Stikkordarkiv: hjernen

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A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain

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Omfattende studie om kronisk smerte som kommer med reelle tiltak for å bedre tilstanden hos pasientene. Nevner spesielt en at en holdningsendring må skje hos legene og sykepleierene hvor man inkluderer pasientes subjektive opplevelse. Nevner grunnlaget for dagens medisin og objektifisering av pasienten: «Foucault412 described the paradoxical position of the clinical encounter, in which the doctor aims to diagnose a disease rather than understand the person’s experience: ‘If one wishes to know the illness from which he is suffering, one must subtract the individual, with his [or her] particular qualities’  »

http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0010/94285/FullReport-hsdr01120.pdf

Conclusion: Our model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care. 

As part of a person’s struggle we described the fragmentation of body and self, and suggested that moving forward with pain involves a process of reintegrating the painful body. 

Under conditions of health, we perform actions automatically and remain unaware of our body until something goes wrong with it. Health presupposes that we remain unaware of our bodies.396 When in pain, the body emerges as an ‘alien presence’;
it ‘dys-appears’. I no longer am a body but have a body,388 and my body becomes an ‘it’ as opposed to an

I’. Wall399 describes this dualism as epitomised by the expression ‘my foot hurts me’ as if in some way the foot is apart from myself (p. 23). It is because ‘the body seizes our awareness particularly at times of disturbance, [that] it can come to appear “other” and opposed to the self’ (p. 70).388 This fragmentation of ‘mind trapped inside an alien body’ means that our bodies become mistrusted and ‘forgotten as a ground of knowledge’ (p. 86).388 Our concept ‘integrating my painful body’ implies an altered therapeutic relationship with the body in which the dualism of mind and body are broken down.

We do not know why certain patients can accept and redefine their sense of self and others cannot.
It may be related to the degree of disruption to self that is caused by pain. The enmeshment model developed by Pincus and Morley406 proposes that, if a person regards their ideal self as unobtainable in the presence of pain, they are less likely to accept chronic pain. The enmeshment model incorporates self-discrepancy theory,407 which proposes that the extent to which pain disrupts our lives depends on the meaning that it holds for us. In self-discrepancy theory meaning incorporates three constructs: (1) actual self – ‘your representation of the attributes that someone (yourself or another) believes you actually possess’; (2) ideal self – ‘your representation of the attributes that someone (yourself or another) would like you, ideally, to possess’; and (3) ought self – ‘your representation of the attributes that someone (yourself or another) believes you should or ought to possess’ (p. 320–1).407

However, it is ‘pathos’, the feeling of suffering and powerlessness, of ‘life going wrong’, that precedes a person’s visit to the doctor (p. 137).396 Our model suggests that central to the therapeutic relationship is the recognition of ‘pathos’; the patient is a subject rather than an ‘object’ of investigation. This concept is central to models of patient-centred care.413

We described a need for a person in pain to feel that the health-care professional is alongside them with their pain. Affirming a person’s experience and allowing an empathetic interpretation of their story is not an adjunct, but integral to health care.395

Our model also suggests possibilities that might help patients to move forward alongside their pain:

  • an integrated relationship with the painful body
  • redefining a positive sense of self now and in the future
  • communicating to, rather than hiding from, others the experience of pain
  • knowing that I am not the only one with pain (but I am still valued)
  • regaining a sense of reciprocity and social participation
  • recognising the limitations of the medical model
  • being empowered to experiment and change the way that I do things without the sanction of the health-care professional.
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Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation

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En studie som gir en tydelig beskrivelse av hvor mye mindfulness demper smerte. De fant ingen korrelasjon mellom pustefrekvens og smertereduksjon, men det kan være flere faktorer som spiller inn der.  I denne studien gjorde de f.eks. kun 20 min meditasjon i 4 dager, med mennesker som ikke har meditert først. De andre studiene inkluderer mennesker som har meditert lenge. I tillegg kan man tydelig se at etter 4 dager med meditasjon så blir pustefrekvensen lavere når man blir påført vond varme, noe som tyder på at de begynner å bruke pusten som smertereduksjon. Det var motsatt før de hadde fått instruksjon i meditasjon.

http://www.jneurosci.org/content/31/14/5540.full

After 4 d of mindfulness meditation training, meditating in the presence of noxious stimulation significantly reduced pain unpleasantness by 57% and pain intensity ratings by 40% when compared to rest.

Meditation-induced reductions in pain intensity ratings were associated with increased activity in the anterior cingulate cortex and anterior insula, areas involved in the cognitive regulation of nociceptive processing. Reductions in pain unpleasantness ratings were associated with orbitofrontal cortex activation, an area implicated in reframing the contextual evaluation of sensory events. Moreover, reductions in pain unpleasantness also were associated with thalamic deactivation, which may reflect a limbic gating mechanism involved in modifying interactions between afferent input and executive-order brain areas. Together, these data indicate that meditation engages multiple brain mechanisms that alter the construction of the subjectively available pain experience from afferent information.

Mindfulness-based mental training.

Mindfulness-based mental training was performed in four separate, 20 min sessions conducted by a facilitator with >10 years of experience leading similar meditation regimens. Subjects had no previous meditative experience and were informed that such training was secular and taught as the cognitive practice of Shamatha or mindfulness meditation. Each training session was held with one to three participants.

On mindfulness meditation training day 1, subjects were encouraged to sit with a straight posture, eyes closed, and to focus on the changing sensations of the breath occurring at the tips of their nostrils. Instructions emphasized acknowledging discursive thoughts and feelings and to return their attention back to the breath sensation without judgment or emotional reaction whenever such discursive events occurred. On training day 2, participants continued to focus on breath-related nostril sensations and were instructed to “follow the breath,” by mentally noting the rise and fall of the chest and abdomen. The last 10 min were held in silence so subjects could develop their meditative practice. On training day 3, the same basic principles of the previous sessions were reiterated. However, an audio recording of MRI scanner sounds was introduced during the last 10 min of meditation to familiarize subjects with the sounds of the scanner. On the final training session (day 4), subjects received minimal meditation instruction but were required to lie in the supine position and meditate with the audio recording of the MRI sounds to simulate the scanner environment. Contrary to traditional mindfulness-based training programs, subjects were not required to practice outside of training.

Subjects also completed the Freiburg Mindfulness Inventory short-form (FMI), a 14-item assessment that measures levels of mindfulness, before psychophysical pain training and after MRI session 2. The FMI is a psychometrically validated instrument with high internal consistency (Cronbach α = 0.86) (Walach et al., 2006). Statements such as “I am open to the experience of the present moment” are rated on a five-point scale from 1 (rarely) to 5 (always). Higher scores indicate more skill with the mindfulness technique.

Decreases in respiration rate have been reported previously to predict reductions in pain ratings (Grant and Rainville, 2009; Zautra et al., 2010). In the present data (MRI session 2; n = 14), no significant relationship between the decreased respiration rates and pain intensity (p = 0.22, r = −0.35), pain unpleasantness (p = 0.41, r = −0.24), or FMI ratings (p = 0.42, r = 0.24) was found.

CBF Respiration rate Heart rate
Session 1
    Rest: neutral 74.12 (3.01) 19.97 (1.29) 72.53 (2.33)
    Rest: heat 71.51 (2.93) 20.45 (1.11) 74.79 (2.39)
    ATB: neutral 70.69 (3.56) 17.05 (1.00) 70.46 (1.79)
    ATB: heat 67.90 (3.08) 19.32 (1.33) 74.07 (2.19)
Session 2
    Rest: neutral 68.57 (3.17) 16.72 (0.82) 74.82 (3.08)
    Rest: heat 66.82 (2.59) 17.12 (0.93) 77.32 (2.95)
    Meditation: neutral 65.09 (3.59) 11.55 (0.74) 73.62 (2.77)
    Meditation: heat 65.47 (3.86) 9.47 (0.67)a 75.38 (2.70)

In the present investigation, meditation reduced all subjects’ pain intensity and unpleasantness ratings with decreases ranging from 11 to 70% and from 20 to 93%, respectively.

Meditation likely modulates pain through several mechanisms. First, brain areas not directly related to meditation exhibited altered responses to noxious thermal stimuli. Notably, meditation significantly reduced pain-related afferent processing in SI (Fig. 5), a region long associated with sensory-discriminative processing of nociceptive information (Coghill et al., 1999). Executive-level brain regions (ACC, AI, OFC) are thought to influence SI activity via anatomical pathways traversing the SII, insular, and posterior parietal cortex (Mufson and Mesulam, 1982; Friedman et al., 1986;Vogt and Pandya, 1987). However, because meditation-induced changes in SI were not specifically correlated with reductions in either pain intensity or unpleasantness, this remote tuning may take place at a processing level before the differentiation of nociceptive information into subjective sensory experience.

Second, the magnitude of decreased pain intensity ratings was associated with ACC and right AI activation (Fig. 6). Activation in the mid-cingulate and AI overlapped between meditation and pain, indicating a likely substrate for pain modulation. Converging lines of evidence suggest that these regions play a major role in the evaluation of pain intensity and fine-tuning afferent processing in a context-relevant manner (Koyama et al., 2005; Oshiro et al., 2009;Starr et al., 2009). Such roles are consistent with the aspect of mindfulness meditation that involves reducing appraisals that normally impart significance to salient sensory events.

Third, OFC activation was associated with decreases in pain unpleasantness ratings (Fig. 6). The OFC has been implicated in regulating affective responses by manipulating the contextual evaluation of sensory events (Rolls and Grabenhorst, 2008) and processing reward value in the cognitive modulation of pain (Petrovic and Ingvar, 2002). Meditation directly improves mood (Zeidan et al., 2010a), and positive mood induction reduces pain ratings (Villemure and Bushnell, 2009). Therefore, meditation-related OFC activation may reflect altered executive-level reappraisals to consciously process reward and hedonic experiences (e.g., immediate pain relief, positive mood) (O’Doherty et al., 2001; Baliki et al., 2010; Peters and Büchel, 2010).

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Mindfulness starts with the body: somatosensory attention and top-down modulation of cortical alpha rhythms in mindfulness meditation

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Studie som nevner at Mindfulness øker alpha-bølger i hjernen, som bidrar til reduksjon i smerte.

http://www.frontiersin.org/Journal/10.3389/fnhum.2013.00012/full

Using a common set of mindfulness exercises, mindfulness based stress reduction (MBSR) and mindfulness based cognitive therapy (MBCT) have been shown to reduce distress in chronic pain and decrease risk of depression relapse. These standardized mindfulness (ST-Mindfulness) practices predominantly require attending to breath and body sensations.

Based on multiple randomized clinical trials, there is good evidence for the efficacy of these ST-Mindfulness programs for preventing mood disorders in people at high risk of depression (Teasdale et al., 2000a,b; Ma and Teasdale, 2004; Segal et al., 2010; Fjorback et al., 2011; Piet and Hougaard, 2011), improving mood and quality of life in chronic pain conditions such as fibromyalgia (Grossman et al., 2007; Sephton et al., 2007; Schmidt et al., 2011) and low-back pain (Morone et al., 2008a,b), in chronic functional disorders such as IBS (Gaylord et al., 2011) and in challenging medical illnesses, including multiple sclerosis (Grossman et al., 2010) and cancer (Speca et al., 2000). ST-Mindfulness has also been shown to decrease stress in healthy people undergoing difficult life situations (Cohen-Katz et al., 2005), such as caring for a loved-one with Alzheimer’s disease (Epstein-Lubow et al., 2006).

Numerous behavioral and neural mechanisms have been proposed to explain these positive outcomes. Proposed mechanisms include changes in neural networks underlying emotion regulation (Holzel et al., 2008), illustrated by findings showing decreased amygdala response after ST-Mindfulness in social anxiety patients exposed to socially threatening stimuli (Goldin and Gross, 2010). Other neural mechanisms highlighted in recent reviews include changes in self-processing (Vago and Silbersweig, 2012) based on multiple studies including a report showing decreases in activation in midline cortical areas used in self-related processing in ST-Mindfulness trained subjects (Farb et al., 2007).

In the first 2 weeks of the 8-week ST-Mindfulness sequence, all formal practice is devoted to a meditative body scan practice of “moving a focused spotlight of attention from one part of the body to another.” Through this exercise, practitioners are said to learn to feel (1) how to control the attentional spotlight even when focusing on painful, aversive sensations (2) how even familiar body sensations change and fluctuate from moment to moment.

In the last 5–6 weeks of class, participants continue to use embodied practices, especially sitting meditation focused on sensations of breathing. These embodied practices are said to teach practitioners (1) how to directlyfeel when the mind has wandered from its sensory focus (2) how to use an intimate familiarity with the fluctuations of sensations of breathing (such as the up and down flow of the breath) as a template for regarding the arising and passing of distressing, aversive thoughts as “mental events” rather than as “facts or central parts of their identity.”

Specifically, we propose that body-focused attentional practice in ST-Mindfulness enhances localized attentional control over the 7–14 Hz alpha rhythm that is thought to play a key role in regulating sensory input to sensory neocortex and in enhancing signal-to-noise properties across the neocortex. Beginning with the enhanced modulation of localized alpha rhythms trained in localized somatic attention practices such as the body-scan, and then proceeding through the 8-week sequence to learn broader modulation of entire sensory modalities (e.g., “whole body attention”) practitioners train in filtering and prioritizing the flow of information through the brain.

In chronic pain situations, nearly all studies of ST-Mindfulness show relief of pain-related distress and increased mood.

 

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Meditation Programs for Psychological Stress and Well-being

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En metaanalyse av studier på meditasjonsprogrammer. Konkluderer med at effekten er såpass stor og viktig at leger bør prate med sine pasienter om meditasjon.

http://archinte.jamanetwork.com/article.aspx?articleid=1809754

Mindfulness meditation programs had moderate evidence of improved anxiety (effect size, 0.38 [95% CI, 0.12-0.64] at 8 weeks and 0.22 [0.02-0.43] at 3-6 months), depression (0.30 [0.00-0.59] at 8 weeks and 0.23 [0.05-0.42] at 3-6 months), and pain (0.33 [0.03- 0.62]) and low evidence of improved stress/distress and mental health–related quality of life.

Clinicians should be aware that meditation programs can result in small to moderate reductions of multiple negative dimensions of psychological stress. Thus, clinicians should be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress.

Reviews to date report a small to moderate effect of mindfulness and mantra meditation techniques in reducing emotional symptoms (eg, anxiety, depression, and stress) and improving physical symptoms (eg, pain).7– 26

Among the 9 RCTs43,44,47,54,55,63,64,73,74 evaluating the effect on pain, we found moderate evidence that mindfulness-based stress reduction reduces pain severity to a small degree when compared with a nonspecific active control, yielding an ES of 0.33 from the meta-analysis. This effect is variable across painful conditions and is based on the results of 4 trials, of which 2 were conducted in patients with musculoskeletal pain,55,64 1 trial in patients with irritable bowel syndrome,43 and 1 trial in a population without pain.44 Visceral pain had a large and statistically significant relative 30% improvement in pain severity, whereas musculoskeletal pain showed 5% to 8% improvements that were considered nonsignificant.

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Whatever next? Predictive brains, situated agents, and the future of cognitive science

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Fantastisk interessant studie som nevner at hjernen ikke benytter seg av input fra omgivelsene til å skape et bilde av omgivelsene, men til å bekrefte det bildet den allerede har skapt, altså bekrefte sin «fantasi» om virkeligheten.

Klikk for å få tilgang til Whatever%20next.pdf

Brains, it has recently been argued, are essentially prediction machines. They are bundles of cells that support perception and action by constantly attempting to match incoming sensory inputs with top-down expectations or predictions. This is achieved using a hierarchical generative model that aims to minimize prediction error within a bidirectional cascade of cortical processing. Such accounts offer a unifying model of perception and action, illuminate the functional role of attention, and may neatly capture the special contribution of cortical processing to adaptive success. This target article critically examines this “hierarchical prediction machine” approach, concluding that it offers the best clue yet to the shape of a unified science of mind and action. Sections 1 and 2 lay out the key elements and implications of the approach. Section 3 explores a variety of pitfalls and challenges, spanning the evidential, the methodological, and the more properly conceptual. The paper ends (sections 4 and 5) by asking how such approaches might impact our more general vision of mind, experience, and agency.

In this paradigm, the brain does not build its current model of distal causes (its model of how the world is) simply by accumulating, from the bottom-up, a mass of low-level cues such as edge-maps and so forth. Instead (see Hohwy 2007), the brain tries to predict the current suite of cues from its best models of the possible causes.

The Helmholtz Machine sought to learn new representations in a multilevel system (thus capturing increasingly deep regularities within a domain) without requiring the provision of copious pre-classified samples of the desired input/output mapping. In this respect, it aimed to improve (see Hinton 2010) upon standard back-propagation driven learning. It did this by using its own top-down connections to provide the desired states for the hidden units, thus (in effect) self-supervising the development of its perceptual “recognition model” using a generative model that tried  to create the sensory patterns for itself (in “fantasy,” as it was sometimes said).3 (For a useful review of this crucial innovation and a survey of many subsequent developments, see Hinton 2007a).

Transposed (in ways we are about to explore) to the neural domain, this makes prediction error into a kind of proxy (Feldman & Friston 2010) for sensory information itself. Later, when we consider predictive processing in the larger setting of information theory and entropy, we will see that prediction error reports the “surprise” induced by a mismatch between the sensory signals encountered and those predicted.

A good place to start (following Rieke 1999) is with what might be thought of as the “view from inside the black box.” For, the task of the brain, when viewed from a certain distance, can seem impossible: it must discover information about the likely causes of impinging signals without any form of direct access to their source. Thus, consider a black box taking inputs from a complex external world. The box has input and output channels along which signals flow. But all that it “knows”, in any direct sense, are the ways its own states (e.g., spike trains) flow and alter. In that (restricted) sense, all the system has direct access to is its own states. The world itself is thus off-limits (though the box can, importantly, issue motor commands and await developments). The brain is one such black box.

 

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Understanding the Process of Fascial Unwinding

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Studie som nevner hvordan «fascial unwinding» skjer ved hjelp av stimulering av mekanoreseptorer i huden. Parasympatikus aktiveres og gjør at muskelspenninger slipper taket.

http://ijtmb.org/index.php/ijtmb/article/view/43/75

Hypothetical Model: During fascial unwinding, the therapist stimulates mechanoreceptors in the fascia by applying gentle touch and stretching. Touch and stretching induce relaxation and activate the parasympathetic nervous system. They also activate the central nervous system, which is involved in the modulation of muscle tone as well as movement. As a result, the central nervous system is aroused and thereby responds by encouraging muscles to find an easier, or more relaxed, position and by introducing the ideomotor action. Although the ideomotor action is generated via normal voluntary motor control systems, it is altered and experienced as an involuntary response.

Conclusions: Fascial unwinding occurs when a physically induced suggestion by a therapist prompts ideomotor action that the client experiences as involuntary. This action is guided by the central nervous system, which produces continuous action until a state of ease is reached. Consequently, fascial unwinding can be thought of as a neurobiologic process employing the self-regulation dynamic system theory.

In this paper, I propose a model based on scientific literature to explain the process and mechanism of fascial unwinding (Fig. 1). The model is based on the theories of ideomotor action by Carpenter(18) and Dorko,(16) fascia neurobiologic theory by Schleip,(4,5) and the psychology of consciousness by Halligan and Oakley.(19)

A set of conditions are required to initiate or facilitate the unwinding process. The therapist’s sensitivity and fine palpation skills form the most important part of these conditions, but it is also imperative that the client be able to relax and “let go” of his or her body.

In the first stage—the initiation or induction phase— the therapist working on a client will introduce touch or stretching onto the tissue. Touch is the entrance requirement for the process of unwinding. Touch stimulates the fascia’s mechanoreceptors and, in turn, arouses a parasympathetic nervous system response.(5) As a result of this latter response, the client is in a state of deep relaxation and calm, sometimes followed with rapid eye movement, twitching, or deep breathing—a state that can be observed clinically.(20,21) In this state, the conscious mind is relaxed and off guard. Stimulation of mechanoreceptors also influences the central nervous system. The central nervous system responds to this proprioceptive input by allowing the muscles to perform actions that decrease tone or that create movement in a joint or limb, making it move into an area of ease. At this point, ideomotor reflexes occur. Ideomotor action pertains to involuntary muscle movement, which can manifest in various ways and is directed at the central nervous system.(22)

These reflexes occur unconsciously, indicating dissociation between voluntary action and conscious experience.(23) In clinical situations, the client is unaware of the unconscious movement and thinks that it is generated by the therapist. This unconscious movement or stretching sensation stimulates a response in the tissue, providing a feedback to the central nervous system as outlined in the theory of ideomotor action.(24) The process is repeated until the client is relaxed or has reached a “still point” or state of ease.

The indirect stimulation of the autonomic nervous system (that is, the parasympathetic nervous system), which results in global muscle relaxation and a more peaceful state of mind, represents the heart of the changes that are so vital to many manual therapies. Gentler types of myofascial stretching and cranial techniques have also long been acknowledged to affect the parasympathetic nervous system.(25) Bertolucci(20) observed that, when a client is being treated with a muscle repositioning technique, the client begins to show involuntary motor reactions—reactions that include the involuntary action of related muscles and rapid eye movements. Several studies have evaluated the physiologic changes in the autonomic nervous system that occur as a result of craniosacral and MFR interventions,(21,26) clinically-known techniques that can trigger the unwinding process.

Recent studies have used heart rate variability, respiratory rate, skin conductance, and skin temperature as measures of physiologic change. Zullow and Reisman(26) indicated an increase in parasympathetic activity resulting from the compression of the fourth intracranial ventricle (CV4) maneuver and sacral holds, as measured by heart rate variability. Using heart rate variability measurement, Henley et al.(25) demonstrated that cervical MFR shifts sympathovagal balance from the sympathetic to the parasympathetic nervous system.

Dorko(16) was the first to suggest that fascial unwinding can be simply explained as an ideomotor movement. McCarthy et al.(29) were the first to document unwinding as an ideomotor-based manual therapy in the treatment of a patient with chronic neck pain. Their research showed that a reduction in pain intensity and perceived disability can be achieved with the introduction of ideomotor treatment.

A model built upon the neurobiologic, ideomotor action, and consciousness theories is proposed to explain the mechanism of unwinding. Touch, stretching, and manual therapy can induce relaxation in the parasympathetic nervous system. They also activate the central nervous system, which is involved in the modulation of muscle tone as well as movement. This activation stimulates the response to stretching: muscles find areas and positions of ease, the client experiences less pain or is more relaxed, thereby introducing the ideomotor action. The ideomotor action is generated through normal voluntary motor control systems, but is altered and experienced as an involuntary reaction. The stretching sensation provides a feedback to the nervous system, which in turn will generate the movements again.