A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia

A mounting body of literature recommends that treatment for fibromyalgia (FM) encompass medications, exercise and improvement of coping skills. However, there is a significant gap in determining an effective counterpart to pharmacotherapy that incorporates both exercise and coping. The aim of this randomized controlled trial was to evaluate the effects of a comprehensive yoga intervention on FM symptoms and coping. A sample of 53 female FM patients were randomized to the 8-week Yoga of Awareness program (gentle poses, meditation, breathing exercises, yoga-based coping instructions, group discussions) or to wait-listed standard care. Data were analyzed by intention to treat. At post-treatment, women assigned to the yoga program showed significantly greater improvements on standardized measures of FM symptoms and functioning, including pain, fatigue, and mood, and in pain catastrophizing, acceptance, and other coping strategies. This pilot study provides promising support for the potential benefits of a yoga program for women with FM.     

A reanalysis of a randomized trial on meditation for migraine headaches: Distraction is not enough but meditation takes time

Objective: Migraine headaches affect about approximately 15% of the population and some notable efforts have been made to develop meditation interventions to address pain and mood among this population. However, key active ingredients and the necessary duration of meditation interventions to produce an effect are still unknown. The purpose of this study is to assess key meditation ingredients that positively impact mood and headache factors across different meditation techniques and to establish an initial time or” dose” needed to reach proactive treatment efficacy.Method: In this longitudinal study, three active management forms of meditation were compared to a cognitive distraction meditation to assess the effects on migraine headaches and emotions over a 30 day period when practiced 20 min per day.Results: The active group showed significant decreases in anger (p = .005) and migraine pain (p = .002) over time. Further analysis showed that the bulk of the change for the active management group occurred in the final 10 days, after 20 days of practice of the technique (p < .05).Conclusion: This suggests that cognitively active forms of meditation are more effective in reducing migraine headache pain and negative mood than distraction techniques. However, individuals engaging in these strategies need to consistently practice these techniques for approximately 20 days to proactively reduce migraine headache pain and negative mood.     

Mind wandering and attention during focused meditation: a fine-grained temporal analysis of fluctuating cognitive states

Studies have suggested that the default mode network is active during mind wandering, which is often experienced intermittently during sustained attention tasks. Conversely, an anticorrelated task-positive network is thought to subserve various forms of attentional processing. Understanding how these two systems work together is central for understanding many forms of optimal and sub-optimal task performance. Here we present a basic model of naturalistic cognitive fluctuations between mind wandering and attentional states derived from the practice of focused attention meditation. This model proposes four intervals in a cognitive cycle: mind wandering, awareness of mind wandering, shifting of attention, and sustained attention. People who train in this style of meditation cultivate their abilities to monitor cognitive processes related to attention and distraction, making them well suited to report on these mental events. Fourteen meditation practitioners performed breath-focused meditation while undergoing fMRI scanning. When participants realized their mind had wandered, they pressed a button and returned their focus to the breath. The four intervals above were then constructed around these button presses. We hypothesized that periods of mind wandering would be associated with default mode activity, whereas cognitive processes engaged during awareness of mind wandering, shifting of attention and sustained attention would engage attentional subnetworks. Analyses revealed activity in brain regions associated with the default mode during mind wandering, and in salience network regions during awareness of mind wandering. Elements of the executive network were active during shifting and sustained attention. Furthermore, activations during these cognitive phases were modulated by lifetime meditation experience. These findings support and extend theories about cognitive correlates of distributed brain networks.     

Baseline characteristics did not identify people with low back pain who respond best to a Movement System Impairment-Based classification treatment

Study designSecondary analysis of data from a randomized controlled trial.BackgroundTreatment based on the Movement System Impairment-Based classification for chronic low back pain results in the same benefit when compared to other forms of exercise. It is possible that participant's characteristics measured at baseline can identify people with chronic low back pain who would respond best to a treatment based on the Movement System Impairment model.ObjectivesTo assess if specific characteristics of people with chronic low back pain measured at baseline can modify the effects of a treatment based on the Movement System Impairment model on pain and disability.MethodsFour variables assessed at baseline that could potentially modify the treatment effects of the treatment based on the Movement System Impairment model were selected (age, educational status, physical activity status and STarT back tool classification). Separate univariate models were used to investigate a possible modifier treatment effect of baseline participant's characteristics on pain and disability after the treatment. Findings of interaction values above 1 point for the outcome mean pain intensity or above 3 points for disability (Roland Morris questionnaire) were considered clinically relevant.ResultsLinear regression analyses for the outcomes of pain and disability did not show interaction values considered clinically relevant for age, educational status, physical activity status and STarT back tool classification.ConclusionAge, educational status, physical activity status and STarT back tool classification did not modify the effects of an 8-week treatment based on the Movement System Impairment model in patients with chronic low back pain.Registered at www.clinicaltrials.gov: NCT02221609 (https://clinicaltrials.gov/ct2/show/NCT02221609).     

Yoga for pain and sleep quality in rheumatoid arthritis: study protocol for a pilot randomized controlled trial

Background:

Yoga is a popular complementary and alternative medicine (CAM) therapy among people with rheumatoid arthritis (RA), perceived as offering self-management options for physical and psychosocial symptoms associated with RA.

Objectives:

The primary aims of the current pilot study are (1) to assess the feasibility and safety of a relaxation-focused yoga intervention tailored for people with RA and (2) to estimate the effect of yoga on RA-related pain, sleep quality, functional disability, disease activity, quality of life, anxiety, depression, and fatigue.

Method:

Twenty-eight participants with at least minimum levels of RA-related pain and sleep disturbance will be recruited from a local public hospital database. Participants meeting inclusion criteria will be randomized into either a yoga group (receiving an 8-week program of once-weekly 75-minute relaxation-based yoga classes and thrice-weekly home practice), or a usual care control group. Outcomes will be assessed at baseline, 9, and 12 weeks. Feasibility is operationalized as acceptability (recruitment, adherence, participant retention, and participant satisfaction) and safety of the yoga intervention. Effect sizes for changes in pain, sleep quality, functional disability, disease activity, quality of life, mental health, and fatigue will be estimated.

Discussion:

Results of this pilot study will provide empirical data to determine if a larger, statistically powered main trial is feasible and safe in a national RA population. Additionally, participant feedback will provide information regarding further adaption and tailoring of the study protocol to a clinical RA population.

Trial registration:

Australian New Zealand Clinical Trials Registry ACTRN12612001019897 (registered 20/09/2012).     

Xenon-induced changes in CNS sensitization to pain

Electrophysiological investigations of the spinal cord in animals have shown that pain sensitizes the central nervous system via glutamate receptor dependent long-term potentiation (LTP) related to an enhancement of pain perception. To expand these findings, we used functional magnetic resonance (fMRI), blood oxygen level dependent (BOLD) and perfusion imaging in combination with repeated electrical stimulation in humans. Specifically we monitored modulation of somatosensory processing during inhibition of excitatory transmission by ocular application of the glutamate receptor antagonist xenon. BOLD responses upon secondary stimulation increased in mid insular and in primary/secondary sensory cortices under placebo and decreased under xenon treatments. Xenon-induced decreases in regional perfusion were confined to stimulation responsive brain regions and correlated with time courses of xenon concentrations in the cranial blood. Moreover, effects of xenon on behavioral, fMRI and perfusion data scaled with stimulus intensity. The dependence of pain sensitization on sufficient pre-activation reflects a multistage process which is characteristic for glutamate receptor related processes of LTP. This study demonstrates how LTP related processes known from the cellular level can be investigated at the brain systems level.     

fMRI of pain processing in the brain: a within-animal comparative study of BOLD vs. CBV and noxious electrical vs. noxious mechanical stimulation in rat

This study aims to identify fMRI signatures of nociceptive processing in whole brain of anesthetized rats during noxious electrical stimulation (NES) and noxious mechanical stimulation (NMS) of paw. Activation patterns for NES were mapped with blood oxygen level dependent (BOLD) and cerebral blood volume (CBV) fMRI, respectively, to investigate the spatially-dependent hemodynamic responses during nociception processing. A systematic evaluation of fMRI responses to varying frequencies of electrical stimulus was carried out to optimize the NES protocol. Both BOLD and CBV fMRI showed widespread activations, but with different spatial characteristics. While BOLD and CBV showed well-localized activations in ipsilateral dorsal column nucleus, contralateral primary somatosensory cortex (S1), and bilateral caudate putamen (CPu), CBV fMRI showed additional bilateral activations in the regions of pons, midbrain and thalamus compared to BOLD fMRI. CBV fMRI that offers higher sensitivity compared to BOLD was then used to compare the nociception processing during NES and NMS in the same animal. The activations in most regions were similar. In the medulla, however, NES induced a robust activation in the ipsilateral dorsal column nucleus while NMS showed no activation. This study demonstrates that (1) the hemodynamic response to nociception is spatial-dependent; (2) the widespread activations during nociception in CBV fMRI are similar to what have been observed in ¹⁴C-2-deoxyglucose (2DG) autoradiography and PET; (3) the bilateral activations in the brain originate from the divergence of neural responses at supraspinal level; and (4) the similarity of activation patterns suggests that nociceptive processing in rats is similar during NES and NMS.     

Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study

The objectives of this pilot study were to assess the feasibility of recruitment and adherence to an eight-session mindfulness meditation program for community-dwelling older adults with chronic low back pain (CLBP) and to develop initial estimates of treatment effects. It was designed as a randomized, controlled clinical trial. Participants were 37 community-dwelling older adults aged 65 years and older with CLBP of moderate intensity occurring daily or almost every day. Participants were randomized to an 8-week mindfulness-based meditation program or to a wait-list control group. Baseline, 8-week and 3-month follow-up measures of pain, physical function, and quality of life were assessed. Eighty-nine older adults were screened and 37 found to be eligible and randomized within a 6-month period. The mean age of the sample was 74.9 years, 21/37 (57%) of participants were female and 33/37 (89%) were white. At the end of the intervention 30/37 (81%) participants completed 8-week assessments. Average class attendance of the intervention arm was 6.7 out of 8. They meditated an average of 4.3 days a week and the average minutes per day was 31.6. Compared to the control group, the intervention group displayed significant improvement in the Chronic Pain Acceptance Questionnaire Total Score and Activities Engagement subscale (P=.008, P=.004) and SF-36 Physical Function (P=.03). An 8-week mindfulness-based meditation program is feasible for older adults with CLBP. The program may lead to improvement in pain acceptance and physical function.     

An fMRI study on the acute effects of exercise on pain processing in trained athletes

Endurance exercise is known to promote sustained antinociceptive effects, and there is evidence that the reduction of pain perception mediated by exercise is driven by central opioidergic neurotransmission. To directly investigate the involved brain areas and the underlying neural mechanisms in humans, thermal heat-pain challenges were applied to 20 athletes during 4 separate functional magnetic resonance imaging (fMRI) scans, i.e., before and after 2 hours of running (exercise condition) and walking (control condition), respectively. Imaging revealed a reproducible pattern of distributed pain-related activation in all 4 conditions, including the mesial and lateral pain systems, and the periaqueductal gray (PAG) as a key region of the descending antinociceptive pathway. At the behavioral level, running as compared with walking decreased affective pain ratings. The influence of exercise on pain-related activation was reflected in a significant time × treatment interaction in the PAG, along with similar trends in the pregenual anterior cingulate cortex and the middle insular cortex, where pain-induced activation levels were elevated after walking, but decreased or unchanged after running. Our findings indicate that enhanced reactive recruitment of endogenous antinociceptive mechanisms after aversive repeated pain exposure is attenuated by exercise. The fact that running, but not walking, reproducibly elevated β-endorphin levels in plasma indicates involvement of the opioidergic system in exercise. This may argue for an elevated opioidergic tone in the brain of athletes, mediating antinociceptive mechanisms. Our findings provide the first evidence using functional imaging to support the role of endurance exercise in pain modulation.     

Cognitive processing in putative functional gastrointestinal disorder: Rumination yields orientation to social threat not pain

Two possible roles of selective attention in the development and maintenance of functional gastrointestinal disorders (FGID) such as irritable bowel syndrome (IBS) were examined. First, hypervigilance to pain within FGID may exacerbate pain perception and pain‐related distress. Second, hypervigilance to socially threatening stimuli could account for the disrupted social functioning reported by patients. Furthermore, stress‐related variations in reported symptom severity and functioning impairments may reflect changes in cognitive bias with psychological state. Patterns of selective attention were probed within a sample of putative FGID participants (pFGID). The effect of rumination induction on performance on a modified exogenous cueing task was examined. Thirty‐three women with pFGID and 27 matched controls responded to dot probes following pain, social threat and neutral word cues, both before and after rumination (passive self‐focused thought), or distraction induction. Reaction times revealed that after rumination but not neutral distraction, pFGID participants showed enhanced attention to social threat words, but not to pain or neutral words. Between‐group differences in mood, anxiety or depression could not account for these effects. These results implicate selective attention in social but not pain‐related idiosyncrasies in FGID including IBS.     

Signal valence in the nucleus accumbens to pain onset and offset

Pain and relief are at opposite ends of the reward–aversion continuum. Studying them provides an opportunity to evaluate dynamic changes in brain activity in reward–aversion pathways as measured by functional magnetic resonance imaging (fMRI). Of particular interest is the nucleus accumbens (NAc), a brain substrate known to be involved in reward–aversion processing, whose activation valence has been observed to be opposite in response to reward or aversive stimuli. Here we have used pain onset (aversive) and pain offset (rewarding) involving a prolonged stimulus applied to the dorsum of the hand in 10 male subjects over 120 s to study the NAc fMRI response. The results show a negative signal change with pain onset and a positive signal change with pain offset in the NAc contralateral to the stimulus. The study supports the idea that the NAc fMRI signal may provide a useful marker for the effects of pain and analgesia in healthy volunteers.     

The contribution of sensory system functional connectivity reduction to clinical pain in fibromyalgia

Fibromyalgia typically presents with spontaneous body pain with no apparent cause and is considered pathophysiologically to be a functional disorder of somatosensory processing. We have investigated potential associations between the degree of self-reported clinical pain and resting-state brain functional connectivity at different levels of putative somatosensory integration. Resting-state functional magnetic resonance imaging was obtained in 40 women with fibromyalgia and 36 control subjects. A combination of functional connectivity-based measurements were used to assess (1) the basic pain signal modulation system at the level of the periaqueductal gray (PAG); (2) the sensory cortex with an emphasis on the parietal operculum/secondary somatosensory cortex (SII); and (3) the connectivity of these regions with the self-referential “default mode” network. Compared with control subjects, a reduction of functional connectivity was identified across the 3 levels of neural processing, each showing a significant and complementary correlation with the degree of clinical pain. Specifically, self-reported pain in fibromyalgia patients correlated with (1) reduced connectivity between PAG and anterior insula; (2) reduced connectivity between SII and primary somatosensory, visual, and auditory cortices; and (3) increased connectivity between SII and the default mode network. The results confirm previous research demonstrating abnormal functional connectivity in fibromyalgia and show that alterations at different levels of sensory processing may contribute to account for clinical pain. Importantly, reduced functional connectivity extended beyond the somatosensory domain and implicated visual and auditory sensory modalities. Overall, this study suggests that a general weakening of sensory integration underlies clinical pain in fibromyalgia.     

tDCS modulates cortical nociceptive processing but has little to no impact on pain perception

Transcranial direct current stimulation (tDCS) effectively modulates cortical excitability. Several studies suggest clinical efficacy in chronic pain syndromes. However, little is known regarding its effects on cortical pain processing. In this double-blind, randomized, cross-over, sham controlled study, we examined the effects of anodal, cathodal, and sham stimulation of the left motor cortex in 16 healthy volunteers using functional imaging during an acute heat pain paradigm as well as pain thresholds, pain intensity ratings, and quantitative sensory testing. tDCS was applied at 1 mA for 15 minutes. Neither cathodal nor anodal tDCS significantly changed brain activation in response to nociceptive stimulation when compared with sham stimulation. However, contrasting the interaction of stimulation modes (anodal/cathodal) resulted in a significant decrease of activation in the hypothalamus, inferior parietal cortex, inferior parietal lobule, anterior insula, and precentral gyrus, contralateral to the stimulation site after anodal stimulation, which showed the opposite behavior after cathodal stimulation. Pain ratings and heat hyperalgesia showed only a subclinical pain reduction after anodal tDCS. Larger-scale clinical trials using higher tDCS intensities or longer durations are necessary to assess the neurophysiological effect and subsequently the therapeutic potential of tDCS.     

Findings from a pilot study of Trauma Center Trauma-Sensitive Yoga versus cognitive processing therapy for PTSD related to military sexual trauma among women Veterans

ObjectiveThe study objective was to explore the preliminary efficacy of trauma-sensitive yoga compared to cognitive processing therapy (CPT) for women Veterans with posttraumatic stress disorder (PTSD) related to military sexual trauma (MST) in a pilot randomized control trial (RCT). We then compared these results to published interim results for the subsequent full-scale RCT.MethodThe analytic sample included women Veterans (N = 41) with PTSD related to MST accessing healthcare in a southeastern Veterans Affairs Health Care System. The majority were African American, non-Hispanic (80.5 %). The protocol-driven group interventions, Trauma Center Trauma-Sensitive Yoga (TCTSY; n = 17) and the evidence-based control condition, CPT (n = 24), were delivered weekly for 10 and 12 sessions, respectively. Multilevel linear models (MLM) were used to compare changes over time between the two groups.ResultsThe primary outcomes presented here are PTSD symptom severity and diagnosis, assessed using the Clinician Administered PTSD Scale (CAPS) and the PTSD Symptom Checklist (PCL) total scores. PTSD symptom severity on both clinician-administered (CAPS) and self-reported (PCL) measures, improved significantly (p < .005) over time, with large within group effect sizes (0.90–0.99) consistent with the subsequent RCT. Participants in the TCTSY group showed clinically meaningful improvements earlier than the CPT group participants from baseline on the CAPS and PCL Total scores.ConclusionsResults support published findings of the effectiveness of TCTSY in the treatment for PTSD related to MST among women Veterans, particularly African American women. TCTSY warrants consideration as an adjunctive, precursor, or concurrent treatment to evidence-based psychotherapies. Future research should include patient preference, men with sexual trauma, and civilian populations.     

Brain activity in near-death experiencers during a meditative state

Aim

To measure brain activity in near-death experiencers during a meditative state.

Methods

In two separate experiments, brain activity was measured with functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) during a Meditation condition and a Control condition. In the Meditation condition, participants were asked to mentally visualize and emotionally connect with the “being of light” allegedly encountered during their “near-death experience”. In the Control condition, participants were instructed to mentally visualize the light emitted by a lamp.

Results

In the fMRI experiment, significant loci of activation were found during the Meditation condition (compared to the Control condition) in the right brainstem, right lateral orbitofrontal cortex, right medial prefrontal cortex, right superior parietal lobule, left superior occipital gyrus, left anterior temporal pole, left inferior temporal gyrus, left anterior insula, left parahippocampal gyrus and left substantia nigra. In the EEG experiment, electrode sites showed greater theta power in the Meditation condition relative to the Control condition at FP1, F7, F3, T5, P3, O1, FP2, F4, F8, P4, Fz, Cz and Pz. In addition, higher alpha power was detected at FP1, F7, T3 and FP2, whereas higher gamma power was found at FP2, F7, T4 and T5.

Conclusions

The results indicate that the meditative state was associated with marked hemodynamic and neuroelectric changes in brain regions known to be involved either in positive emotions, visual mental imagery, attention or spiritual experiences.     

Perceiving pain in others: validation of a dual processing model

Accurate perception of another person’s painful distress would appear to be accomplished through sensitivity to both automatic (unintentional, reflexive) and controlled (intentional, purposive) behavioural expression. We examined whether observers would construe diverse behavioural cues as falling within these domains, consistent with cognitive neuroscience findings describing activation of both automatic and controlled neuroregulatory processes. Using online survey methodology, 308 research participants rated behavioural cues as “goal directed vs. non-goal directed,” “conscious vs. unconscious,” “uncontrolled vs. controlled,” “fast vs. slow,” “intentional (deliberate) vs. unintentional,” “stimulus driven (obligatory) vs. self driven,” and “requiring contemplation vs. not requiring contemplation.” The behavioural cues were the 39 items provided by the PROMIS pain behaviour bank [27], constructed to be representative of the diverse possibilities for pain expression. Inter-item correlations among rating scales provided evidence of sufficient internal consistency justifying a single score on an automatic/controlled dimension (excluding the inconsistent fast vs. slow scale). An initial exploratory factor analysis on 151 participant data sets yielded factors consistent with “controlled” and “automatic” actions, as well as behaviours characterized as “ambiguous.” A confirmatory factor analysis using the remaining 151 data sets replicated EFA findings, supporting theoretical predictions that observers would distinguish immediate, reflexive, and spontaneous reactions (primarily facial expression and paralinguistic features of speech) from purposeful and controlled expression (verbal behaviour, instrumental behaviour requiring ongoing, integrated responses). There are implicit dispositions to organize cues signaling pain in others into the well-defined categories predicted by dual process theory.     

Finding the evidence to change practice for assessing pain in children who are cognitively impaired

We report on a quality improvement project whose purpose was to systematically review behavioral pain assessment tools for children who are cognitively impaired, with the goal of identifying a valid and reliable tool for clinical practice. In addition, we sought to partner with parents and/or caregivers to expand their role in pain assessment. The project team conducted an extensive synthesis of the literature to examine the availability and quality of published pain assessment tools for use with children with cognitive impairment (CI) or developmental disability. Once completed, we identified 2 of the available 10 tools to test in the clinical setting. Data from this quality improvement project provided evidence to support the adoption of the revised Faces, Legs, Activity, Cry, and Consolability pain assessment tool for children with CI into clinical practice.