Asimina Lazaridou

Yoga and mindfulness as therapeutic interventions for stroke rehabilitation: a systematic review.

Aim. This paper reports a systematic review and critical appraisal of the evidence on the effectiveness of behavioral therapies such as yoga and mindfulness practices for stroke rehabilitation. Background. The experience of stroke can have a negative impact on both psychological and physical health and on quality of life. Yoga and relevant practices are promising therapies that have been used with patients with a variety of conditions. In order to draw conclusions on effectiveness for stroke patients, the evidence requires systematic assessment. Methods. A comprehensive search of major biomedical and complementary medicine databases was conducted. Relevant research was categorized by study type and appraised according to study design. Results. Five randomized controlled clinical trials and four single case studies were found. Additionally, one qualitative research study was identified. Studies reported positive results, including improvements in cognition, mood, and balance and reductions in stress. Modifications to different yoga practices make comparison between studies difficult, and a lack of controlled studies precludes any firm conclusions on efficacy. Conclusion. Yoga and mindfulness could be clinically valuable self-administered intervention options for stroke rehabilitation. Further research is needed to evaluate these specific practices and their suitability in stroke rehabilitation.

Getting personal: The role of individual patient preferences and characteristics in shaping pain treatment outcomes

The topical review entitled “Must we reduce pain intensity to treat chronic pain?” by Sullivan and Ballantyne makes a cogent and thoughtful case for the consideration of outcomes other than pain intensity when evaluating the effectiveness of treatments applied to patients with chronic pain. Although pain intensity is usually designated as the primary outcome in randomized controlled trials (RCTs) of analgesics, it has been clear for some time that the nature of pain as a subjective internal state, evaluated through introspection, poses a substantial challenge to clinical investigators who wish to measure its intensity, and that a comprehensive assessment of chronic pain requires multidimensional assessment instruments. Sullivan and Ballantyne suggest that the privileging of pain intensity as an outcome over other domains such as function, or quality of life, has contributed to the escalation of chronic opioid therapy in the United States, and to the well-documented phenomenon of adverse selection, which has had profound deleterious consequences. In this context, as described in the topical review, it is noteworthy that most efficacious empirically supported nonpharmacological treatments (eg, Cognitive Behavioral Therapy) often use pain interference, or painrelated function, as their primary outcome rather than pain intensity. We certainly concur that an array of multidimensional outcomes is important in characterizing the effects of any given treatment. Our group recently reported that patientreported medication side effects (for a variety of analgesics, not just opioids) are prospectively associated with increased functional interference in patients with chronic pain. Such effects are often overlooked in the calculus of determining whether a given treatment is beneficial overall, but these findings suggest that the potential impact of side effects on physical and cognitive function are likely to be significant contributors to key outcomes. Moreover, a large-scale survey by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) group reported that a number of treatment domains are rated as “extremely important” to patients when determining the effectiveness of a given intervention. These include enjoyment of life, emotional well-being, fatigue, weakness, difficulty concentrating, and sleep-related problems. As Sullivan and Ballantyne note, administration of opioids may have strongly beneficial effects on pain intensity while providing no benefit or potentially producing deterioration in other outcome domains. Furthermore, a narrow focus on verbal report of recalled pain intensity seems problematic in that a series of studies has revealed that patients use a troublingly broad array of approaches when rating their average weekly pain, and these approaches are unlikely to be stable over time. As Broderick et al. summarize their interview-based findings: “Most patients were unable to coherently articulate how they derived their ratings. Moreover, there was no consistency across patients” (page 142). Happily, a recent IMMPACT review of trials of opioids for chronic noncancer pain suggests that such trials are, over time, increasingly measuring and reporting a diverse array of outcomes such as physical functioning and sleep (which can be measured in a fairly “objective” manner using indices such as return to work, or devices such as wrist actigraphs), although there is still much work to be done in this arena. We would like to highlight a critical implication of this topical review that is largely implicit: The field is in need of much more high-quality clinical research investigating what phenotypic patient characteristics are reliably associated with treatment outcomes. Such phenotyping research serves as a foundation for personalized pain therapeutics (ie, empirically based algorithms that determine the optimal treatments, or treatment combinations, for individual patients) that would presumably improve the clinical care of patients with pain, enhance success rates for putative analgesic drugs in RCTs, and minimize iatrogenic harm. As Sullivan and Ballantyne suggest, not all patients with chronic pain benefit from opioid therapy, and some clearly experience detrimental effects. They note that “Patients who report chronic pain of very high intensity (eg, 10/10) may actually be the patients who will benefit least from the most potent analgesics” (page 8), though we would argue that this particular position is not consistent with the preponderance of evidence in this area. Findings from an array of RCTs suggest that the patients reporting the highest pain intensity levels obtain the largest benefit from analgesics, which has led to IMMPACT recommendations to consider raising pain intensity entry criteria for RCTs if the intent is to maximize assay sensitivity for a given medication. In a placebo-controlled crossover trial among patients with postherpetic neuralgia, we found that high baseline pain intensity ratings were prospectively associated with larger analgesic effects across several active treatments, Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Mindfulness and sexuality

Mindfulness seems to associate with positive effects on health and overall wellbeing. However, little research has indicated association between mindfulness and sexuality. The goal of this study was to test the hypothesis that mindfulness correlates with sexuality in healthy people. We conducted a cross-sectional study with people who practice yoga or meditation (n = 51), people who have done a sport for over 10 years (n = 21) and people who have done none of the above (n = 145) by studying correlations between mindfulness and sexuality. A total of 215 men and women participated in this study (M = 31.61, SD = 9.24). We measured mindfulness and sexuality by distri-buting the Langers Mindfulness Scale and the Multidimensional Sexuality Questionnaire. We explored whether mindfulness subscales correlate with any of the sexuality subscales in these three study groups, irrespectively. People in the meditation/yoga group had been practicing mindfulness and different meditative practices (including vipassana and yoga) for over 10 years. We found significant higher scores in the novelty-seeking component in people who meditate compared to athletes. Even though our results showed that the group of people who do a sport have less sexual anxiety and sexual depression compared to the meditators, these results were not at a statistically significant level. Additionally, no significant differences were found between the other groups. We found positive correlations between all mindfulness subscales (engagement, novelty seeking, novelty producing and flexibility) and sexual motivation, and between novelty seeking and sexual consciousness. Our findings seem to indicate that mindfulness correlates positively with sexual motivation and sexual consiousness. In particular, people who practice meditation or yoga showed higher levels in novelty seeking (mindfulness subscale) compared to people who play sport. Novelty seeking might be an important component in affecting sexuality.

Effects of Cognitive-behavioral Therapy (CBT) on Brain Connectivity Supporting Catastrophizing in Fibromyalgia

Objective(s): Fibromyalgia (FM) is a chronic, common pain disorder characterized by hyperalgesia. A key mechanism by which cognitive-behavioral therapy (CBT) fosters improvement in pain outcomes is via reductions in hyperalgesia and pain-related catastrophizing, a dysfunctional set of cognitive-emotional processes. However, the neural underpinnings of these CBT effects are unclear. Our aim was to assess CBT’s effects on the brain circuitry underlying hyperalgesia in FM patients, and to explore the role of treatment-associated reduction in catastrophizing as a contributor to normalization of pain-relevant brain circuitry and clinical improvement. Methods: In total, 16 high-catastrophizing FM patients were enrolled in the study and randomized to 4 weeks of individual treatment with either CBT or a Fibromyalgia Education (control) condition. Resting state functional magnetic resonance imaging scans evaluated functional connectivity between key pain-processing brain regions at baseline and posttreatment. Clinical outcomes were assessed at baseline, posttreatment, and 6-month follow-up. Results: Catastrophizing correlated with increased resting state functional connectivity between S1 and anterior insula. The CBT group showed larger reductions (compared with the education group) in catastrophizing at posttreatment (P<0.05), and CBT produced significant reductions in both pain and catastrophizing at the 6-month follow-up (P<0.05). Patients in the CBT group also showed reduced resting state connectivity between S1 and anterior/medial insula at posttreatment; these reductions in resting state connectivity were associated with concurrent treatment-related reductions in catastrophizing. Discussion: The results add to the growing support for the clinically important associations between S1-insula connectivity, clinical pain, and catastrophizing, and suggest that CBT may, in part via reductions in catastrophizing, help to normalize pain-related brain responses in FM.

fMRI as a molecular imaging procedure for the functional reorganization of motor systems in chronic stroke

Previous brain imaging studies suggest that stroke alters functional connectivity in motor execution networks. Moreover, current understanding of brain plasticity has led to new approaches in stroke rehabilitation. Recent studies showed a significant role of effective coupling of neuronal activity in the SMA (supplementary motor area) and M1 (primary motor cortex) network for motor outcome in patients after stroke. After a subcortical stroke, functional magnetic resonance imaging (fMRI) during movement reveals cortical reorganization that is associated with the recovery of function. The aim of the present study was to explore connectivity alterations within the motor-related areas combining motor fMRI with a novel MR-compatible hand-induced robotic device (MR_CHIROD) training. Patients completed training at home and underwent serial MR evaluation at baseline and after 8 weeks of training. Training at home consisted of squeezing a gel exercise ball with the paretic hand at ~75% of maximum strength for 1 h/day, 3 days/week. The fMRI analysis revealed alterations in M1, SMA, PMC (premotor cortex) and Cer (cerebellum) in both stroke patients and healthy controls after the training. Findings of the present study suggest that enhancement of SMA activity could benefit M1 dysfunction in stroke survivors. These results also indicate that connectivity alterations between motor areas might assist the counterbalance of a functionally abnormal M1 in chronic stroke survivors and possibly other patients with motor dysfunction.

Diffusion tensor and volumetric magnetic resonance imaging using an MR-compatible hand-induced robotic device suggests training-induced neuroplasticity in patients with chronic stroke

Stroke is the third leading cause of mortality and a frequent cause of long-term adult impairment. Improved strategies to enhance motor function in individuals with chronic disability from stroke are thus required. Post-stroke therapy may improve rehabilitation and reduce long-term disability; however, objective methods for evaluating the specific impact of rehabilitation are rare. Brain imaging studies on patients with chronic stroke have shown evidence for reorganization of areas showing functional plasticity after a stroke. In this study, we hypothesized that brain mapping using a novel magnetic resonance (MR)-compatible hand device in conjunction with state-of-the-art magnetic resonance imaging (MRI) can serve as a novel biomarker for brain plasticity induced by rehabilitative motor training in patients with chronic stroke. This hypothesis is based on the premises that robotic devices, by stimulating brain plasticity, can assist in restoring movement compromised by stroke-induced pathological changes in the brain and that these changes can then be monitored by advanced MRI. We serially examined 15 healthy controls and 4 patients with chronic stroke. We employed a combination of diffusion tensor imaging (DTI) and volumetric MRI using a 3-tesla (3T) MRI system using a 12-channel Siemens Tim coil and a novel MR-compatible hand-induced robotic device. DTI data revealed that the number of fibers and the average tract length significantly increased after 8 weeks of hand training by 110% and 64%, respectively (p<0.001). New corticospinal tract (CST) fibers projecting progressively closer to the motor cortex appeared during training. Volumetric data analysis showed a statistically significant increase in the cortical thickness of the ventral postcentral gyrus areas of patients after training relative to pre-training cortical thickness (p<0.001). We suggest that rehabilitation is possible for a longer period of time after stroke than previously thought, showing that structural plasticity is possible even after 6 months due to retained neuroplasticity. Our study is an example of personalized medicine using advanced neuroimaging methods in conjunction with robotics in the molecular medicine era.

The impact of anxiety and catastrophizing on interleukin-6 responses to acute painful stress

Objective To examine the influence of anxiety and pain-related catastrophizing on the time course of acute interleukin-6 (IL-6) responses to standardized noxious stimulation among patients with chronic pain. Methods Data were collected from 48 participants in the following demographically matched groups: patients with chronic pain (n=36) and healthy controls (n=12). Participants underwent a series of Quantitative Sensory Testing (QST) procedures assessing responses to mechanical and thermal stimuli during two separate visits, in a randomized order. One visit consisted of standard, moderately painful QST procedures, while the other visit involved nonpainful analogs to these testing procedures. Blood samples were taken at baseline, and then for up to 2 hours after QST in order to study the time course of IL-6 responses. Results Results of multilevel analyses revealed that IL-6 responses increased across assessment time points in both visits (p<0.001). While patients with chronic pain and healthy controls did not differ in the magnitude of IL-6 responses, psychological factors influenced IL-6 trajectories only in the chronic pain group. Among patients, increases in catastrophizing over the course of the QST session were associated with elevated IL-6 responses only during the painful QST session (p<0.05). When controlling for anxiety, results indicated that the main multilevel model among patients remained significant (p<0.05). Conclusion Under specific conditions (eg, application of a painful stressor), catastrophizing may be associated with amplified proinflammatory responses in patients with persistent pain. These findings suggest that psychosocial interventions that reduce negative pain-related cognitions may benefit patients’ inflammatory profiles.

Encoding of Self-Referential Pain Catastrophizing in the Posterior Cingulate Cortex in Fibromyalgia

Pain catastrophizing is a common feature of chronic pain, including fibromyalgia (FM), and is strongly associated with amplified pain severity and disability. While previous neuroimaging studies have focused on evoked pain response modulation by catastrophizing, the brain mechanisms supporting pain catastrophizing itself are unknown. We designed a functional magnetic resonance imaging (fMRI)–based pain catastrophizing task whereby patients with chronic pain engaged in catastrophizing‐related cognitions. We undertook this study to test our hypothesis that catastrophizing about clinical pain would be associated with amplified activation in nodes of the default mode network (DMN), which encode self‐referential cognition and show altered functioning in chronic pain.

Mindfulness and spirituality: therapeutic perspectives

ABSTRACT Social aspects that relate to beliefs and spirituality are subjects of the soul and mind, material to be studied out of the materialistic world. They transcend the body and nest in the experiences of the soul. Nonetheless, taught by mindfulness, a practice that stems from eastern spirituality the religious and/or the spiritual are experiences lived through the body. We conducted a pilot cross-sectional study to test the hypothesis that mindfulness correlates with spiritual beliefs. The results provide insight on the potential impact of mindfulness interventions in patients that value spirituality and metacognitive beliefs in the psychotherapeutic process. These preliminary findings provide a potential insight into the possible mechanisms underlying the application of mindfulness in psychotherapy.

Interactive effects of pain catastrophizing and mindfulness on pain intensity in women with fibromyalgia

The objective of this study was to examine the association between facets of trait mindfulness, pain catastrophizing, and pain severity in a sample of patients with fibromyalgia. Patients with fibromyalgia completed validated baseline and diary assessments of clinical pain, mindfulness, and pain catastrophizing. Multilevel modeling analyses indicated that the daily association between catastrophizing and pain intensity was moderated by certain mindfulness facets. Our findings suggest that various aspects of mindfulness may interact differently with pain and catastrophizing, which may have implications for the design and testing of interventions targeting mindfulness and catastrophizing in fibromyalgia patients.