"What helps your back pain?" A qualitative analysis of pain management strategies in opioid-treated adults with chronic low back pain.

OBJECTIVE: The purpose of this qualitative analysis was to better understand what pain management strategies adults with opioid-treated chronic low back pain (CLBP) found most helpful. DESIGN: A subgroup of participants from a larger randomized control trial of two psychological interventions were asked: "What helps your back pain?" at baseline and 12 months (exit) in brief, video-recorded interviews. Videos were analyzed using qualitative thematic content analysis utilizing Transana™. SETTING: Participants were recruited from the community and outpatient clinics in three United States sites. PARTICIPANTS: Seventy-nine adults with long-term (≥3 months) opioid-treated (≥15 mg/day morphine equivalent) CLBP. MAIN OUTCOME MEASURE(S): Participants' baseline and exit qualitative responses to the question "What helps your back pain?" RESULTS: At baseline, participants identified medication (n = 63), body position (n = 59), thermal application (n = 50), physical activity (n = 49), and stretching (n = 24) as the CLBP management strategies they found helpful. At exit, the reports of medication (n = 55), physical activity (n = 41), and stretching (n = 21) were often considered helpful for CLBP and remained relatively stable, while position (n = 36) and thermal application (n = 35) strategies were mentioned less frequently and psychological strategies (n = 29) were mentioned more frequently (up from n = 5) compared to baseline. CONCLUSIONS: Over time, the reports of medication and active pain management strategies, eg, physical activity, remained stable, while the reports of some passive pain management strategies, eg, position and thermal, declined over time. Increased use of psychological strategies implies that study interventions were incorporated as useful pain self-management strategies.

Risk Factors for Self-Harm Ideation Among Persons Treated With Opioids for Chronic Low Back Pain.

OBJECTIVES: Chronic pain is a significant health concern that adversely affects all aspects of life, including emotional well-being. Opioids are prescribed for the management of refractory, severe chronic pain, although they have been associated with adverse effects, including addiction and overdose. The aim of this study was to examine factors that predict thoughts of self-harm among adults with chronic pain who are prescribed opioids. MATERIALS AND METHODS: Seven hundred sixty-five (N=765) persons with opioid-treated chronic lower back pain completed the Current Opioid Misuse Measure (COMM) and other validated questionnaires as part of a larger study. Response to 1 question from the COMM ("How often have you seriously thought about hurting yourself?") was used to assess suicide risk on a 5-point scale (0=never; 4=very often). RESULTS: Participants were categorized into 3 groups according to their responses to the self-harm question: never (N=628; 82.1%), seldom or sometimes (N=74; 9.7%), and often or very often (N=63; 8.2%). Multivariate adjusted odds ratio (aOR) analyses indicated that reports of alcohol or drug overuse within the past month (aOR=1.41,[95% CI 1.11-1.78]), posttraumatic stress (PTSD; aOR=1.24,[1.07 to 1.44]), pain catastrophizing (aOR=1.03,[1.01 to 1.05]), not loving oneself (aOR=0.99,[.98-1.00]) and poor perceived mental health (aOR=0.94,[.92 to 97]) were most associated with thoughts of self-harm. Importantly, the ideation frequency of self-harm was highest among individuals treated with higher daily doses of opioids. DISCUSSION: These results support the need for continued monitoring of adults treated with opioids for chronic pain, particularly among those on high-dose opioids who present with increased negative affect and concerns of substance misuse.

Tai Chi training for attention deficit hyperactivity disorder: A feasibility trial in college students.

OBJECTIVE: Many young adults are affected by attention deficit hyperactivity disorder (ADHD) and often desire non-pharmacological treatment options. Mind-body techniques might serve as complementary therapies to first-line stimulant medications, but studies are limited. Tai Chi is an increasingly popular practice that integrates movement with cognitive skills relevant to ADHD. We performed a feasibility trial of Tai Chi training in undergraduates to inform the design of a fully powered randomized controlled trial (RCT). METHOD: Undergraduates with ADHD were recruited, screened, enrolled, and assessed at baseline. They were assigned to three parallel seven-week intervention arms, Tai Chi, Active Control (cardio-aerobic fitness), and Inactive Control (no contact), with follow-up assessments. Feasibility of a larger clinical trial was evaluated, especially with respect to enrollment and retention. Additionally, potential clinical outcome measures were examined for practicality and reliability. RESULTS: 21 participants were assessed at baseline and 19 at follow-up (90 % retention). The primary clinical outcome measure, self-reported inattention symptoms (Conners' CAARS-S:L DSM-IV Inattentive Symptoms subscale), exhibited good test-retest reliability in controls (r = 0.87, n = 10) and correlated with reduced mindfulness (FFMQ acting with awareness subscale) at baseline (r = -0.74, n = 20). Class attendance and self-reported daily practice time were variable. Randomization to group classes was hindered by the college students' restricted schedules. CONCLUSION: The high retention rate and good data quality suggest that an RCT of Tai Chi for ADHD is feasible. Further measures are identified to improve enrollment rates, adherence, and randomization procedures. Future work might extend to other young adult populations and high school students.

Individually Tailored Yoga for Chronic Neck or Back Pain in a Low-income Population: A Pilot Study.

BACKGROUND: Low-income people are disproportionately affected by chronic back and neck pain. Yoga may be an effective therapy. AIMS: This feasibility pilot study evaluated an individualized yoga plan for the treatment of chronic spinal pain. RESULTS: Individuals showed a mean change of -2.4 from pre/post 10-cm pain scale recordings (P = 0.028, 95% confidence interval [CI]: -0.390--4.477) and a mean increase of 0.26 on the EQ-5D-3L (P = 0.029, 95% CI: 0.04-0.47). The intervention was well-received. CONCLUSIONS: An individually tailored yoga program was acceptable to these participants. Pain and quality of life scores appeared to improve.

Differential Reduction of IP-10 and C-Reactive Protein via Aerobic Exercise or Mindfulness-Based Stress-Reduction Training in a Large Randomized Controlled Trial.

Exercise and meditation improve health and well-being, potentially through decreasing systemic inflammation. In this study, healthy adults (N = 413) were randomized to 8 weeks of training in aerobic exercise, matched mindfulness-based stress reduction, or wait-list control. Three inflammation-related biomarkers (C-reactive protein, interleukin-6, and interferon-gamma-inducible protein-10) were assessed preintervention, directly postintervention, and 17 weeks later. Within-group analyses found that exercise participants had decreased serum interferon-gamma-inducible protein-10 postintervention and 17 weeks later, whereas C-reactive protein was lower in mindfulness-based stress-reduction participants 17 weeks postintervention only. Self-reported physical activity or amount of meditation practice did not predict biomarker changes. This study suggests that (a) training in aerobic exercise can lower interferon-gamma-inducible protein-10, a chemokine associated with interferon activity and illness, and (b) training in mindfulness meditation may have a delayed effect on C-reactive protein, an important inflammatory biomarker. The findings highlight the likelihood of multiple, distinct pathways underlying the health-promoting effects of these lifestyle interventions.

Multivariate semi-continuous proportionally constrained two-part fixed effects models and applications.

Semi-continuous data, also known as zero-inflated continuous data, have a substantial portion of responses equal to a single value (typically 0) and a continuous, right-skewed distribution among the remaining positive values. For jointly modeling multivariate clustered semi-continuous responses, the covariate effects in the positive parts can be proportionally constrained to the covariate effects in the logistic part, yielding a multivariate two-part fixed effects model. It is shown that, both theoretically and experimentally, the proportionally constrained model is more efficient than the unconstrained model in terms of parameter estimation, and thus provides a deeper understanding of the data structure when the proportionality structure holds. A robust variance estimation method is also introduced and tested under various model mis-specified cases. The proposed model is applied to data from a randomized controlled trial evaluating potential preventive effects of meditation or exercise on duration and severity of acute respiratory infection illness. The new analysis infers that meditation not only has highly significant effects on reduction of acute respiratory infection severity and duration, but also has significant effects on preventing acute respiratory infection, which was not previously reported in the literature.

Benefits of 8-wk Mindfulness-based Stress Reduction or Aerobic Training on Seasonal Declines in Physical Activity.

Mindfulness-based stress reduction (MBSR) and aerobic exercise training (AET) programs improve health and well-being. Exercise participation has been related to mindfulness and may be altered by MBSR training. PURPOSE: This study aimed to compare 8 wk of MBSR, AET, and no-treatment control during the fall season on objectively measured physical activity in healthy adults. METHODS: Participants (n = 66) wore an ActiGraph GT3X+ accelerometer for 7 d prerandomization and after 8 wk MBSR or AET interventions, or neither (control). Mean daily minutes (min) of moderate-to-vigorous physical activities (MVPA) were calculated along with weekly time spent in bouts of MVPA ≥10 min (MVPABouts) to assess physical activity sufficient to meet national guidelines. Groups were compared on pairwise changes in outcomes across time. Effect sizes were calculated using Cohen's d. RESULTS: Sufficient data (≥3 weekdays, ≥1 weekend day, and ≥10 h·d) were obtained from 49 participants (18 MBSR, 14 AET, and 17 control). Daily MVPA decreased in all groups from prerandomization to postintervention (August to November); control decreased 17.9 ± 25.7 min·d, MBSR decreased 5.7 ± 7.5 min·d, and AET decreased 7.4 ± 14.3 min·d (mean ± SD), without significant differences among the groups (all P > 0.05). MVPABouts decreased 77.3 ± 106.6 min·wk in control and 15.5 ± 37.0 min·wk in MBSR (between-group difference: P = 0.08; d = 0.86), whereas it increased by 5.7 ± 64.1 min·wk in AET (compared with control: P = 0.029; d = 0.97; compared with MBSR; P = 0.564; d = 0.29). CONCLUSION: Data from participants in a randomized controlled trial showed that although AET increases MVPA bouts compared with no treatment, MBSR training may also mitigate the influence of shorter day length and cooler weather on participation in physical activities. Future research is needed to determine how MBSR affects exercise to inform interventions. Interventions combining MBSR and exercise may be particularly successful at increasing physical activity participation.

Validation of the Nasal Mucus Index, a novel measurement of acute respiratory infection severity.

BACKGROUND: To assess the concurrent and predictive validity of the Nasal Mucus Index (NMI), a novel measurement of acute respiratory infection (ARI) severity. OBJECTIVE: ARI, including the common cold and influenza, imposes a great burden on individuals and society. Previous research has attempted to assess the severity of ARI with self-reported and laboratory-based measurements. Self-reported measurements may introduce bias. Laboratory-based metrics are often expensive. Therefore, there is a need for non-self-reported, affordable, and validated ARI severity tests. METHODS: Participants (N = 719) with an ARI episode underwent nasal lavage on days 1 and 3. The samples were visually assessed for the amount of mucus present in the sample and were given a subsequent NMI score. Collected samples were further assessed for interleukin (IL) 8 values (in pg/mL) and polymorphonuclear neutrophils (PMN) per high-power field. The participants rated episode severity and nasal symptoms daily by using the validated Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21). A subset of nasal symptoms was used as an additional comparator. NMI scores were compared with same-day IL-8 level, PMN count, and WURSS-21 scores for concurrent validation purposes by using the Spearman ρ as the index of correlation. NMI scores were correlated with overall episode severity measurements to assess predictive validity. Overall episode severity was measured as the WURSS-21 area under the curve, nasal symptoms area under the curve, and episode duration. RESULTS: The NMI score correlated significantly with the same-day IL-8 level (ρ = 0.443, p < 0.001), PMN count (ρ = 0.498, p < 0.001), WURSS-21 score (ρ = 0.098, p = 0.004), and nasal symptom score (ρ = 0.162, p < 0.001). No significant predictive correlations were found. CONCLUSION: Associations with inflammatory biomarkers and self-reported severity measurements provided evidence of concurrent validity for the novel NMI score. The NMI can be used in future research as a simple, inexpensive, non-self-reported indicator of ARI severity.

The Overlap of Dietary Supplement and Pharmaceutical Use in the MIDUS National Study.

Introduction. In the United States, dietary supplement (DS) use is common, often takes place outside of the purview of health care providers, and may involve DS in combination with pharmaceuticals. This situation has led to concerns about interactions between DS and pharmaceuticals, as well as the risks from polypharmacy and polysupplement use. Methods. We used data from the Midlife in the US study (MIDUS 2 Survey) to examine DS and prescription pharmaceutical use in 3876 study participants in order to determine the demographics of high-users (5 or more) of DS and pharmaceuticals and the presence of DS-pharmaceutical co-use. Results. Over 69% of study participants regularly used DS, 49.6% regularly used both DS and pharmaceuticals, and 6.3% and 8.7% were high-users of pharmaceuticals and DS, respectively. High-users of DS, pharmaceuticals, and either were more likely than the whole cohort to be female and of lower income. Conclusions. These findings corroborate those of other national studies with respect to the demographics of DS users but add new information about people at risk of DS-pharmaceutical interactions, not an insignificant proportion of the population examined by this dataset.

Item reduction of the Wisconsin Upper Respiratory Symptom Survey (WURSS-21) leads to the WURSS-11.

PURPOSE: To develop a shorter version of the Wisconsin Upper Respiratory Symptom Survey (WURSS-21), a self-report questionnaire for evaluating daily symptoms and functional impairments during acute respiratory illness (ARI). METHODS: WURSS-21 data were retrieved from 4 studies (n = 1167) spanning the years 2002-2010. Similar methodologies were employed among these studies. Degree of missingness, ceiling/floor effects, and exploratory (EFA) and confirmatory (CFA) factor analyses were investigated and used to guide item retention. Stability of the reduced WURSS was evaluated across the first 3 days of ARI. RESULTS: Degree of missingness was <1 % and appeared to be completely at random. Seven WURSS items with >30 % of ratings of zero (floor effects) were eliminated. Cross-loading items (head congestion, sleep well and breathe easily) were excluded following EFA on subset-1. Subsequent CFA using subset-2 showed satisfactory indices of fit. The reduced WURSS-11 instrument demonstrated 3 dimensions of 3 items each and was stable across 3 days of illness. The indicated dimensions (items) include nasal (runny nose, plugged nose, sneezing), throat (cough, sore throat, scratchy throat), and quality of life (feeling tired, think clearly, accomplish daily activities). CONCLUSION: The WURSS-11 has similar dimensional structure as the WURSS-21. This shorter version may reduce the time and burden required for completing the survey.

Modeling eye gaze patterns in clinician-patient interaction with lag sequential analysis.

OBJECTIVE: The aim of this study was to examine whether lag sequential analysis could be used to describe eye gaze orientation between clinicians and patients in the medical encounter. This topic is particularly important as new technologies are implemented into multiuser health care settings in which trust is critical and nonverbal cues are integral to achieving trust. This analysis method could lead to design guidelines for technologies and more effective assessments of interventions. BACKGROUND: Nonverbal communication patterns are important aspects of clinician-patient interactions and may affect patient outcomes. METHOD: The eye gaze behaviors of clinicians and patients in 110 videotaped medical encounters were analyzed using the lag sequential method to identify significant behavior sequences. Lag sequential analysis included both event-based lag and time-based lag. RESULTS: Results from event-based lag analysis showed that the patient's gaze followed that of the clinician, whereas the clinician's gaze did not follow the patient's. Time-based sequential analysis showed that responses from the patient usually occurred within 2 s after the initial behavior of the clinician. CONCLUSION: Our data suggest that the clinician's gaze significantly affects the medical encounter but that the converse is not true. APPLICATION: Findings from this research have implications for the design of clinical work systems and modeling interactions. Similar research methods could be used to identify different behavior patterns in clinical settings (physical layout, technology, etc.) to facilitate and evaluate clinical work system designs.

Practitioner empathy and the duration of the common cold.

OBJECTIVE: This study's objective was to assess the relationship of empathy in medical office visits to subsequent outcomes of the common cold. METHODS: A total of 350 subjects ? 12 years of age received either a standard or enhanced physician visit as part of a randomized controlled trial. Enhanced visits emphasized empathy on the part of the physician. The patient-scored Consultation and Relational Empathy (CARE) questionnaire assessed practitioner-patient interaction, especially empathy. Cold severity and duration were assessed from twice-daily symptom reports. Nasal wash was performed to measure the immune cytokine interleukin-8 (IL-8). RESULTS: Eighty-four individuals reported perfect (score of 50) CARE scores. They tended to be older with less education but reported similar health status, quality of life, and levels of optimism. In those with perfect CARE scores, cold duration was shorter (mean 7.10 days versus 8.01 days), and there was a trend toward reduced severity (mean area under receiver-operator characteristics curve 240.40 versus 284.49). After accounting for possible confounding variables, cold severity and duration were significantly lower in those reporting perfect CARE scores. In these models, a perfect score also correlated with a larger increase in IL-8 levels. CONCLUSIONS: Clinician empathy, as perceived by patients with the common cold, significantly predicts subsequent duration and severity of illness and is associated with immune system changes.

Treatment of the common cold with unrefined echinacea. A randomized, double-blind, placebo-controlled trial.

BACKGROUND: Echinacea preparations are widely used to treat the common cold. OBJECTIVE: To assess the efficacy of dried, encapsulated, whole-plant echinacea as early treatment for the common cold. DESIGN: Randomized, double-blind, placebo-controlled community-based trial. SETTING: University of Wisconsin-Madison, Madison, Wisconsin. PARTICIPANTS: 148 registered students with common colds of recent onset. INTERVENTION: An encapsulated mixture of unrefined Echinacea purpurea herb (25%) and root (25%) and E. angustifolia root (50%) taken in 1-g doses six times on the first day of illness and three times on each subsequent day of illness for a maximum of 10 days. MEASUREMENTS: Severity and duration of self-reported symptoms of upper respiratory tract infection. RESULTS: No statistically significant differences were detected between the echinacea and placebo groups for any of the measured outcomes. Trajectories of severity over time were nearly identical in the two groups. Mean cold duration was 6.01 days in both groups as a whole, 5.75 days in the placebo group, and 6.27 days in the echinacea group (between-group difference, -0.52 day [95% CI, -1.09 to 0.22 days]). After controlling for severity and duration of symptoms before study entry, sex, date of enrollment, and use of nonprotocol medications, researchers found no statistically significant treatment effect (adjusted hazard ratio, 1.24 [CI, 0.86 to 1.78]). Multivariable regression models assessing severity scores over time failed to detect statistically significant differences between the echinacea and placebo groups. CONCLUSION: Compared with placebo, unrefined echinacea provided no detectable benefit or harm in these college students who had the common cold.