{"id":1081,"date":"2016-06-29T14:52:16","date_gmt":"2016-06-29T14:52:16","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1081"},"modified":"2017-08-21T10:52:10","modified_gmt":"2017-08-21T10:52:10","slug":"primary-care-corner-with-geoffrey-modest-md-tai-chi-for-knee-oa-mindfulness-for-chronic-pain","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/06\/29\/primary-care-corner-with-geoffrey-modest-md-tai-chi-for-knee-oa-mindfulness-for-chronic-pain\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Tai Chi for Knee OA; Mindfulness for Chronic Pain"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<ol>\n<li>A recent studyfound that Tai Chi was at least as good, and\u00a0sometimes better, than physical therapy (PT) for patients with painful\u00a0knee osteoarthritis, OA (see<strong>\u00a0<\/strong>doi:10.7326\/M15-2143). There have been some earlier studies finding efficacy of Tai Chi for knee osteoarthritis, rheumatoid arthritis, and fibromyalgia, by\u00a0decreasing pain and improving physical and psychological health. The current study compared Tai Chi with PT.<\/li>\n<\/ol>\n<p>Details:<\/p>\n<ul>\n<li>204 people with symptomatic knee OA<\/li>\n<li>Mean age 60, 70% women, \u00a053% white\/35% black, BMI 33, duration of knee pain 8 years, mostly moderate radiologic OA (Kellgren-Lawrence grade 2 in 38%, 3 in 37%), 50% hypertensive, 20% diabetic, mean WOMAC pain score (Western Ontario and McMaster Universities Osteoarthritis Index) 253 (range 0-500)<\/li>\n<li>Interventions (patients allowed to continue meds, including\u00a0acetaminophen and NSAIDs):\n<ul>\n<li>Tai Chi: 60 minute sessions 2x\/week for 12 weeks.\u00a0Explanation of mind-body exercise theory and procedures. Patients instructed to do home Tai Chiat least 20 min\/d (videotaped with feedback throughout the study). At end of 12 weeks, patients asked to continue at home for the duration of the study<\/li>\n<li>PT: 30 minute sessions 2x\/week for 6 weeks. Individual assessment and targeted regimens. Exercise at home. At end of 6 weeks, patient asked to continue with 30-minute sessions 4 x\/week for 6 weeks. [i.e., shorter intervention than Tai Chi, but this is a\u00a0standard PT regimen]<\/li>\n<\/ul>\n<\/li>\n<li>Results (with 52 week follow-up)\n<ul>\n<li>Overall attendance: 74% for Tai Chi and 81% for PT<\/li>\n<li>Clinical outcomes (WOMAC pain, physical function and stiffness scores; patient global assessment score; Beck depression inventory;\u00a0 SF-36,\u00a0 a health survey; arthritis self-efficacy score; and both the 6-minute and 20-minute walk scores):\u00a0patients in each group showed improvement over time, including at 52 weeks, well after the active interventions. But, comparing the interventions:\u00a0<strong>Tai Chiwas better than PT for essentially every outcome and at weeks\u00a012, 24 and 52<\/strong>. However, the difference was statistically\u00a0significant only\u00a0for the physical component of SF-36 and Beck depression inventory.<\/li>\n<li>Use of NSAIDs and analgesics: also generally less with\u00a0Tai Chi, but not reach statistical significance.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>This was perhaps a somewhat unexpected finding since the focus of PT is so different from Tai Chi. PT\u00a0largely involves stretching and strengthening exercises and some local therapies, leading to improved quadriceps dynamics in particular, developing\u00a0increased support for the knee and decreasing the load on the joint itself (at least that is my understanding. Studies have shown that quadriceps weakness correlates with the degree of knee pain). Tai Chicombines meditation, slow and gentle movements, deep diaphragmatic breathing and relaxation (i.e., physical as well as psychosocial\/emotional\/behavioral elements).<\/li>\n<li>In this study on Tai Chi, it is impressive that the results\u00a0remained pretty consistent at 12, 24, 52 weeks. My guess is that the Tai Chi group did continue their home-based exercises after the formal study stopped (data not in article), but either way, that suggests that the benefits\u00a0are durable (and perhaps\u00a0Tai Chi really can be incorporated into one&#8217;s life long-term)<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ol start=\"2\">\n<li>A\u00a0complementary article appeared near the same time in JAMA, stressing a role for mindfulness meditation in pain management (seedoi:10.1001\/jama.2016.4875). Briefly, mindfulness meditation involves an\u00a0increasing awareness of body sensations (e.g. breathing), techniques to promote mindful practice (yoga, meditation), learning how to understand and change how we react to stress,\u00a0understanding\u00a0the relationship between stress and pain, and viewing the reactions to stress without judgment.\u00a0This JAMA\u00a0Perspective highlights some pretty impressive studies:<\/li>\n<\/ol>\n<ul>\n<li>A randomized controlled trial showing that mindfulness-based stress reduction (MSBR<strong>)<\/strong>was comparable to\u00a0cognitive behavioral therapy (CBT) in reducing chronic low back pain, finding that there was no difference between MBSR and cognitive behavioral therapy (CBT), both with about a 45% reduction in pain (vs 25% with usual care). For my review of full article, see prior blog:\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/04\/07\/primary-care-corner-with-geoffrey-modest-md-low-back-pain-improves-with-stress-reduction-mindfulness-and-cognitive-behavioral-therapy\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/04\/07\/primary-care-corner-with-geoffrey-modest-md-low-back-pain-improves-with-stress-reduction-mindfulness-and-cognitive-behavioral-therapy\/<\/a><\/li>\n<li>Another RCT involved\u00a0282 older adults\u00a0with\u00a0chronic low back pain, also finding that those with 8 weeks of mindfulness meditation followed by 6 monthly sessions showing that\u00a045% of the\u00a0patients\u00a0experienced &gt;30% reduction in pain vs 25% of the patients\u00a0in the control group.<\/li>\n<li>Using functional magnetic resonance imaging of volunteers exposed to a noxious stimulus, those who practiced mindfulness meditation had a 57% decrease in how unpleasant the stimulus felt and a 40% decreased rating of pain intensity vs control (and those who paid attention just to breathing did not have these benefits). They found that meditation\u00a0was associated with\u00a0more activation of the orbitofrontal cortex (OFC), an area of the brain which &#8220;controls how people put into context what they sense in the environment&#8221;. Subjects\u00a0commented that they did in fact\u00a0feel\u00a0the pain but were able to &#8220;let it go&#8221; and not dwell on it. The meditation also led to less activation of the thalamus, which serves as the pain gateway from the spinal cord to the brain, and activation of the anterior cingulate cortex (ACC), involved in cognitive control and emotional regulation. And, interestingly enough, though there are plenty of opioid receptors in the OFC and ACC, mindfulness did not affect these receptors (naloxone had no effect).<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>Overall Commentary:<\/p>\n<ul>\n<li><strong>These articles reinforce the intimate connection between pain perception and one&#8217;s psychosocial state<\/strong>.<\/li>\n<li>There seems to be\u00a0a shift in thinking about chronic vs acute pain, with argument that the issue with chronic pain involves different\/more extensive\u00a0central involvement (hyperalgesia, changes in functional neuroimaging, more somatic symptoms such as fatigue, memory problems, insomnia, mood disorders), which supports\u00a0the use of\u00a0different\u00a0CNS-directed treatments (SNRIs, anticonvulsants) &#8212; for more info\u00a0see\u00a0Phillips K. Best Pract Res Clin Rheumatol 2011; 25: 141.<\/li>\n<li>Those with chronic pain often have increased response to peripheral stimuli (hyperalgesia\/allodynia), rate pain as more severe,\u00a0and <strong>those with chronic widespread pain often have specific focal triggers, such as myofascial trigger points, ligamentous trigger points, or osteoarthritis of the spine or\u00a0joints.<\/strong> And these focal\u00a0triggers\u00a0can lead to\/perpetuate the\u00a0chronic pain\u00a0(see\u00a0Staud R.\u00a0Best Pract Res Clin Rheumatol 2011; 25: 155.)\u00a0This ties together the complex interaction between peripheral triggers\/local changes (e.g. increased lactic acid production, cytokines) and the central interpretation of that pain, including the sensation of\u00a0chronic widespread pain. (It is really common for a patient with a particularly painful local site to have much more diffuse bodily\u00a0pain. in my experience, I have sometimes been able to treat the triggering source with injections, leading to a generalized decrease in pain overall).<\/li>\n<li>Also, it is pretty clear that stress itself may be a bad actor: stress leads to muscle tightness (perhaps part of the fight\/flight response and readiness to act). But chronic stress leads to chronic muscle tightness\u00a0and pain\u00a0transmitted\u00a0largely through the spinothalamic tract pain fibers to\u00a0the thalamus\/ACC\/etc.\u00a0and then to\u00a0the cerebral primary somatic sensory cortex. As noted above, several of these processing stations alter their pain\u00a0response by\u00a0meditation.<\/li>\n<li>In terms of the peripheral musculoskeletal\u00a0effects of chronic stress,\u00a0it seems to me that there are certain areas of muscle tightness that are more\u00a0common\u00a0with\u00a0chronic stress, such as at the occipital insertion of the trapezius, diffusely in\u00a0the muscles around the cranium\/tension headaches,\u00a0costochondral areas in the sternum, lower back, and several of the &#8220;trigger points&#8221;\u00a0of\u00a0fibromyalgia.)<\/li>\n<li>To me, the above studies suggest a couple of things:\n<ul>\n<li>Decreasing the functional impact of stressors, whether through mindfulness meditation, Tai Chi or CBT, can decrease the direct\u00a0effects of stress on the muscles (and there is the argument that many people\u00a0with chronic pain &#8220;catastrophize&#8221; it: thinking negative thoughts about how pain will affect their function, which might expectantly\u00a0exacerbate pain\u00a0sensation. these psychological techniques directly affect how stress is perceived and handled)<\/li>\n<li>And, there are impressive data that there are also meditation\u00a0effects on\u00a0how various parts of the brain itself (thalamus, anterior cingulate cortex, etc.) fundamentally\u00a0respond\u00a0to\u00a0painful stimuli<\/li>\n<\/ul>\n<\/li>\n<li>The CDC stresses that the preferred therapy for pain management is maximizing nonpharmacologic and nonopioid pharmacologic pain management (see\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/03\/25\/primary-care-corner-with-geoffrey-modest-md-new-cdc-guidelines-for-opiate-prescribing\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/03\/25\/primary-care-corner-with-geoffrey-modest-md-new-cdc-guidelines-for-opiate-prescribing\/<\/a> for review)<\/li>\n<li>So, whether the beneficial effect of mindful meditation, CBT or Tai Chi is through moderating the perception\u00a0of stress or the changing\u00a0the way pain is handled centrally, or both (hard to separate), it seems to me to be increasingly clear that there are some important and perhaps fundamental differences in how patients with chronic pain\u00a0experience their\u00a0pain, and that we should be more aggressively pursuing a more global approach, including mindfulness meditation, Tai Chi, or CBT as a really important nonpharmacologic\u00a0component\u00a0to\u00a0helping people with chronic pain.\u00a0this approach coincides with\u00a0the CDC focus on maximizing\u00a0nonpharmacologic adjunctive therapies\u00a0as\u00a0a way to avoid opiates or at least minimize their use. In this context, it is intriguing that the above alterations in\u00a0central pain pathways by mindfulness meditation do not seem to be entirely\u00a0related to opiate receptors, both suggesting that either endogenous or exogenous opiates may not be necessary for effective chronic pain management and that there may be room for development of other, nonopiate meds as part of chronic pain treatment&#8230;<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Tai Chi for Knee OA; Mindfulness for Chronic Pain  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/06\/29\/primary-care-corner-with-geoffrey-modest-md-tai-chi-for-knee-oa-mindfulness-for-chronic-pain\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1081","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1081","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1081"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1081\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1081"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1081"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1081"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}