Defining Spirituality in Healthcare: A Systematic Review and Conceptual Framework.

Objective: To investigate the definitions of spirituality in the healthcare field, identifying its main dimensions and proposing a framework that operationalizes the understanding of this concept. Methods: This is a systematic review following the PRISMA guideline (PROSPERO: CRD42021262091), searching for spirituality definitions published in scientific journals. Searches were carried out in PubMed (all articles listed up to October 2020) and in the reference lists of the articles found in the database, followed by selection under specific eligibility criteria. Results: From a total of 493 articles, 166 were included in the final analysis, showing that there is a large body of scientific literature proposing and analyzing spirituality definitions. In these articles, 24 spirituality dimensions were found, most commonly related to the connectedness and meaning of life. Spirituality was presented as a human and individual aspect. These findings led us to construct a framework that represents spirituality as a quantifiable construct. Conclusions: Understanding spirituality is an important aspect for healthcare research and clinical practice. This proposed framework may help to better understand the complexity of this topic, where advances are desirable, given the relevance it has acquired for integral health care.

Development of an Instrument to Assess Spirituality: Reliability and Validation of the Attitudes Related to Spirituality Scale (ARES).

Background: Several instruments that measure spirituality present overlaps with positive emotions, impacting the interpretation of their findings. In order to minimize these problems, we aimed to develop, assess the reliability and validate a new scale to evaluate spirituality. Methods: The instrument was designed using a theoretical framework minimizing tautological issues (i.e., Koenig's framework), a qualitative study investigating the definitions of spirituality, the development of the first version of instrument by experts' meetings and a qualitative cognitive debriefing. Then, the instrument was examined for its content validity by a multidisciplinary group of judges and was pilot-tested in two different groups - less religious (medical students - n = 85) and more religious (practicing religious members - n = 85). Finally, psychometric properties and validity were assessed. Results: The developed Attitudes Related to Spirituality Scale (ARES) is a self-report 11-item instrument using five-level Likert items. ARES presented appropriate psychometric properties revealing excellent internal consistency (alpha = 0.98) and temporal stability (ICC = 0.98). Likewise, ARES was strongly correlated with other validated R/S instruments (i.e., Duke Religion Index and Brief Multidimensional Measure of Religiousness/Spirituality) and was able to discriminate higher and lower religious groups. In the exploratory factor analysis, a unidimensional structure of the scale was described. Fit indices for the scale demonstrated good fit in the unidimensional model. Conclusion: The ARES is a reliable, valid and stable one-dimension instrument that is appropriate for use in the Portuguese-speaking population. Descriptors: Spirituality; Scale; Factorial Analysis; Instrument; Measure; Psychometrics.

Migraine patients' journey until a tertiary headache center: an observational study.

BACKGROUND: Migraine diagnosis is based on clinical aspects and is dependent on the experience of the attending physician. This study aimed to describe the patients journey profile until they start their experience in a tertiary headache center. METHODS: In a cross-sectional study, medical charts from migraine patients were reviewed to describe which treatments, procedures and follow-up strategies are performed until the first appointment with a headache specialist. Patients from both sexes, ≥18 years old, which came to their first visit from March to July 2017 were included. Sociodemographic information, headache characteristics, diagnostic methods previously used, clinical history, family history and the treatments previously used were assessed in the first appointment with a specialist. Patient Health Questionnaire-9 and General Anxiety Disorder-7 were also applied. Descriptive analyses were performed to describe the sample profile and statistical tests were used to evaluate factors associated with the type of migraine (chronic or episodic). RESULTS: The sample consisted of 465 patients. On average, the pain started 17.1 (SD = 11.4) years before the first appointment with a headache specialist. Most of patients were classified as having chronic migraine (51.7%), with an average frequency of 15.5 (SD = 9.9) days per month. Regarding patients' journey until a specialist, most patients were submitted to laboratory tests (74.0%), cranial tomography (66.8%) and magnetic resonance imaging (66.8%) as diagnostic methods, and preventive drugs (70.2%) and acupuncture (61.0%) as treatments. After stratification by migraine type as episodic or chronic, patients with chronic migraine were submitted to more magnetic resonance imaging test, acupuncture, psychotherapy, used preventive drugs, and reported to have used topiramate without beneficial effects. CONCLUSIONS: Brazilian patients with migraine experiment a long journey until getting to a headache specialist and are submitted to a great number of unnecessary exams, especially those with chronic migraine.

Consensus of the Brazilian Headache Society on the treatment of chronic migraine.

Chronic migraine poses a significant personal, social and economic burden and is characterized by headache present on 15 or more days per month for at least three months, with at least eight days of migrainous headache per month. It is frequently associated with analgesic or acute migraine medication overuse and this should not be overlooked. The present consensus was elaborated upon by a group of members of the Brazilian Headache Society in order to describe current evidence and to provide recommendations related to chronic migraine pharmacological and nonpharmacological treatment. Withdrawal strategies in medication overuse headache are also described, as well as treatment risks during pregnancy and breastfeeding. Oral topiramate and onabotulinum toxin A injections are the only treatments granted Class A recommendation, while valproate, gabapentin, and tizanidine received Class B recommendation, along with acupuncture, biofeedback, and mindfulness. The anti-CGRP or anti-CGRPr monoclonal antibodies, still unavailable in Brazil, are promising new drugs already approved elsewhere for migraine prophylactic treatment, the efficacy of which in chronic migraine is still to be definitively proven.

Consensus of the Brazilian Headache Society on the treatment of chronic migraine / Consenso da Sociedade Brasileira de Cefaleia sobre o tratamento da migrânea crônica

ABSTRACT Chronic migraine poses a significant personal, social and economic burden and is characterized by headache present on 15 or more days per month for at least three months, with at least eight days of migrainous headache per month. It is frequently associated with analgesic or acute migraine medication overuse and this should not be overlooked. The present consensus was elaborated upon by a group of members of the Brazilian Headache Society in order to describe current evidence and to provide recommendations related to chronic migraine pharmacological and nonpharmacological treatment. Withdrawal strategies in medication overuse headache are also described, as well as treatment risks during pregnancy and breastfeeding. Oral topiramate and onabotulinum toxin A injections are the only treatments granted Class A recommendation, while valproate, gabapentin, and tizanidine received Class B recommendation, along with acupuncture, biofeedback, and mindfulness. The anti-CGRP or anti-CGRPr monoclonal antibodies, still unavailable in Brazil, are promising new drugs already approved elsewhere for migraine prophylactic treatment, the efficacy of which in chronic migraine is still to be definitively proven.

RESUMO A migrânea (enxaqueca) crônica determina uma carga pessoal, social e econômica significativa e é caracterizada por dor de cabeça presente em quinze ou mais dias por mês por ao menos três meses, com no mínimo oito dias de cefaleia migranosa a cada mês. É frequentemente associada ao uso excessivo de medicação analgésica ou antimigranosa aguda e isso não deve ser negligenciado. Este consenso foi elaborado por um grupo de membros da Sociedade Brasileira de Cefaleia, para descrever as evidências atualmente disponíveis e fornecer recomendações relacionadas ao tratamento farmacológico e não farmacológico da migrânea crônica. Estratégias de retirada na cefaleia por uso excessivo de medicamentos também são descritas, assim como os riscos dos tratamentos durante a gravidez e a amamentação. O topiramato oral e as injeções de toxina onabotulínica A são os únicos tratamentos que receberam a recomendação classe A, enquanto que o valproato, a gabapentina e a tizanidina receberam recomendação classe B, juntamente com acupuntura, biofeedback e mindfulness. Os anticorpos monoclonais anti-CGRP ou anti-CGRPr, ainda não disponíveis no Brasil, são novos fármacos promissores, já aprovados em outros países para o tratamento profilático da migrânea, cuja eficácia na migrânea crônica ainda está por ser definitivamente comprovada.

Neurophysiological, cognitive-behavioral and neurochemical effects in practitioners of transcendental meditation - A literature review.

The term meditation can be used in many different ways, according to the technique to which it refers. Transcendental Meditation (MT) is one of these techniques. TM could serve as a model for research on spiritual meditation, unlike the meditation techniques based on secular knowledge. The purpose of the present study is to conduct a bibliographic review to organize scientific evidence on the effects of TM on neurophysiology, neurochemistry, and cognitive and behavioral aspects of its practitioners. To conduct this critical narrative review of the literature, we searched for scientific papers on the PubMed database of the National Center for Biotechnology Information. The keywords used in the search were Transcendental Meditation, Neuroscience of meditation e Meditation and behavior. We selected 21 papers that analyzed different aspects that could be altered through meditation practice. We concluded that TM has positive and significant documentable neurochemical, neurophysiological, and cognitive-behavioral effects. Among the main effects are the reduction of anxiety and stress (due to the reduction of cortisol and norepinephrine levels), increase of the feeling of pleasure and well-being (due to the increase of the synthesis and release of dopamine and serotonin), and influence on memory recall and possible consolidation. Further studies are needed using creative and innovative methodological designs that analyze different neural circuitry and verify the clinical impact on practitioners.

Neurophysiological, cognitive-behavioral and neurochemical effects in practitioners of transcendental meditation - A literature review

SUMMARY The term meditation can be used in many different ways, according to the technique to which it refers. Transcendental Meditation (MT) is one of these techniques. TM could serve as a model for research on spiritual meditation, unlike the meditation techniques based on secular knowledge. The purpose of the present study is to conduct a bibliographic review to organize scientific evidence on the effects of TM on neurophysiology, neurochemistry, and cognitive and behavioral aspects of its practitioners. To conduct this critical narrative review of the literature, we searched for scientific papers on the PubMed database of the National Center for Biotechnology Information. The keywords used in the search were Transcendental Meditation, Neuroscience of meditation e Meditation and behavior. We selected 21 papers that analyzed different aspects that could be altered through meditation practice. We concluded that TM has positive and significant documentable neurochemical, neurophysiological, and cognitive-behavioral effects. Among the main effects are the reduction of anxiety and stress (due to the reduction of cortisol and norepinephrine levels), increase of the feeling of pleasure and well-being (due to the increase of the synthesis and release of dopamine and serotonin), and influence on memory recall and possible consolidation. Further studies are needed using creative and innovative methodological designs that analyze different neural circuitry and verify the clinical impact on practitioners.

RESUMO O termo meditação pode ser utilizado de diversas formas, de acordo com a técnica a que se refere. A meditação transcendental (MT) é uma dessas técnicas meditativas. A MT pode ser um modelo para pesquisas de meditação espiritual, diferentemente de técnicas de meditação baseadas em uma compreensão secular. O presente estudo objetiva realizar uma revisão bibliográfica para organizar as evidências científicas sobre os efeitos da MT sobre a neurofisiologia, neuroquímica e aspectos cognitivos e comportamentais dos seus praticantes. Para a realização desta revisão narrativa crítica da literatura, foi realizado um levantamento dos artigos científicos presentes na base de dados PubMed do National Center for Biotechnology Information. As palavras-chave utilizadas na busca foram Transcendental Meditation, Neuroscience of meditation e Meditation and behavior. Foram selecionados 21 artigos que analisavam diferentes aspectos que poderiam ser alterados pela prática meditativa. Conclui-se que a MT produz efeitos neuroquímicos, neurofisiológicos e cognitivo-comportamentais documentáveis em seus praticantes, de caráter positivo e significativo. Entre os principais efeitos estão a diminuição da ansiedade e do estresse (via diminuição nos níveis de cortisol e noradrenalina), aumento na sensação de prazer e bem-estar (em decorrência ao aumento na síntese e liberação de dopamina e serotonina) e influência na evocação e possível consolidação da memória. São necessários mais estudos utilizando desenhos metodológicos inovadores e criativos, analisando diferentes circuitos neurais e verificando o impacto clínico sobre os praticantes.

The association between spirituality and religiousness and mental health.

The present study aims to investigate how different levels of spirituality and religiousness (high spirituality and high religiousness -S/R, high spirituality and low religiousness -S/r, low spirituality and high religiousness s/R and low spirituality and low religiousness - s/r) are associated with quality of life, depressive symptoms, anxiety, optimism and happiness among adults. A cross-sectional study was carried out among 1,046 Brazilian adults. Concerning the different levels of spirituality and religiousness, 49.2% had s/r, 26.5% S/R, 17.2% S/r and 7.1% s/R. Participants with S/R had better outcomes as compared to those with s/r and those with S/r in WHOQOL Psychological, Social Relationship and Environment, Optimism and happiness. Participants with s/R had better outcomes as compared to those with s/r in WHOQOL Psychological and Social Relationship, Optimism and happiness. Participants with S/r were different from those with s/r, with higher levels of WHOQOL Environment and happiness but also anxiety. The results revealed that, having higher levels of both spirituality and religiousness were more correlated to better outcomes than having just one of them or none of them. Likewise, having higher levels of religiousness in detriment of higher levels of spirituality was also associated with better outcomes in comparison to others.

Botulinum toxin A (BT-A) versus low-level laser therapy (LLLT) in chronic migraine treatment: a comparison.

OBJECTIVE: The aim of this work was to evaluate patients with chronic migraine treated with botulinum toxin A (BT-A) and compare this with low level laser therapy (LLLT), referencing: pain days, pain intensity, intake of drugs/self-medication, anxiety and sleep disorders. METHODS: Patients were randomized into two groups: BT-A group (n = 18) and LLLT group (n = 18). Each patient kept three pain diaries: one before (baseline) (30 days), one during treatment (30 days) and one after the post-treatment phase (30 days). Repeated ANOVA plus the Bonferroni post-test, Student's t test, and factorial analysis were applied, and p < 0.05 was accepted as significant. RESULTS: Our data showed that both treatments were able to reduce headache days, acute medication intake and decrease the intensity of pain. Anxiety was reduced in the BT-A group, while sleep disturbance was reduced in the LLLT group. CONCLUSION: Our data showed that both treatments can be used to treat chronic migraine, without notable differences between them.

Botulinum toxin A (BT-A) versus low-level laser therapy (LLLT) in chronic migraine treatment: a comparison / Toxina botulínica A (BT-A) versus laser terapia de baixa potência (LLLT) em enxaqueca crônica: Uma triagem comparativa

ABSTRACT The aim of this work was to evaluate patients with chronic migraine treated with botulinum toxin A (BT-A) and compare this with low level laser therapy (LLLT), referencing: pain days, pain intensity, intake of drugs/self-medication, anxiety and sleep disorders. Methods: Patients were randomized into two groups: BT-A group (n = 18) and LLLT group (n = 18). Each patient kept three pain diaries: one before (baseline) (30 days), one during treatment (30 days) and one after the post-treatment phase (30 days). Repeated ANOVA plus the Bonferroni post-test, Student's t test, and factorial analysis were applied, and p < 0.05 was accepted as significant. Results: Our data showed that both treatments were able to reduce headache days, acute medication intake and decrease the intensity of pain. Anxiety was reduced in the BT-A group, while sleep disturbance was reduced in the LLLT group. Conclusion: Our data showed that both treatments can be used to treat chronic migraine, without notable differences between them.

RESUMO O estudo comparou pacientes com cefaleia crônica (CM) tratados com toxina botulínica A (BT-A) versus terapia a laser de baixa intensidade (LLLT), relativos a: dias de dor, automedicação, nervosismo e distúrbios do sono. Métodos: Os pacientes foram randomizados em dois grupos: Grupo BT-A (n = 18) e Grupo LLLT (n = 18). Cada paciente preencheu três diários de dor, sendo um antes do início do tratamento (30 dias), durante o tratamento (30 dias) e um após tratamento (30 dias). ANOVA e pós-teste Bonferroni, teste T de Student e análise fatorial foram utilizados e valores de p < 0,05 foram considerados significativos. Resultados: Ambos os tratamentos foram capazes de reduzir os dias de dor e a ingestão aguda de medicação. Além disso, a ansiedade foi reduzida no grupo BT-A, enquanto que o distúrbio do sono foi reduzido no grupo LLLT. Conclusão: Nossos resultados mostraram que ambos os tratamentos são eficientes contra CM, sem diferença entre eles.

Mechanisms Behind Religiosity and Spirituality's Effect on Mental Health, Quality of Life and Well-Being.

This cross-sectional study aims to evaluate the role of meaning, peace, faith and religiosity on mental health, quality of life (QOL) and well-being in 782 adults. We found associations between (a) meaning and peace with less depression and more QOL, (b) peace with less stress and (c) faith and religiousness with more psychological QOL. Meaning and peace were more strongly associated with health outcomes, and those with high levels of intrinsic religiosity but low levels of meaning/peace have worse outcomes than those with low religiousness and high meaning/peace. However, religious participants found great meaning and peace than nonreligious participants.

Assistência religiosa-espiritual hospitalar: os "porquês" e os "comos" / Hospital religious-spiritual assistance: the "whys" and the "hows"

A relação entre religiosidade-espiritualidade e a saúde física e mental adquire uma importância maior para pacientes internados em um hospital. Assim, os serviços de internação devem investir em ações que possam apoiar os recursos religiosos-espirituais e buscar formas para atender estas necessidades especiais. A assistência religiosa-espiritual hospitalar (AREH) se refere à atenção profissional aos mundos espirituais e religiosos subjetivos dos pacientes, mundos compostos de percepções, suposições, sentimentos e crenças sobre a relação do sagrado com sua doença, hospitalização e recuperação ou possível morte. Há pelo menos cinco razões para que uma instituição invista em um programa de AREH: 1. o bem-estar religioso-espiritual é prioritário durante uma internação; 2. a apreciação religiosa-espiritual é um padrão para a acreditação hospitalar; 3. pode desfazer mal-entendidos religiosos-espirituais que afetariam o tratamento; 4. os pacientes querem uma perspectiva religiosa-espiritual da instituição; e 5. os custos poderiam ser reduzidos com apoio religioso-espiritual. As formas de se oferecer AREH podem ser de modo individual ou coletivo; pode ser focado em uma denominação religiosa específica ou ser multifé. O apoio em um nível básico pode ser da alçada dos profissionais de saúde e, em um nível crescente de especialização, pode ser oferecido por um voluntário treinado, por um ministro religioso da comunidade ou por um capelão hospitalar. O público-alvo da AREH inclui não apenas o paciente internado, mas também seus familiares, seus cuidadores e os profissionais de saúde. Apesar da existência de leis que garantam o acesso do interno ao apoio religioso, o Brasil não possui regulamentação para a profissionalização desta atividade. O presente artigo explora todos os conceitos anteriores e descreve o que se espera de um programa de AREH.

The relationship between religiosity-spirituality and physical and mental health assumes greater importance for hospital inpatients. Thus, inpatient services should invest in actions that can support religious-spiritual resources and seek ways to address these special needs. Religious-spiritual hospital care (assistência religiosa-espiritual hospitalar - AREH) refers to the professional attention to the subjective spiritual and religious worlds of patients, worlds composed of perceptions, assumptions, feelings and beliefs about the relationship of the sacred with his/her illness, hospitalization and recovery or possible death. There are at least five reasons for an institution to invest in an AREH program: 1. Religious-spiritual well-being is yet higher priority during hospitalization; 2. Religious-spiritual appreciation is a standard for hospital accreditation; 3. It can undo religious-spiritual misunderstandings that would affect treatment; 4. Patients want a religious-spiritual perspective from the institution; and 5. Costs could be reduced with religious-spiritual support. The forms of offering AREH can be as individual or collective way; can be focused on a specific religious denomination or be multi-faith. Support at a basic level may be the responsibility of health professionals and, as the level of complexity increases, may be provided by a trained volunteer, community religious minister, or hospital chaplain. The target audience of the AREH includes not only the inpatient, but also their relatives, caregivers and health professionals. Despite the existence of laws that guarantee the inpatients access to religious support, Brazil does not have regulations for the professionalization of this activity. This article explores all the above concepts and describes what is expected from an AREH program.

Espiritualidade, saúde e suas aplicações práticas: desenvolvimento do Programa de Saúde, Espiritualidade e Religiosidade / Spirituality, health and its practical applications: development of the Health, Spirituality and Religious Program

O presente trabalho descreve o desenvolvimento e relato de experiências do Pro-grama de Saúde Espiritualidade e Religiosidade ­ ProSER. O ProSER foi implantado em 2008, com a finalidade de promover uma atenção mais ampla às necessidades espirituais e religiosas no contexto de saúde, bem como produzir e difundir conhe-cimento na interface saúde, espiritualidade e religiosidade para centros acadêmi-cos e instituições de saúde. Esse estudo tem como objetivo descrever a trajetória e atuação do ProSER nas áreas de ensino, pesquisa e assistência. A atuação do ProSER tem promovido mudanças nos cuidados em saúde, por meio de suas moda-lidades de assistência, além da disseminação de conhecimento para outros profis-sionais de saúde e centros acadêmicos, através de trabalhos científicos e cursos.

This paper describes the development and reporting of ProSER - Spirituality and Religiousness Health Program's experiences. ProSER was founded in 2008 to promote broader attention to spiritual and religious needs in health context, as well as to produce and disseminate knowledge at the health, spirituality and religiosity interface for academic centers and health institutions. This study aims to describe the trajectory and performance of ProSER in the areas of training, research and care. ProSER's work has promoted changes in health care mindset through its assistance modalities, as well as the dissemination of knowledge to other health professionals and academic centers, through scientific articles, classes and courses.

Mental and Physical Health and Spiritual Healing: An Evaluation of Complementary Religious Therapies Provided by Spiritist Centers in the City of São Paulo, Brazil.

The present study aims to describe the characteristics of the complementary religious treatment conducted by Spiritist centers in the city of São Paulo (Brazil), to understand how physical and mental health problems are addressed and how the directors of these centers differentiate between persons with spiritual experiences from those with psychiatric disorders. From 365 Spiritist centers, which received the questionnaire, 55 (15.1 %) were included in the final analysis. There were on average 261 people per week attending spiritual sessions in each center, totalizing approximately 15,000 attendees per week in all 55 centers. The most common treatment performed in these centers was disobsession (Spirit release therapy) (92.7 %); the least common was the 'spiritual surgery', present in only 5.5 %. The most frequent health problems reported by attendees were depression (45.1 %), cancer (43.1 %) and diseases in general (33.3 %). Concerning the directors' awareness to differentiate between spiritual experiences and psychiatric disorders, we found some remarkable divergent opinions. In conclusion, the Spiritist centers are an important health related support system for the city of São Paulo, responsible for a significant share of the city's total health consultations. The most common conditions the patients suffer from were depression and cancer.

Anxiety and fear-avoidance in musculoskeletal pain.

Musculoskeletal pain (MP) is common in the general population and has been associated with anxiety in several ways: (a) muscle tension is included as a part of the diagnostic criteria for generalized anxiety disorder, (b) pain can be a common symptom and a good indicator of an anxiety disorder, (c) anxiety is an independent predictor of quality of life in patients with chronic MP, (d) anxiety leads to higher levels of pain chronification, and (e) fear, anxiety, and avoidance are related to MP. The objective of this article is to explore the mechanisms underlying the relation between anxiety disorders and musculoskeletal pain as well as its management. We have also highlighted the role of spirituality and religiosity in MP treatment. We found some similarities between proposed mechanisms and explicative models for both conditions as well as an overlapping between the treatments available. The recognition of this association is important for professionals who deal with chronic pain.