Søren Ballegaard

The Effect of Daily Self-Measurement of Pressure Pain Sensitivity Followed by Acupressure on Depression and Quality of Life versus Treatment as Usual in Ischemic Heart Disease: A Randomized Clinical Trial

Background Depressive symptoms and reduced quality of life (QOL) are parts of the chronic stress syndrome and predictive of adverse outcome in patients with ischemic heart disease (IHD). Chronic stress is associated with increased sensitivity for pain, which can be measured by algometry as Pressure Pain Sensitivity (PPS) on the sternum. Aim To evaluate if stress focus by self-measurement of PPS, followed by stress reducing actions including acupressure, can decrease depressive symptoms and increase psychological well-being in people with stable IHD. Design Observer blinded randomized clinical trial over 3 months of either intervention or treatment as usual (TAU). Statistical analysis: Intention to treat. Methods Two hundred and thirteen participants with IHD were included: 106 to active treatment and 107 to TAU. Drop-out: 20 and 12, respectively. The active intervention included self-measurement of PPS twice daily followed by acupressure as mandatory action, aiming at a reduction in PPS. Primary endpoint: change in depressive symptoms as measured by Major depression inventory (MDI). Other endpoints: changes in PPS, Well-being (WHO-5) and mental and physical QOL (SF-36). Results At 3 months PPS decreased 28%, to 58, in active and 11%, to 72, in TAU, p<0.001. MDI decreased 22%, to 6.5, in active group vs. 12%, to 8.3 in TAU, p = 0.040. WHO-5 increased to 71.0 and 64.8, active group and TAU, p = 0.015. SF-36 mental score sum increased to 55.3 and 53.3, active and TAU, p = 0.08. Conclusions PPS measurements followed by acupressure reduce PPS, depressive symptoms and increase QOL in patients with stable IHD. Trial Registration ClinicalTrials.gov NCT01513824

Pressure pain sensitivity: a new method of stress measurement in patients with ischemic heart disease.

Abstract Background. Chronic stress is prevalent in patients with ischemic heart disease (IHD) and worsens the long-term prognosis. Chronic stress is vaguely defined, but is associated with depressive symptoms, reduced psychological wellbeing, and reduced quality of life (QOL). Stress seems to induce hyperalgesia.The aim of the present study was to evaluate hyperalgesia by pressure pain sensitivity (PPS) in patients with IHD, and compare PPS to questionnaires measuring depressive symptoms, reduced psychological wellbeing, and QOL as markers of stress. Design. A cross-sectional study of 361 subjects with IHD. Methods. PPS was measured on the sternum, and compared to the questionnaires: Clinical stress symptoms score (CSS), Major Depression Inventory (MDI), WHO-5 Wellbeing Index, and SF-36 QOL score. Results. PPS correlated to CSS (r = 0.20, p < 0.001), MDI (r = 0.14, p = 0.02), SF-36 mental component summary score (MCS) (r = − 0.10, p = 0.049), SF-36 physical component summary score (PCS) (r = − 0.17, p = 0.001), and self-perceived stress level (r = 0.15, p = 0.006). CSS correlated similarly (r = 0.5–0.7, all p < 0.001). Comparing subjects within the lowest vs. highest tertiles of PPS and CSS, the mean MDI score was 4 vs. 15, WHO-5 was 77 vs. 53, SF-36 PCS was 53 vs. 43, and SF-36 MCS was 58 vs. 46; all p < 0.001. Conclusions. PPS reflected to a modest degree markers of chronic stress in IHD. PPS and CSS together might be useful as easy-to use tools for evaluating these markers in IHD patients.

The association between pressure pain sensitivity, and answers to questionnaires estimating psychological stress level in the workplace A feasibility study

Abstract Objectives. To examine the association between pressure pain sensitivity (PPS) at the sternum as a measure of persistent stress assessed by questionnaires in a working population. Methods. In 308 office employees PPS measurement was compared to Quality of life questionnaires: SF-36 for general physical and mental health, the Major Depression Inventory (MDI); 50 specific clinical symptoms for persistent stress; subjective evaluation of present and long-term stress level on a 7-point ordinal scale. Repeated measures were used to validate the PPS method. Results. A significant correlation between PPS and a persistent stress condition evaluated from SF-36, MDI and a number of clinical symptoms were found (all p < 0.01). Persons with PPS ≥ 60 units had an elevated health risk profile based on the questionnaires, when compared to persons with PPS ≤ 40 (all p < 0.05) (all odds ratios > 2). When categorizing a person with PPS ≥ 60 as persistently stressed (27% of subject), and using SF-36, MDI and the number of stress signs for risk calculation, the remaining 73% of the subjects, with no elevated health risk factors, were identified with an 80% specificity. During home measurements, with a full day between measurements, between-measurement correlation coefficient was 0.87 and categorization reproducibility 87% (both p < 0.001). Conclusions. In office workers, the PPS measurement correlated to several QOL questionnaires and was found useful for persistent stress screening. Validation studies demonstrated sufficient reproducibility including during self measurement at home.

The association between changes in pressure pain sensitivity and changes in cardiovascular physiological factors associated with persistent stress

Abstract Objectives. To evaluate the possible association between pressure pain sensitivity of the chest bone (PPS) and cardiovascular physiological factors related to persistent stress in connection with a three-month PPS-guided stress-reducing experimental intervention programme. Methods. Forty-two office workers with an elevated PPS (≥ 60 arbitrary units) as a sign of increased level of persistent stress, completed a single-blinded cluster randomized controlled trial. The active treatment was a PPS (self-measurement)-guided stress management programme. Primary endpoints: Blood pressure (BP), heart rate (HR) and work of the heart measured as Pressure-Rate-Product (PRP); Secondary endpoints: Other features of the metabolic syndrome. Results. PPS decreased and changes in PPS after the intervention period were significantly associated with HR, PRP, body mass index (BMI) and visceral fat index (all correlation coefficients > 0.2, p < 0.05). Compared to the control cluster group, the active cluster group obtained a significant reduction in PPS, Low-density lipoprotein (LDL) cholesterol and total number of elevated risk factors (p < 0.05). On an individual level, significant and clinically relevant between-group reductions were observed in respect to BP, HR, PRP, total and LDL cholesterol, and total number of elevated risk factors (p < 0.05). Conclusions. The stress intervention method applied in this study induced a decrease in PPS which was associated with a clinically relevant decrease in resting blood pressure, heart rate, work of the heart and serum cholesterols.

Chronic psychological stress seems associated with elements of the metabolic syndrome in patients with ischaemic heart disease

Abstract Background and objectives: Chronic psychological stress, the metabolic syndrome (MS) and ischaemic heart disease (IHD) seem closely connected. In this study, we evaluate the association between chronic stress and elements of MS in patients with stable IHD. Design: Cross-sectional cohort study. Methods: Three hundred and fifty patients with stable IHD were included. Chronic stress was evaluated by the two questionnaires, Major Depression Inventory (MDI) and the psychological wellbeing index WHO-5, as well as by Pressure Pain Sensitivity (PPS), a physiological measure of hyperalgesia at the sternum known to be associated to elements of the chronic stress syndrome. Elements of MS were evaluated by dual-energy X-ray absorptiometry, body weight, HOMA-IR and blood lipids. Results: Depressive symptoms were associated with a high percentage of body fat (β = 0.179, p = .001), and high level of triglycerides (β = 0.150, p = .007). Low psychological wellbeing was associated with a high percentage of body fat (β = –0.165, p = .002) and low level of HDL cholesterol (β = 0.128, p = .024). Chronic stress measured by PPS was associated with a high percentage body fat (β = 0.327, p < .001), low body weight (β = –0.218, p < .001) and low HDL-cholesterol (β = –0.137, p = .013). Adjusting for several life style factors did not change these results. Conclusions: In patients with stable IHD, different measures of chronic psychological stress seem associated with a high percentage of body fat and adverse blood lipids independent of several lifestyle factors.

Association between pressure pain sensitivity and autonomic function as assessed by a tilt table test

Abstract Background. We tested the hypothesis that pressure sensitivity of the sternum (PPS) is associated with autonomic nervous system (ANS) function as assessed by tilt table test (TTT). in patients with stable ischemic heart disease. Objectives. (1) To evaluate an association between PPS and systolic blood pressure (SBP) and heart rate (HR) responses to TTT; and (2) to test the hypothesis that a reduction of resting PPS raises the PPS, SBP and HR responses to TTT response and lowers risk factors for ANS dysfunction (ANSD). Methods. Cross-sectional study: In 361 patients with stable ischemic heart disease we measured PPS, SBP, and HR during TTT. Intervention study: We reassessed subjects with persistent stress who concluded a stress intervention trial by a second TTT. Results. Cross-sectional study: Resting PPS and the PPS response to TTT were correlated (r = − 0.37). The PPS response to TTT was correlated with that of SBP (r = 0.44) and HR (r = 0.49), and with the number of risk factors for ANSD (r = − 0.21) (all p < 0.0001). Intervention study: A reduction in resting PPS was associated with an increment in PPS response to TTT (r = − 0.52, p < 0.0001). The greater this increment, the greater was the reduction in ANSD risk factors (r = − 0.23; p = 0.003). Conclusion. The results are consistent with the hypothesis that PPS at rest and in response to TTT reflects ANS function.

Pressure pain sensitivity as a marker for stress and pressure pain sensitivity-guided stress management in women with primary breast cancer.

Abstract Objectives. To validate (1) Pressure Pain Sensitivity (PPS) as a marker for stress and (2) a PPS-guided intervention in women with primary Breast Cancer (BC). Methods. (1) A total of 58 women with BC were examined before and after 6 months of intervention. A control group of 165 women office employees was divided in a High Stress Group (HSG, n = 37) and a Low Stress Group (LSG, n = 128) to evaluate the association between PPS, questionnaire-related Quality of Life (QOL) and self-evaluated stress. (2) A PPS-guided stress management program (n = 40) was compared to a Psychosocial Group Intervention (PGI, n = 91) and no treatment (n = 86) with respect to a European Organization for Research and Treatment of Cancer (EORTC) questionnaire measured QOL. Results. (1) Resting PPS and changes in PPS during the intervention period correlated significantly to EORTC and Short Form 36 (SF 36) main scores: (all p < 0.05). Between BC, HSG and LSG there was a significant and positive correlation with respect to PPS, SF 36 main scores, depression, and clinical stress scores (all p < 0.05). However, the BC group scored significantly lower than both HSG and LSG (both p < 0.05) with respect to self-evaluated stress. (2) The PPS-guided intervention group improved EORTC main score, pain and nausea, when compared to the control groups (all p < 0.05). Conclusions. PPS was positively associated with QOL, which was in contrast to self-evaluated stress. PPS-guided intervention improved QOL in women with breast cancer.

Diabetes and ischemic heart disease: double jeopardy with regard to depressive mood and reduced quality of life

The aim of this study was to test i) whether patients having diabetes and ischemic heart disease (IHD), i.e., patients suffering from two chronic diseases, demonstrate a higher degree of chronic stress when compared with patients suffering from IHD alone, and ii) whether suffering from the two chronic diseases results in an elevation in specific elements of the chronic stress concept. A total of 361 participants with IHD were included, of whom 47 suffered from concomitant diabetes. Stress was measured by pressure pain sensitivity (PPS) and by the following questionnaires: the Major Depression Inventory (MDI), the SF-36 Quality of Life questionnaire (SF-36 QOL), the WHO-5 Well-being Index, and the clinical stress signs (CSSs) scale. Participants with diabetes and IHD had a higher MDI score, a lower SF-36 physical component summary score, and a lower score of several sub-measurements of the SF-36 mental component score when compared with patients with IHD without diabetes. No significant differences were observed regarding stress measured by the PPS measure, the WHO-5 Well-being Index, or the number of CSSs. In conclusion, the combination of diabetes and IHD seems to be associated with increased depressive symptoms, lower overall physical QOL, and reduced mental QOL on several sub-elements of the questionnaire. This should be recognized in the management of patients with double diagnoses.

Pressure pain sensitivity

Introduction: the relationship between psychiatric symptoms and cancer has sparked a lot of interest in the scientific community. The available literature is mostly on the impact of cancer diagnosis. However, little is known about the patients psychological status before that. Studies in this area show that cancer patients often present depressive symptoms before the diagnosis of neoplastic disease, probably due to cytokine production by the tumors. Low concentrations of cytokines would be sufficient to change the patient’s emotional state. Case description: to alert clinicians to the possibility that psychiatric symptoms may be a signal of underlying cancer disease, especially in patients above 50 years without psychiatric history, we present the following case. A woman of 53 years, followed in the Portuguese Institute of Oncology of Coimbra since October 2009 for mixed adenocarcinoma of the lung (stage IB). Approximately 1 month later, in November 2009, she was referred to psychiatric consultation because of depressive symptoms and complains since 1 year before. She also reported history of thyroid goiter, emphysema, and depressive episode occurred 10 years begore. Since the cancer was diagnosed, depression has shown a fluctuating evolution. Various therapeutic settings were made, being currently medicated with venlafaxine 225 mg, trazodone 150 mg AC i.d., and lorazepam 2.5 mg i.d.. Comment: the emergence of psychiatric symptoms, especially in patients above 50 years, should alert the physician to the presence of a possible hidden cancer, especially in the case of patients without psychiatric history.Introduction: Stress has been hypothesized to be involved in obesity development. Apart from a direct pathway through cortisol, stress may indirectly facilitate obesity by influencing other lifestyle factors: stressed persons may consume more comfort foods, may have a more sedentary behaviour and may suffer from sleep problems. Methods: In 326 Belgian children (5-12y) of the ChiBS study, the longitudinal relation between stress and body composition was examined over two years. Stress was measured by salivary cortisol (4 samples/day, 2 days) and questionnaires concerning negative life events, problem behaviour and emotions. For body composition, BMI, waist-to-height and fat% estimation by air displacement were used. Furthermore, physical activity, screentime, food consumption, eating behaviour and sleep duration were measured as lifestyle factors. Cross-lagged analyses with Mplus and moderation by cortisol and lifestyle factors were tested. Results: Children with higher stress scores had a less healthy lifestyle. They had an unhealthier diet especially due to more sweet food consumption, performed more emotional eating, were less active and slept less. Two years later, these stressed children maintained the same unhealthy life style except that they were more physical active instead of less. Salivary cortisol and lifestyle were moderators in the stress-obesity relation: stressed children had also more overweight or a higher fat percentage, but only when they had an unhealthier lifestyle or higher cortisol. Discussion: These results confirm that stress can deteriorate lifestyle and cortisol homeostasis already in childhood and that these changes make them vulnerable to overweight. Consequently, obesity prevention should target both lifestyle and stress.

Pressure pain sensitivity: a new method of stress 2 measurement in patients with ischemic heart disease

Introduction: the relationship between psychiatric symptoms and cancer has sparked a lot of interest in the scientific community. The available literature is mostly on the impact of cancer diagnosis. However, little is known about the patients psychological status before that. Studies in this area show that cancer patients often present depressive symptoms before the diagnosis of neoplastic disease, probably due to cytokine production by the tumors. Low concentrations of cytokines would be sufficient to change the patient’s emotional state. Case description: to alert clinicians to the possibility that psychiatric symptoms may be a signal of underlying cancer disease, especially in patients above 50 years without psychiatric history, we present the following case. A woman of 53 years, followed in the Portuguese Institute of Oncology of Coimbra since October 2009 for mixed adenocarcinoma of the lung (stage IB). Approximately 1 month later, in November 2009, she was referred to psychiatric consultation because of depressive symptoms and complains since 1 year before. She also reported history of thyroid goiter, emphysema, and depressive episode occurred 10 years begore. Since the cancer was diagnosed, depression has shown a fluctuating evolution. Various therapeutic settings were made, being currently medicated with venlafaxine 225 mg, trazodone 150 mg AC i.d., and lorazepam 2.5 mg i.d.. Comment: the emergence of psychiatric symptoms, especially in patients above 50 years, should alert the physician to the presence of a possible hidden cancer, especially in the case of patients without psychiatric history.Introduction: Stress has been hypothesized to be involved in obesity development. Apart from a direct pathway through cortisol, stress may indirectly facilitate obesity by influencing other lifestyle factors: stressed persons may consume more comfort foods, may have a more sedentary behaviour and may suffer from sleep problems. Methods: In 326 Belgian children (5-12y) of the ChiBS study, the longitudinal relation between stress and body composition was examined over two years. Stress was measured by salivary cortisol (4 samples/day, 2 days) and questionnaires concerning negative life events, problem behaviour and emotions. For body composition, BMI, waist-to-height and fat% estimation by air displacement were used. Furthermore, physical activity, screentime, food consumption, eating behaviour and sleep duration were measured as lifestyle factors. Cross-lagged analyses with Mplus and moderation by cortisol and lifestyle factors were tested. Results: Children with higher stress scores had a less healthy lifestyle. They had an unhealthier diet especially due to more sweet food consumption, performed more emotional eating, were less active and slept less. Two years later, these stressed children maintained the same unhealthy life style except that they were more physical active instead of less. Salivary cortisol and lifestyle were moderators in the stress-obesity relation: stressed children had also more overweight or a higher fat percentage, but only when they had an unhealthier lifestyle or higher cortisol. Discussion: These results confirm that stress can deteriorate lifestyle and cortisol homeostasis already in childhood and that these changes make them vulnerable to overweight. Consequently, obesity prevention should target both lifestyle and stress.