Yoga for posttraumatic stress disorder - a systematic review and meta-analysis.

BACKGROUND: Yoga is increasingly used as a therapeutic treatment and seems to improve psychiatric conditions such as anxiety disorders and depression. The aim of this systematic review was to assess the evidence of yoga for reducing symptoms of posttraumatic stress disorder (PTSD). METHODS: The Cochrane Library, Medline/PubMed, PsycINFO, Scopus, and IndMED were searched through July 2017 for randomized controlled trials (RCTs) assessing the effects of yoga on symptoms of PTSD. Mean differences (MD) and standardized mean differences (SMD) with 95% confidence intervals (CI) were computed. The quality of evidence and the strength of recommendation were graded according to the GRADE recommendations. RESULTS: Seven RCTs (N = 284) were included. Meta-analysis revealed low quality evidence for clinically relevant effects of yoga on PTSD symptoms compared to no treatment (SMD = - 1.10, 95% CI [- 1.72, - 0.47], p < .001, I2 = 72%; MD = - 13.11, 95% CI [- 17.95, - 8.27]); and very low evidence for comparable effects of yoga and attention control interventions (SMD = - 0.31, 95%CI = [- 0.84, 0.22], p = .25; I2 = 43%). Very low evidence was found for comparable retention of patients in the trial for yoga and no treatment (OR = 0.68, 95%CI [0.06, 7.72]) or attention control interventions (OR = 0.66, 95%CI [0.10, 4.46]). No serious adverse events were reported. LIMITATIONS: Few RCTs with only limited sample size were available. CONCLUSIONS: Only a weak recommendation for yoga as an adjunctive intervention for PTSD can be made. More high quality research is needed to confirm or disconfirm these findings.

Postural awareness and its relation to pain: validation of an innovative instrument measuring awareness of body posture in patients with chronic pain.

BACKGROUND: Habitual postural patterns are associated with musculoskeletal pain, and improving a maladaptive posture requires postural awareness in order to lead to clinical improvements. This study aimed to develop and evaluate the psychometric properties of an innovative postural awareness scale. METHODS: A 12-item Postural Awareness Scale (PAS) was developed and administered to 512 chronic pain patients (50.3 ± 11.4 years, 91.6% female, 37.1% spinal/shoulder pain) to assess its factor structure and reliability. To determine convergent validity, measures of body awareness, body responsiveness, body image, and mindfulness were correlated with the PAS, as were clinical measures of pain intensity, disability, and mental health. Sensitivity to change was assessed in 202 outpatients participating in a 10-week multimodal mind-body program. RESULTS: Factor analysis revealed two factors (Ease/Familiarity with Postural Awareness and Need for Attention Regulation with Postural Awareness) that explained 50.8% of the variance. Cronbach's alpha for the complete scale was 0.80; Spearman-Brown coefficient of split-half reliability was 0.67; and intra-class correlation was ICC2,1 = 0.75 (95% confidence interval = 0.71, 0.78). Significant positive correlations were found for body awareness (r = 0.23), body responsiveness (r = 0.41), body image (r = 0.22-0.32), and mindfulness (r = 0.38); negative correlations for pain intensity (r = - 0.14), disability (r = - 0.12), depression (r = - 0.23), and stress (r = - 0.29). Postural awareness scores increased with a mind-body program (p < 0.001); changes in the PAS were negatively correlated with changes in pain intensity (r = - 0.35) in patients with spinal/shoulder pain. CONCLUSION: Self-reported postural awareness is associated with clinical symptoms in chronic pain patients; improvements in postural awareness are longitudinally associated with reduced pain in patients with spinal/shoulder pain.

Emotional release and physical symptom improvement: a qualitative analysis of self-reported outcomes and mechanisms in patients treated with neural therapy.

BACKGROUND: Neural Therapy (NT) is a common complementary treatment approach using injections with short-acting local anesthetics to treat pain and chronic diseases. However, little is known about the underlying mechanisms and the domains of treatment response. This study therefore analyzed patient experiences following NT injections with procaine. METHODS: Maximum variation sampling was used to collect data from semi-structured interviews conducted with 22 hospital inpatients aged 59.6 ± 14.9 years (81.8% female). Each had multiple (9.4 ± 6.9) diagnoses. They were undergoing two weeks of integrative treatment, which included individualized NT. The interview data were analyzed in MAXQDA using qualitative content analysis. RESULTS: With injection, patients first described local anesthetic effects including temporary blocking of pain and increased local warmth. Second, patients reported on vegetative reactions frequently leading to turmoil within the body like initial aggravation of existing symptoms or the appearance of new, concealed or phantom symptoms. This often required the need for rest to deal with the treatment stimulus. As a third step, many patients could gain physical and emotional release and relief in symptoms, mood and functioning. Emotional release was often accompanied by weeping and initially overwhelmed affected patients with dissociated memories. However, in cases where patients were able to experience those memories with a new distance, a fourth step of integration was achievable. It included reframing processes as well as a gain in pain perception and body-awareness. As a possible fifth step, patients experienced improved mood, increased pain acceptance and empowerment. Adverse events of NT included pain from the injections, vegetative complaints and emotional turmoil that lasted for minutes or hours, with a maximum of two days. CONCLUSIONS: Patients treated with procaine injections reported different psychophysiological outcomes contributing to the understanding of the mechanisms underlying NT. Further efficacy studies should separate specific NT from non-specific/placebo effects. TRIAL REGISTRATION: DRKS00004567 .

Low Inter-Rater Reliability and Reproducibility of Neck Reflex/"Adler-Langer" Points in Neural Therapy Diagnostics but Increased Pressure Pain Threshold after Therapy: Results of a Randomized Controlled Observer-Blind Trial.

BACKGROUND: Neck reflex points or Adler-Langer points are commonly used in neural therapy to detect so-called interference fields. Chronic irritations or inflammations in the sinuses, teeth, tonsils, or ears are supposed to induce tension and tenderness of the soft tissues and short muscles in the upper cervical spine. The individual treatment strategy is based on the results of diagnostic Adler-Langer point palpation. This study investigated the inter- and intra-rater reliability and explored treatment effects. METHODS: We performed a randomized controlled trial with 104 inpatients (80.8% female, 51.8 ± 12.74 years) of a German department for internal and integrative medicine. Patients were randomized to individual neural therapy according to the pathological findings (n = 48) or no treatment (n = 56). In each patient, three experienced raters (20-45 years of experience in neural therapy) and two novice raters (medical students) rated Adler-Langer points rigidity on a standardized rating scale ("strong," "weak," "none"). The patients independently evaluated the tenderness on palpation of the eight points using the same scale. Pressure pain thresholds were assessed at the eight Adler-Langer points. All patients were retested after 30 min. The five raters were blinded to treatment allocation and assessments of the other raters. Video recordings were obtained to assess the consistency of the areas tested by the different raters. RESULTS: Agreement between patients and raters (Cohen's kappa = 0.161-0.400) and inter-rater reliability were low (Fleiss kappa = 0.132-0.150). Moreover, the individual agreement (pre-post comparisons in untreated patients) was similarly low even in experienced raters (Cohen's kappa = 0.099-0.173). Video documentation suggests that raters do not place their fingers in the correct segments (percentage of correct position: 42.0-60.6%). Pressure pain thresholds at five of the eight Adler-Langer points showed significant changes after treatment compared to none in the control group. CONCLUSION: Under this artificial experimental setting, this method of Adler-Langer point palpation has not proven to be a reliable diagnostic tool. But it could be shown that, as claimed by the method, the tenderness in five of eight Adler-Langer points decreased after neural therapy.

Integrative oncology for breast cancer patients: introduction of an expert-based model.

BACKGROUND: Malignant breast neoplasms are among the most frequent forms of cancer in the Western world. Conventional treatment of breast cancer may include surgery, hormonal therapy, chemotherapy, radiation and/or immunotherapy, all of which are often accompanied by severe side effects. Complementary and alternative medicine (CAM) treatments have been shown to be effective in alleviating those symptoms. Furthermore, with patient survival rates increasing, oncologists, psychologists and other therapists have to become more sensitive to the needs of cancer survivors that go beyond than the mere alleviation of symptoms. Many CAM methods are geared to treat the patient in a holistic manner and thus are also concerned with the patient's psychological and spiritual needs. DISCUSSION: The use of certain CAM methods may become problematic when, as frequently occurs, patients use them indiscriminately and without informing their oncologists. Herbal medicines and dietary supplements, especially, may interfere with primary cancer treatments or have other detrimental effects. Thus, expertise in this highly specialized field of integrative medicine should be available to patients so that they can be advised about the benefits and negative effects of such preparations and practices.Being a beneficial combination of conventional and CAM care, integrative oncology makes possible the holistic approach to cancer care. The concept of integrative oncology for breast cancer is jointly practiced by the Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, academic teaching hospital of the University of Duisburg-Essen, and the Breast Center at Kliniken Essen-Mitte in Germany. This model is introduced here; its scope is reviewed, and its possible implications for the practice of integrative medicine are discussed. SUMMARY: Evidence-based integrative care is crucial to the field of oncology in establishing state-of-the-art care for breast cancer patients.

Isolated and combined effects of electroacupuncture and meditation in reducing experimentally induced ischemic pain: a pilot study.

Acupuncture and meditation are promising treatment options for clinical pain. However, studies investigating the effects of these methods on experimental pain conditions are equivocal. Here, the effects of electroacupuncture (EA) and meditation on the submaximum effort tourniquet technique (SETT), a well-established, opiate-sensitive pain paradigm in experimental placebo research were studied. Ten experienced meditators (6 male subjects) and 13 nonmeditators (6 male subjects) were subjected to SETT (250 mmHG) on one baseline (SETT only) and two treatment days (additional EA contralaterally to the SETT, either at the leg on ST36 and LV3 or at the arm on LI4 and LI10 in randomized order). Numeric Rating Scale (NRS) ratings (scale 0-10) were recorded every 3 min. During baseline, meditation induced significantly greater pain tolerance in meditators when compared with the control group. Both the EA conditions significantly increased pain tolerance and reduced pain ratings in controls. Furthermore, EA diminished the group difference in pain sensitivity, indicating that meditators had no additional benefit from acupuncture. The data suggest that EA as a presumable bottom-up process may be as effective as meditation in controlling experimental SETT pain. However, no combined effect of both the techniques could be observed.

Integrated care for migraine and chronic tension-type headaches: A prospective observational study.

BACKGROUND AND PURPOSE: This prospective observational study aimed to investigate the effects of an interdisciplinary multimodal integrated care program in patients with chronic migraine and/or tension-type headache. MATERIALS AND METHODS: Patients (n = 158) underwent inpatient, outpatient and/or semi-stationary treatment including conventional as well as complementary headache treatment. Headache frequency was defined as the primary outcome; secondary outcomes included pain (VAS, PPS), medication use, quality of life (SF-36), function (HDI, PSFS), depression and anxiety (HADS), and pain self-efficacy (PSEQ). RESULTS: Headache frequency decreased from 17.0 ±â€¯8.8 days/month at treatment start to 11.4 ±â€¯9.2 at treatment end and to 10.6 ±â€¯9.3 at 6-month follow-up (p < 0.001). All other outcome measures also improved across the course of the study (all p < 0.001). CONCLUSIONS: An integrated care approach based on integrative medicine improved headache symptoms and functioning in patients with chronic migraine and/or tension-type headache. Interdisciplinary multimodal treatment approaches seem to adequately address the specific treatment needs of headache patients.

Gua Sha therapy for chronic low back pain: A randomized controlled trial.

OBJECTIVE: To test the efficacy of Gua Sha therapy in patients with chronic low back pain. METHODS: 50 patients with chronic low back pain (78% female, 49.7 ±â€¯10.0 years) were randomized to two Gua Sha treatments (n = 25) or waitlist control (n = 25). Primary outcome was current pain intensity (100-mm visual analog scale); secondary outcome measures included function (Oswestry Disability Index), pain on movement (Pain on Movement Questionnaire), perceived change in health status, pressure pain threshold, mechanical detection threshold, and vibration detection threshold. RESULTS: After treatment, patients in the Gua Sha group reported lower pain intensity (p < 0.001) and better overall health status (p = 0.002) compared to the waitlist group. No further group differences were found. No serious adverse events occurred. CONCLUSIONS: Gua Sha appears to be an acceptable, safe, and effective treatment for patients with chronic low back pain. Further rigorous studies are needed to confirm and extend these results.

Being aware of the painful body: Validation of the German Body Awareness Questionnaire and Body Responsiveness Questionnaire in patients with chronic pain.

Body awareness is an attentional focus on and awareness of internal body sensations. This study aimed to validate German versions of the Body Awareness Questionnaire (BAQ) and the Body Responsiveness Questionnaire (BRQ) in chronic pain patients and to assess their associations with pain-related variables and to assess their responsiveness to intervention. The instruments were translated to German and administered to 512 chronic pain patients (50.3±11.4 years, 91.6% female) to assess their factor structure and reliability. Cronbach's α for the BAQ total score was 0.86. Factor analysis of the BRQ revealed the two factors Importance of Interoceptive Awareness (Cronbach's α = 0.75) and Perceived Connection (Cronbach's α = 0.75) and the single-item Suppression of Bodily Sensations. The BAQ was independently associated with lower mindfulness, self-esteem, stress, and depression; Importance of Interoceptive Awareness with mindfulness, self-acceptance, self-esteem, and physical contact; Perceived Connection with self-acceptance, vitality, and lower sensory pain; Suppression of Bodily Sensations with lower self-esteem, physical contact, and higher depressive symptoms. After a 10-week multimodal mind-body program (n = 202), the BAQ and Importance of Interoceptive Awareness increased and pain intensity and Suppression of Bodily Sensation decreased. In conclusion, body awareness and body responsiveness are associated with pain-related variables in patients with chronic pain. Mind-body interventions may positively influence both pain and body awareness, hinting at a potential mechanism of action of these interventions to be tested in further research.

The Effects of Cupping Massage in Patients with Chronic Neck Pain - A Randomised Controlled Trial.

BACKGROUND: Chronic neck pain is a major public health burden with only limited evidence for the effectiveness of complementary therapies. This study aimed to test the efficacy of cupping massage in patients with neck pain. PATIENTS AND METHODS: Patients with chronic non-specific neck pain were randomly assigned to cupping massage or a wait list control. The intervention group received 5 cupping massages on a twice-weekly basis while the control patients continued their usual treatments. The primary outcome measure was neck pain intensity (0-100 mm visual analogue scale (VAS)) after 3 weeks. Secondary outcomes included pain on movement, functional disability, health-related quality of life, mechanical detection and pain thresholds and adverse events. RESULTS: 50 patients (52.6 ± 10.3 years, 92% female) were randomised to either cupping massage or a wait list (N = 25 each). Patients in the cupping group reported significantly less neck pain post intervention (difference per protocol -14.3 mm, 95% confidence interval (CI) -27.7 to -1.0, p = 0.037; difference intention-to-treat -10.8 mm, 95% CI -21.5 to -0.1, p = 0.047). Significant group differences in favour of the intervention were further found for pain on movement (p = 0.019) and functional disability (p < 0.001), the quality-of-life subscales pain (p = 0.002) and mental health (p = 0.003) and the mental component summary (p = 0.036). Changes were also found for pressure pain sensitivity at the site of maximal pain (p = 0.022). Five adverse events were reported. CONCLUSIONS: Cupping massage appears to be effective in reducing pain and increasing function and quality of life in patients with chronic non-specific neck pain. More rigorous studies are needed to confirm and extend these results.

Integrative medicine for chronic pain: A cohort study using a process-outcome design in the context of a department for internal and integrative medicine.

INTRODUCTION: Integrative medicine inpatient treatment has been shown to improve physical and mental health in patients with internal medicine conditions. The aim of this study was to investigate the effectiveness of a 2-week integrative medicine inpatient treatment in patients with chronic pain syndromes and the association of treatment success with patient-related process variables. METHODS: Inpatients with chronic pain syndromes participating in a 2-week integrative medicine inpatient program were included. Patients' pain intensity, pain disability, pain perception, quality of life, depression, and perceived stress were measured on admission, discharge, and 6 months after discharge. Likewise process variables including ability and will to change, emotional/rational disease acceptance, mindfulness, life and health satisfaction, and easiness of life were assessed. RESULTS: A total of 310 inpatients (91% female, mean age 50.7 ±â€Š12.4 year, 26.5% low back pain, and 22.9% fibromyalgia) were included. Using mixed linear models, significant improvements in pain intensity, pain disability, pain perception, quality of life, depression, and perceived stress were found (all P < 0.05). Ability to change and implementation, disease acceptance, mindfulness, life and health satisfaction, and light heartedness/easiness likewise improved (all P < 0.05). Improved outcomes were associated with increases in process variables, mainly ability to change and implementation, disease acceptance, life and health satisfaction, and light heartedness/easiness (R = 0.03-0.40). CONCLUSIONS: Results of this study suggest that a 2-week integrative medicine inpatient treatment can benefit patients with chronic pain conditions. Functional improvements are associated with improved ability to change and implementation, disease acceptance, and satisfaction.

Craniosacral Therapy for the Treatment of Chronic Neck Pain: A Randomized Sham-controlled Trial.

OBJECTIVES: With growing evidence for the effectiveness of craniosacral therapy (CST) for pain management, the efficacy of CST remains unclear. This study therefore aimed at investigating CST in comparison with sham treatment in chronic nonspecific neck pain patients. MATERIALS AND METHODS: A total of 54 blinded patients were randomized into either 8 weekly units of CST or light-touch sham treatment. Outcomes were assessed before and after treatment (week 8) and again 3 months later (week 20). The primary outcome was the pain intensity on a visual analog scale at week 8; secondary outcomes included pain on movement, pressure pain sensitivity, functional disability, health-related quality of life, well-being, anxiety, depression, stress perception, pain acceptance, body awareness, patients' global impression of improvement, and safety. RESULTS: In comparison with sham, CST patients reported significant and clinically relevant effects on pain intensity at week 8 (-21 mm group difference; 95% confidence interval, -32.6 to -9.4; P=0.001; d=1.02) and at week 20 (-16.8 mm group difference; 95% confidence interval, -27.5 to -6.1; P=0.003; d=0.88). Minimal clinically important differences in pain intensity at week 20 were reported by 78% within the CST group, whereas 48% even had substantial clinical benefit. Significant between-group differences at week 20 were also found for pain on movement, functional disability, physical quality of life, anxiety and patients' global improvement. Pressure pain sensitivity and body awareness were significantly improved only at week 8. No serious adverse events were reported. DISCUSSION: CST was both specifically effective and safe in reducing neck pain intensity and may improve functional disability and the quality of life up to 3 months after intervention.

Efficacy of Cabbage Leaf Wraps in the Treatment of Symptomatic Osteoarthritis of the Knee: A Randomized Controlled Trial.

OBJECTIVES: Osteoarthritis (OA) of the knee is one of the most common chronic diseases among older adults. This study aimed to test the effects of cabbage leaf wraps (CLWs) in the treatment of symptomatic OA. METHODS: Patients with OA of the knee at stages II to III (Kellgren-Lawrence) were randomly assigned to 4 weeks of treatment with CLWs (daily for at least 2h), topical pain gel (TPG) (10 mg diclofenac/g, at least once daily), or usual care (UC). The primary outcome measure was pain intensity (VAS) after 4 weeks. Secondary outcomes included functional disability Western Ontario and McMaster Universities Arthritis Index (WOMAC), quality of life (SF-36), self-efficacy (Arthritis Self-Efficacy Scale-D), physical function (30 s Chair Stand Test), pressure pain sensitivity (PPT), satisfaction, and safety after 4 and 12 weeks. RESULTS: In total, 81 patients were included in this study (42 women, 65.9±10.3 y). After 4 weeks patients in the CLW group reported significantly less pain compared with those in the UC group (difference, -12.1; 95% [confidence interval] CI, -23.1, -1.0; P=0.033) but not when compared with the TPG group (difference, -8.6; 95% CI, -21.5, 4.4; P=0.190). Significant effects were also found in WOMAC, SF-36, 30-second Chair Stand Test, and PPT scores in the CLW group compared with the UC group. Compared with TPG, effects from CLW were found for WOMAC after 4 weeks and for quality of life after 12 weeks. Patients were satisfied with both active interventions, and except for 2 adverse events in both groups the applications were well tolerated. CONCLUSIONS: CLWs are more effective for knee OA than UC, but not compared with diclofenac gel. Therefore, they might be recommended for patients with OA of the knee. Further research is warranted.

[Successful endoscopic neural therapy of a patient with chronic pain syndrome after rectum gunshot injury]. / Erfolgreiche endoskopische Neuraltherapie eines Patienten mit chronischem Schmerzsyndrom bei Zustand nach Rektumschussverletzung.

BACKGROUND: We report about a 39-year-old patient, who was injured by a gunshot which penetrated the abdominal wall and the rectum. As a consequence, he developed a chronic pain syndrome with persistent severe rectal pain during and up to 30 min after defecation. Outpatient treatment for more than 10 years with analgetic agents, glucocorticoids, and salicylates did not show sufficient therapeutic benefit. CASE REPORT: During flexible rectoscopy, a rectum scar was located and a local injection of procaine into the rectum scar was performed. The patient described a strong and sharp pain during the infiltration which lasted about 5-10 s. Subsequently, the pain resolved. After the intervention as well as at discharge, the patient was completely pain-free. CONCLUSION: This is the first case report describing the successful endoscopic neural therapy of an intraluminal focus causing a chronic pain syndrome refractory to conventional analgetic and anti-inflammatory treatment.

Pain modulation by meditation and electroacupuncture in experimental submaximum effort tourniquet technique (SETT).

CONTEXT: Although acupuncture and meditation are widely utilized in the clinical treatment of pain, trials to evaluate their efficacy and modes of action under experimental conditions have yielded equivocal results. OBJECTIVE: This feasibility study investigated whether electroacupuncture (EA) and meditation effectively relieve pain within a well-established ischemic pain paradigm (submaximum effort tourniquet technique, SETT). DESIGN: In this semirandomized trial, experienced meditators were compared with nonmeditators. The nonmeditating subjects were randomly assigned to either an EA group or a nontreatment group. SETTING: The trial was conducted at the Department of Complementary and Integrative Medicine, University of Duisburg-Essen, Essen, Germany. PARTICIPANTS: Eight Vipassana meditators (mean experience hours = 2,626.8 ± 1,602.3 hours SD) and 40 control subjects were enrolled. INTERVENTIONS: SETT (250 mm Hg, time limit = 30 minutes, pain rating limit = 10) was applied twice (baseline vs treatment) on the nondominant arm; EA was applied to the contralateral acupoints LI4 and LI10 (stimulation 20 minutes prior to and throughout the SETT); meditators were asked to meditate throughout the whole experimental procedure. MAIN OUTCOME MEASURE: Pain ratings were obtained every three minutes on a numerical rating scale (0-10). The ratio of the tolerated time to the ratings served as the pain tolerance index. RESULTS: At baseline, meditators exhibited significantly greater pain tolerance than the other two groups. During the second or treatment session, pain sensitivity did not change significantly in the nontreatment group, whereas pain tolerance significantly increased and pain ratings decreased to the level of meditation-induced analgesia in the EA group. Electroacupuncture induced no additional pain control benefit for meditators.

[Gua Sha for migraine in inpatient withdrawal therapy of headache due to medication overuse]. / Gua Sha bei Migräne in der stationären Entzugsbehandlung von medikamenteninduziertem Kopfschmerz.

Gua Sha is a therapeutic method of Traditional Chinese Medicine (TCM) widely used in Asia, particularly in the treatment of chronic pain. By use of the surface-frictioning technique (called 'Gua') petechiae and a skin rash similar to millet-seed (called 'Sha') are induced. As first observations on the application of that method have been promising, we present the case of a 72-year-old woman. The patient who suffered from chronic headaches, highly profited from Gua Sha during her 14-day inpatient multimodal treatment. This case provides first evidence that Gua Sha is effective in the treatment of headaches. Further research and clinical trials are required to corroborate that evidence.