relaxation pathway by intentionally ignoring mental “chatter”, bringing one’s attention to experiences occurring in the present moment and focusing on your breathing. Mindfulness can commonly be achieved through the practice of meditation and stress management methods and techniques. According to research studies, mindfulness is an effective treatment option which can help decrease chronic low back pain. Researchers have previously compared mindfulness-based stress reduction, or MBSR, with cognitive behavioral therapy to determine whether these mindfulness interventions could improve chronic low back pain. The following article was also conducted to determine if mindfulness meditation is an effective treatment option for chronic low back pain. The results of both research studies were promising, demonstrating that mindfulness can be more effective for chronic low back pain than traditional treatment options as well as the use of drugs and/or medication.

 

Discussion

 

The results showed that the experimental group who were subjected to the MBSR showed a significant improvement in their overall pain severity, physical and mental quality of life scores due to the training received as compared to the control group who received only usual medical care. The program reduced pain perception and enhanced both physical and mental quality of life and impacted on the experimental group clearly in comparison of the usual medical care. Baranoff et al., 2013,[18] Nykl�cek and Kuijpers, 2008,[19] and Morone (2) et al., 2008[20] reported the same results.

 

Kabat-Zinn et al. believed the process of pain reduction occurred by �uncoupling� the physical sensation, from the emotional and cognitive experience of pain, the patient is able to reduce the pain.[21] In the current study, the participants uncoupled the different components of the experience of pain. Breathing exercise distract their mind from pain to breathing and mindful living made them aware about maladaptive coping strategies.

 

In the first session, information given about the fundamentals of mindfulness, describing the mindfulness supporting attitudes included being nonjudgmental toward thought, emotions or sensations as they arise, patience, nonstriving, compassion, acceptance and curiosity gave them a wisdom and believe that they are suffering from painful thoughts more than the pain itself.

 

Furthermore, during body scan practice they learned to see their real body conditions, as it truly was, without trying to change the reality. Accepting their chronic illness condition helped them see the other possible abilities in their social and emotional roles. In fact the body scan practice helped them change the relationship with their body and pain. Through direct experience in body scan, one realizes the interconnection between the state of the mind and the body, and thereby increases patients� self-control over their life. Mindful living techniques also improved their quality of life by teaching them to pay more attention to their daily life necessities, which led to the experience of subtle positive emotions, like peace and joy, self-esteem and confidence. Furthermore, they appreciated positive things. Once they learned to see the persistent pain objectively and observe other sensations in their body, they applied the same principles through mindful living techniques in their everyday life. As a result, they learned how to manage their health and began to engage in their duties mindfully.

 

A number of research studies such as Plews-Ogan et al.,[22] Grossman et al.,[23] and Sephton et al., (2007)[24] showed effectiveness of mindfulness meditation program on quality of life of patients with chronic pain conditions.

 

Conclusion

 

All together the result of this study and previous studies highlighted the effectiveness of complementary and alternative treatment for patients with chronic LBP. Regarding the considerable role of quality of life in professional and personal life designing the effective psychotherapies especially for enhancement of quality of life of patients with chronic LBP strongly suggested by the authors.

 

This study involved with several limitations such as ununiformed usual care received by patients. The provided physiotherapy sessions or methods and medicine prescribed by different physicians in slightly different manner. Although some patients commonly dose not completed physiotherapy sessions. The sample size was small and it was only limited to three centers. This is suggested for future researchers to conduct study with considering physiologic variables such as MRI, NMR and neurologic signals to test the efficacy of MBSR to decrease pain sufferer.

 

In conclusion, more evidence-based larger scale researches with longer-term follow-up need to be done to increase the therapeutic weight and value of MBSR as a part of complementary alternative medicine being preventive and rehabilitation method among CLBP patients.

 

Acknowledgement

 

We are thankful from patients who were corporate with us. Dr. Afzalifard and staff of physiotherapy centers of Ardebil.

 

Footnotes

 

  • Source of support: Nil.
  • Conflict of interest: None declared.

 

In conclusion,�mindfulness�is the most prevalent treatment with the best supporting evidence towards improving and managing chronic low back pain. Mindfulness interventions, such as mindfulness-based stress reduction and cognitive behavioral therapy, have demonstrated to be effective for chronic low back pain. Furthermore, mindfulness meditation was also demonstrated to effectively help improve as well as manage chronic low back pain caused by stress. However, further research studies are still required to determine a solid outcome measure for mindfulness interventions and chronic pain. 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

 

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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

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Choosing Chiropractic? | Familia Dominguez | Patients | El Paso, TX Chiropractor

 

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References
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2.�Kovacs FM, Abraira V, Zamora J, Fern�ndez C. Spanish Back Pain Research Network. The transition from acute to subacute and chronic low back pain: A study based on determinants of quality of life and prediction of chronic disability.�Spine (Phila Pa 1976)�2005;30:1786�92.�[PubMed]
3.�Melzack R, Wall PD. Pain mechanisms: A new theory.�Science.�1965;150:971�9.�[PubMed]
4.�Beverly ET. USA: The Guilford Press; 2010. Cognitive Therapy for Chronic Pain: A Step-by-Step Guide.
5.�Kabat-Zinn J, Lipworth L, Burney R, Sellers W. Four-Year Follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance.�Clin J Pain.�1986;2:159�73.
6.�Wetherell JL, Afari N, Rutledge T, Sorrell JT, Stoddard JA, Petkus AJ, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain.�Pain.�2011;152:2098�107.�[PubMed]
7.�Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review.�Clin Psychol Sci Pract.�2003;10:125�43.
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9.�Glombiewski JA, Hartwich-Tersek J, Rief W. Two psychological interventions are effective in severely disabled, chronic back pain patients: A randomised controlled trial.�Int J Behav Med.�2010;17:97�107.[PubMed]
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17.�Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item short form health survey (SF-12): A population-based validation study from Tehran, Iran.�Health Qual Life Outcomes.�2011;9:12.�[PMC free article]�[PubMed]
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20.�Morone NE, Lynch CS, Greco CM, Tindle HA, Weiner DK. �I felt like a new person.� the effects of mindfulness meditation on older adults with chronic pain: Qualitative narrative analysis of diary entries.�J Pain.�2008;9:8 41�8.�[PMC free article]�[PubMed]
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Effects of Stress Management Treatment for Low Back Pain in El Paso, TX

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

by | 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

 

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

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

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

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

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

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

 

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.

 

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

 

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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

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Choosing Chiropractic? | Familia Dominguez | Patients | El Paso, TX Chiropractor

 

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Mindfulness Interventions in Chronic Pain Treatment in El Paso, TX

Mindfulness Interventions in Chronic Pain Treatment in El Paso, TX

by | 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

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

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.

 

Dr Jimenez White Coat

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

 

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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

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Choosing Chiropractic? | Familia Dominguez | Patients | El Paso, TX Chiropractor

 

 

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Wilcock A. A. (1999).�Reflections on doing, being and becoming.�Australian Occupational Therapy Journal,�46, 1�11.�dx.doi.org/10.1046/j.1440-1630.1999.00174.x
Williams J. M. G., & Kabat-Zinn J. (2011).�Mindfulness: Diverse perspectives on its meaning, origins, and multiple applications at the intersection of science and Dharma.�Contemporary Buddhism,�12dx.doi.org/10.1080/14639947.2011.564811
*�Wong S. Y., Chan F. W., Wong R. L., Chu M. C., Kitty Lam Y. Y., Mercer S. W., & Ma S. H. (2011).�Comparing the effectiveness of mindfulness-based stress reduction and multidisciplinary intervention programs for chronic pain: A randomized comparative trial.�Clinical Journal of Pain,�27, 724�734.�dx.doi.org/10.1097/AJP.0b013e3182183c6e�[PubMed]
Wood W. (1998).�It is jump time for occupational therapy.�American Journal of Occupational Therapy,�52, 403�411.�dx.doi.org/10.5014/ajot.52.6.403�[PubMed]
*�Zangi H. A., Mowinckel P., Finset A., Eriksson L. R., H�ystad T. O., Lunde A. K., & Hagen K. B. (2012).�A mindfulness-based group intervention to reduce psychological distress and fatigue in patients with inflammatory rheumatic joint diseases: A randomised controlled trial.�Annals of the Rheumatic Diseases,�71, 911�917.�dx.doi.org/10.1136/annrheumdis-2011-200351�[PubMed]
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Stress Management & Chiropractic Treatment in El Paso, TX

Stress Management & Chiropractic Treatment in El Paso, TX

by | 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

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.

 

Table 1 Characteristics of the Included Studies

 

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

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].

 

Dr Jimenez White Coat

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

 

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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!

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Choosing Chiropractic? | Familia Dominguez | Patients | El Paso, TX Chiropractor

 

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