In Ischemic Heart Disease, Reduced Sensitivity to Pressure at the Sternum Accompanies Lower Mortality after Five Years: Evidence from a Randomized Controlled Trial.

Background: Autonomic nervous system dysfunction (ANSD) is associated with negative prognosis of ischemic heart disease (IHD). Elevated periosteal pressure sensitivity (PPS) at the sternum relates to ANSD and sympathetic hyperactivity. Two previous observational case-control studies of the effect of reduction of PPS suggested lower all-cause mortality from IHD and stroke. We now used a specific daily, adjunct, non-pharmacological program of reduction of elevated PPS to test the hypothetical association between the intervention and reduced all-cause mortality in patients with stable IHD in a randomized controlled trial (RCT). Methods: We completed active (n = 106) and passive interventions (n = 107) and compared the five-year mortalities. We also compared the five-year individual all-cause mortality of each participant to approximately 35.000 members of the general population of Denmark. Pooling the mortality data from the active group of the RCT with the two preliminary studies, we registered the mortality following active intervention of 1.168 person-years, compared to 40 million person-years of the pooled general population. Results: We recorded fewer deaths of the active RCT intervention group than of the corresponding control group from the general population (p = 0.01), as well as of the passive RCT intervention group (p = 0.035). The meta-analysis of the three studies together demonstrated reduced 4.2-year all-cause mortality of 60% (p = 0.007). Conclusions: The test of the hypothetical effect of an intervention aimed at the attenuation of ANSD accompanied by a lowered PPS revealed reduced all-cause mortality in patients with stable IHD.

In Type 2 Diabetes Mellitus, normalization of hemoglobin A1c accompanies reduced sensitivity to pressure at the sternum.

Background: The autonomic nervous system (ANS) maintains glucose homeostasis. While higher than normal glucose levels stimulate the ANS toward reduction, previous findings suggest an association between sensitivity to, or pain from, pressure at the chest bone (pressure or pain sensitivity, PPS) and activity of the ANS. A recent randomized controlled trial (RCT) of type 2 diabetes (T2DM) suggested that addition of an experimental, non-pharmacological intervention more effectively than conventional treatment lowered the levels of both PPS and HbA1c. Materials and analyses: We tested the null hypothesis that conventional treatment (n = 60) would reveal no association between baseline HbA1c and normalization of HbA1c in 6 months, related to change of PPS. We compared the changes of HbA1c in PPS reverters who experienced a minimum reduction of 15 units of PPS and in PPS non-reverters who experienced no reduction. Depending on the result, we tested the association in a second group of participants with addition of the experimental program (n = 52). Results: In the conventional group, PPS reverters experienced normalization of HbA1c that corrected the basal increase, thus disproving the null hypothesis. With the addition of the experimental program, PPS reverters experienced similar reduction. The reduction of HbA1c among reverters averaged 0.62 mmol/mol per mmol/mol increase of baseline HbA1c (P < 0.0001 compared to non-reverters). For baseline HbA1c ≥ 64 mmol/mol, reverters averaged 22% reduction of HbA1c (P < 0.01). Conclusion: In consecutive analyses of two different populations of individuals with T2DM, we demonstrated that the higher the baseline HbA1c, the greater the reduction of HbA1c but only in individuals with a concomitant reduction of sensitivity to PPS, suggesting a homeostatic effect of the autonomic nervous system on glucose metabolism. As such, ANS function, measured as PPS, is an objective measure of HbA1c homeostasis. This observation may be of great clinical importance.

Reduction of Pressure Pain Sensitivity as Novel Non-pharmacological Therapeutic Approach to Type 2 Diabetes: A Randomized Trial.

BACKGROUND: Autonomic nervous system dysfunction (ANSD) is known to affect glucose metabolism in the mammalian body. Tradition holds that glucose homeostasis is regulated by the peripheral nervous system, and contemporary therapeutic intervention reflects this convention. OBJECTIVES: The present study tested the role of cerebral regulation of ANSD as consequence of novel understanding of glucose metabolism and treatment target in type 2 diabetes (T2D), suggested by the claim that the pressure pain sensitivity (PPS) of the chest bone periosteum may be a measure of cerebral ANSD. DESIGN: In a randomized controlled trial of 144 patients with T2D, we tested the claim that 6 months of this treatment would reduce PPS and improve peripheral glucose metabolism. RESULTS: In the active treatment group, mean glycated hemoglobin A1c (HbA1c) declined from 53.8 to 50.5 mmol/mol (intragroup p = 0.001), compared with the change from 53.8 to 53.4 mmol/mol in the control group, with the same level of diabetes treatment but not receiving the active treatment (between group p = 0.036). Mean PPS declined from 76.6 to 56.1 units (p < 0.001) in the active treatment group and from 77.5 to 72.8 units (p = 0.02; between group p < 0.001) in the control group. Changes of PPS and HbA1c were correlated (r = 0.37; p < 0.001). CONCLUSION: We conclude that the proposed approach to treatment of T2D is a potential supplement to conventional therapy. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03576430).

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

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.

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.

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

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.

Does collective efficacy moderate the associations between physical work load and intention to leave or sickness absence?

AIM: This paper is a report of a study, which examines the moderating effect of collective efficacy on the associations between physical workload, intention to leave and sickness absence. BACKGROUND: The positive association between physical workload and both intention to leave and sickness absence in the healthcare sector is well-established. However, knowledge is limited with respect to how social contextual factors such as collective efficacy moderate these associations. METHODS: A questionnaire was distributed over a 4-month period in 2006/2007 to all employees at elderly care centres in 35 Danish municipalities who were asked to rate their groups' collective efficacy. The final sample consisted of 6929 female employees from 290 work groups. Employees were predominantly healthcare helpers and assistants, but also nurses and other healthcare professionals participated in the study. Information on collective efficacy was aggregated to work group level. RESULTS: Collective efficacy moderated the association between physical workload and intention to leave, i.e. employees with high levels of physical workload had lower intention to leave if they worked in a group with high levels of collective efficacy and higher intention to leave if they worked in a group with low levels of collective efficacy. No moderating effect of collective efficacy on the association between physical workload and sickness absence was found. CONCLUSION: Our findings suggest that enhancing the sense of collective efficacy might be a mean for organizations and managers to reduce intention to leave, but further research is needed.

Long-term effects of integrated rehabilitation in patients with stroke: a nonrandomized comparative feasibility study.

BACKGROUND AND PURPOSE: Integrated rehabilitation (IR) in patients with stroke with respect to death rate and feasibility, initiated as a reduced death rate, was observed in patients with angina pectoris receiving IR. DESIGN: A case-control study included 73 consecutive patients with ischemic stroke. Death rates were compared with those of the general Danish population matched for age, gender, and observation period, as well as data from the community-based Copenhagen Stroke Study. INTERVENTIONS: IR was conducted in an outpatient clinic, by professionals as well as by the patient: the former as a specific acupuncture treatment, the latter as a comprehensive biofeedback guided stress management program including diets, physical- and relaxation exercise, Chinese health philosophy, cognitive and mindfulness-related exercises, and specific biofeedback guided acupressure. RESULTS: The 4(1/2)-year accumulated risk of death was 11.6% (95 confidence limits: 3.2%-20.0%) for the 73 patients with stroke treated with IR, compared to 18.4% for the general Danish population matched for sex, age, and time period. The corresponding figures for patients receiving conventional stroke treatment were 43.2% (95 confidence limits: 39.7%- 46.7%), and 20.0% for the general Danish population matched for sex, age, and time period. CONCLUSIONS: IR was found to be feasible for patients with stroke as a complementary treatment to conventional stroke treatment, and added no risk of dying when compared to Danish stroke patients receiving conventional medical treatment. The results invite further testing in a randomized trial.

Do fear-avoidance beliefs play a role on the association between low back pain and sickness absence? A prospective cohort study among female health care workers.

Health care workers have a high prevalence of sickness absence because of low back pain (LBP). This study examined whether fear-avoidance beliefs (FAB): 1) predicted sickness absence and 2) moderated the association between LBP and sickness absence among 1724 newly educated health care workers with LBP >or= day during the previous 12 months. High FAB was associated with sickness absence days 1 year later (relative risk, 1.45, 95% confidence interval = 1.24 to 1.70), controlled for LBP, previous sickness absence, and age. When controlling for work environmental factors, the association remained significant but decreased. Furthermore, the results showed that health care workers with high degree of LBP would have more sickness absence days if they also had high FAB. To reduce sickness absence, education about pain management must be presumed to be beneficial.

A simple and objective marker for stress.

OBJECTIVE: To examine the association between pressure pain sensitivity (PPS) at sternum and various well established physiological stress measures among opera singers during a performance as a measure for transitional stress, and resting values in out-clinic patients as a measure for persistent stress. METHODS: Changes in PPS on the index finger and sternum, middle blood pressure (MAP), heart rate (HR), pressure-rate-product (PRP) and salivary cortisol (SCO) were recorded in 26 opera solo singers during a performance. Resting PPS, HR, MAP, PRP and presence of a noxious withdrawal reflex (NWR) were recorded in 181 out-clinic patients. RESULTS: During opera performance, the PPS on sternum changed concomitantly with MAP (correlation coefficient (r) r=0.42, p<0.005), HR (r=0.55, p<0.001), PRP (r=0.54, p<0.001) and SCO (r=0.26, p=0.066). During rest, a significant correlation was found between PPS on sternum and HR, PRP and presence of noxious withdrawal reflex (all p<0.01). CONCLUSIONS: The PPS measurement at sternum was associated with well established physiological stress measures and may represent a simple, objective and reliable measure of physiological stress used by both non-professional and professionals.