- Email: [email protected]
(270) Increased Salience Network Connectivity following Spinal Manipulative Therapy is Associated with Reduced Pain in Chronic Low Back Pain Patients
Abstracts
S42 The Journal of Pain
Treatment Approaches (Complementary & Alternative) (269) Which Patients for Yoga? Investigating Differential Effects of a Six-Week Daily Yoga Intervention on Pain, Catastrophizing, and Sleep among Women with Fibromyalgia A. Koulouris, A. Lazaridou, K. Dorado, M. Paschali, E. Schwartz, M. Patton, R. Edwards, and K. Schreiber; Brigham and Women’s Hospital Harvard Medical School, Boston, MA Fibromyalgia (FM) is characterized by chronic widespread pain, sleep disturbance, fatigue, and catastrophizing. This pilot study explored whether gentle, daily yoga-based exercise practice could improve pain and sleep quality, and whether certain patient phenotypes were associated with greater improvement. Fibromyalgia patients (n = 36) attended a six-week yoga program, with weekly, in-person, pain-tailored group yoga classes, and were sent daily yoga videos to practice for 30 minutes at home. Participants completed the Brief Pain Inventory (BPI), Revised Fibromyalgia Impact Questionnaire (FIQR), Promis-29 scales, Pittsburgh Sleep Quality Index (PSQI), and the Pain Catastrophizing Scale (PCS). Additionally, they completed daily electronic diaries and wore a wrist actigraph to measure sleep efficiency during 3 weeks, at baseline, 2nd, and 6th week of yoga. Pain, fatigue, and sleep quality, although improved overall, varied among participants. Multilevel modeling analysis of daily ratings in week 6 revealed no main effect for baseline anxiety and catastrophizing on pain, fatigue and sleep efficiency. However, a significant interaction between these was observed for all three outcomes (fatigue: B=.060§.022, p=0.01, sleep efficiency: B=-.40§ .015, p = 0.01, pain: B=.055§.020, p=0<0.01), such that patients with higher catastrophizing and lower anxiety at baseline showed greatest benefit. Additionally, those with greater decrease in pain catastrophizing throughout the study demonstrated a greater decrease in FIQR (Rho:0.450, p=0.006). Although yoga improved FM symptoms overall, patients with certain psychosocial characteristics may benefit more. In particular, participants who initially exhibited higher catastrophizing and lower anxiety, showed significant improvements in fatigue, sleep efficiency and pain at the end of the intervention. Future studies should include phenotypic characterization of patients undergoing behavioral interventions such as yoga, to help understand which patients benefit most, and guide personalized intervention in future.
(270) Increased Salience Network Connectivity following Spinal Manipulative Therapy is Associated with Reduced Pain in Chronic Low Back Pain Patients K. Isenburg, M. Loggia, D. Ellingsen, E. Protsenko, I. Mawla, M. Kowalski, D. Swensen, D. O’Dwyer-Swensen, R. Edwards, V. Napadow, and N. Kettner; Massachusetts General Hospital, Boston, MA Chronic low back pain (cLBP) has been associated with maladaptive brain plasticity, and non-pharmacological therapies such as Spinal Manipulative Therapy (SMT) have shown promise in reducing pain and modifying intrinsic brain physiology. However, more translational research is needed using clinical models. We investigated functional salience network (SLN) connectivity response to SMT, and linked response to cLBP pain reduction. Fifteen cLBP patients (8 female, 37.7 § 9.7 (M§ SD) years old), and 16 healthy controls (HC, 8 female, 38.2 § 10.4 years old) were scanned with resting state fMRI before and after a single session of spinal manipulation and spinal mobilization (grades V and III of the Maitland Joint Mobilization Grading Scale) at separate visits. Patients rated clinical pain (0-100) pre- and post-therapy. Intrinsic SLN connectivity was assessed using dual regression probabilistic independent component analysis. Voxelwise analyses were cluster corrected for multiple comparison (z>2.3, p<0.05), followed by Region of Interest (ROI) analyses (a<0.05). Both manipulation (t=3.3, p=0.005) and mobilization (t=2.56, p=0.02) reduced clinical back pain following SMT. However, manipulation (but not mobilization) significantly increased SLN connectivity to thalamus (F=18.18, p<0.001) and M1 (F=4.89, p=0.04). Additionally, this increase for cLBP was greater than for HC following manipulation (Thal: F=12.75, p<0.001; M1: F=12.16, p<0.002). Furthermore, a voxelwise regression analysis indicated that greater SMT-induced increase in SLN connectivity to lateral prefrontal cortex (LPFC) was associated with with greater clinical back pain reduction. Interestingly, for spinal mobilization, a
ROI-based regression analysis using this LPFC cluster found a similar non-significant trend between pain reduction and LPFC connectivity post-mobilization (R=-0.44, p=0.1). Our data suggest that while manipulation increases SLN connectivity to sensorimotor processing regions (i.e. thalamus, M1), increased SLN connectivity to cognitive processing regions (i.e. LPFC) supports SMT analgesia, with more robust recruitment of this brain-based mechanism by spinal manipulation compared to mobilization.
(271) Attitudes of Older Adults with Chronic Musculoskeletal Pain towards Immersive Virtual Reality L. Nakad and B. Rakel; University of Iowa, Iowa City, IA Older adults are especially susceptible to chronic musculoskeletal (MSK) pain. Drugs provide inadequate relief and overuse can lead to adverse events. Immersive virtual reality (IVR), a computer-generated simulation of a 3-D image, can act as distraction therapy by drawing attention away from pain. The purpose of this study is to explore the attitudes and treatment acceptability of older adults with chronic MSK pain towards IVR as distraction therapy for chronic pain exacerbations. The aims are: 1) describe attitudes of older adults suffering from chronic MSK pain towards IVR using focus groups; 2) describe IVR treatment acceptability and side effects using surveys. This is a descriptive, exploratory study using mixed methods and convergent parallel design. Inclusion criteria: 1) diagnosis of chronic MSK pain; 2) 65 and older; 3) residency at participating facility. Exclusion criteria: 1) cognitive impairment; 2) hearing/visual deficit. Treatment acceptability was measured with 8 items scored on a 5-pt Likert scale. Side effects to IVR were measured with Virtual Reality Sickness Questionnaire (VRSQ). Participation consisted of 2 visits. The first visit included the consent process, eligibility screening, survey completion, and 15-minutes of IVR and the second visit was a focus group. Data collection and analysis is ongoing, and the current sample size is 15. Most participants found IVR to be an acceptable way to manage pain (73.4%) and would be willing to use it for their pain (73.3%). 46.6% believed it would likely reduce their pain. Few experienced side effects (26%), such as general discomfort and eyestrain. Qualitative data suggests: 1) greater ease of use with sufficient practice; 2) a preference towards relaxation, meditation, or biofeedback simulations with realistic images; 3) an uncertainty of effectiveness with movement-evoked pain. The findings of this study will help optimize IVR as a therapy for chronic MSK pain.
(272) An 8 Week Modified Yoga Program for Chronic Pain S. Hall; HealthPartners, St. Paul, MN The utilization of complementary care is on the rise for patients with chronic pain, partly due to the opioid epidemic and recent guidelines stating opioids are ineffective for chronic pain. Physical activity is a primary recommendation for various types of chronic pain. The 2007 National Health Interview Survey found that U.S. adults are choosing yoga as one of the top 10 complementary approaches. Stemming from ancient Indian philosophy, yoga is a mind-body practice that typically combines physical postures, breathing techniques and meditation. Yoga has been shown to have neuroprotective effects on the brain, possibly even reversing the effects of chronic pain. Patients with chronic pain can be hesitant to start yoga due to the public’s view of needing to be flexible and fit in order to do yoga. People with chronic pain may also fear exercise due to past experiences that flared their pain. There are many different schools and types of yoga available, making it confusing to choose a class to attend. Therefore, we developed an 8 week “yoga for chronic pain” program to introduce the benefits of yoga and modify the yoga practice for patients with chronic pain. There is a weekly didactic on how yoga can be helpful for various aspects of chronic painfatigue, sleep, improved mood. This is followed by a gentle guided posture, breathing and meditation practice. Participants are given a variety of resources, encouraged to start a home practice and log their minutes of practice each week. In 2018, we had two groups of patients complete our 8-week yoga program and we measured their pain interference, sleep, mood, and pain medication usage at the start, end and 3 months following completion of our program. In this poster, we will present our findings (currently under analysis). (Villemure, et al, Cerebral Cortex 2014)
S42 The Journal of Pain
Treatment Approaches (Complementary & Alternative) (269) Which Patients for Yoga? Investigating Differential Effects of a Six-Week Daily Yoga Intervention on Pain, Catastrophizing, and Sleep among Women with Fibromyalgia A. Koulouris, A. Lazaridou, K. Dorado, M. Paschali, E. Schwartz, M. Patton, R. Edwards, and K. Schreiber; Brigham and Women’s Hospital Harvard Medical School, Boston, MA Fibromyalgia (FM) is characterized by chronic widespread pain, sleep disturbance, fatigue, and catastrophizing. This pilot study explored whether gentle, daily yoga-based exercise practice could improve pain and sleep quality, and whether certain patient phenotypes were associated with greater improvement. Fibromyalgia patients (n = 36) attended a six-week yoga program, with weekly, in-person, pain-tailored group yoga classes, and were sent daily yoga videos to practice for 30 minutes at home. Participants completed the Brief Pain Inventory (BPI), Revised Fibromyalgia Impact Questionnaire (FIQR), Promis-29 scales, Pittsburgh Sleep Quality Index (PSQI), and the Pain Catastrophizing Scale (PCS). Additionally, they completed daily electronic diaries and wore a wrist actigraph to measure sleep efficiency during 3 weeks, at baseline, 2nd, and 6th week of yoga. Pain, fatigue, and sleep quality, although improved overall, varied among participants. Multilevel modeling analysis of daily ratings in week 6 revealed no main effect for baseline anxiety and catastrophizing on pain, fatigue and sleep efficiency. However, a significant interaction between these was observed for all three outcomes (fatigue: B=.060§.022, p=0.01, sleep efficiency: B=-.40§ .015, p = 0.01, pain: B=.055§.020, p=0<0.01), such that patients with higher catastrophizing and lower anxiety at baseline showed greatest benefit. Additionally, those with greater decrease in pain catastrophizing throughout the study demonstrated a greater decrease in FIQR (Rho:0.450, p=0.006). Although yoga improved FM symptoms overall, patients with certain psychosocial characteristics may benefit more. In particular, participants who initially exhibited higher catastrophizing and lower anxiety, showed significant improvements in fatigue, sleep efficiency and pain at the end of the intervention. Future studies should include phenotypic characterization of patients undergoing behavioral interventions such as yoga, to help understand which patients benefit most, and guide personalized intervention in future.
(270) Increased Salience Network Connectivity following Spinal Manipulative Therapy is Associated with Reduced Pain in Chronic Low Back Pain Patients K. Isenburg, M. Loggia, D. Ellingsen, E. Protsenko, I. Mawla, M. Kowalski, D. Swensen, D. O’Dwyer-Swensen, R. Edwards, V. Napadow, and N. Kettner; Massachusetts General Hospital, Boston, MA Chronic low back pain (cLBP) has been associated with maladaptive brain plasticity, and non-pharmacological therapies such as Spinal Manipulative Therapy (SMT) have shown promise in reducing pain and modifying intrinsic brain physiology. However, more translational research is needed using clinical models. We investigated functional salience network (SLN) connectivity response to SMT, and linked response to cLBP pain reduction. Fifteen cLBP patients (8 female, 37.7 § 9.7 (M§ SD) years old), and 16 healthy controls (HC, 8 female, 38.2 § 10.4 years old) were scanned with resting state fMRI before and after a single session of spinal manipulation and spinal mobilization (grades V and III of the Maitland Joint Mobilization Grading Scale) at separate visits. Patients rated clinical pain (0-100) pre- and post-therapy. Intrinsic SLN connectivity was assessed using dual regression probabilistic independent component analysis. Voxelwise analyses were cluster corrected for multiple comparison (z>2.3, p<0.05), followed by Region of Interest (ROI) analyses (a<0.05). Both manipulation (t=3.3, p=0.005) and mobilization (t=2.56, p=0.02) reduced clinical back pain following SMT. However, manipulation (but not mobilization) significantly increased SLN connectivity to thalamus (F=18.18, p<0.001) and M1 (F=4.89, p=0.04). Additionally, this increase for cLBP was greater than for HC following manipulation (Thal: F=12.75, p<0.001; M1: F=12.16, p<0.002). Furthermore, a voxelwise regression analysis indicated that greater SMT-induced increase in SLN connectivity to lateral prefrontal cortex (LPFC) was associated with with greater clinical back pain reduction. Interestingly, for spinal mobilization, a
ROI-based regression analysis using this LPFC cluster found a similar non-significant trend between pain reduction and LPFC connectivity post-mobilization (R=-0.44, p=0.1). Our data suggest that while manipulation increases SLN connectivity to sensorimotor processing regions (i.e. thalamus, M1), increased SLN connectivity to cognitive processing regions (i.e. LPFC) supports SMT analgesia, with more robust recruitment of this brain-based mechanism by spinal manipulation compared to mobilization.
(271) Attitudes of Older Adults with Chronic Musculoskeletal Pain towards Immersive Virtual Reality L. Nakad and B. Rakel; University of Iowa, Iowa City, IA Older adults are especially susceptible to chronic musculoskeletal (MSK) pain. Drugs provide inadequate relief and overuse can lead to adverse events. Immersive virtual reality (IVR), a computer-generated simulation of a 3-D image, can act as distraction therapy by drawing attention away from pain. The purpose of this study is to explore the attitudes and treatment acceptability of older adults with chronic MSK pain towards IVR as distraction therapy for chronic pain exacerbations. The aims are: 1) describe attitudes of older adults suffering from chronic MSK pain towards IVR using focus groups; 2) describe IVR treatment acceptability and side effects using surveys. This is a descriptive, exploratory study using mixed methods and convergent parallel design. Inclusion criteria: 1) diagnosis of chronic MSK pain; 2) 65 and older; 3) residency at participating facility. Exclusion criteria: 1) cognitive impairment; 2) hearing/visual deficit. Treatment acceptability was measured with 8 items scored on a 5-pt Likert scale. Side effects to IVR were measured with Virtual Reality Sickness Questionnaire (VRSQ). Participation consisted of 2 visits. The first visit included the consent process, eligibility screening, survey completion, and 15-minutes of IVR and the second visit was a focus group. Data collection and analysis is ongoing, and the current sample size is 15. Most participants found IVR to be an acceptable way to manage pain (73.4%) and would be willing to use it for their pain (73.3%). 46.6% believed it would likely reduce their pain. Few experienced side effects (26%), such as general discomfort and eyestrain. Qualitative data suggests: 1) greater ease of use with sufficient practice; 2) a preference towards relaxation, meditation, or biofeedback simulations with realistic images; 3) an uncertainty of effectiveness with movement-evoked pain. The findings of this study will help optimize IVR as a therapy for chronic MSK pain.
(272) An 8 Week Modified Yoga Program for Chronic Pain S. Hall; HealthPartners, St. Paul, MN The utilization of complementary care is on the rise for patients with chronic pain, partly due to the opioid epidemic and recent guidelines stating opioids are ineffective for chronic pain. Physical activity is a primary recommendation for various types of chronic pain. The 2007 National Health Interview Survey found that U.S. adults are choosing yoga as one of the top 10 complementary approaches. Stemming from ancient Indian philosophy, yoga is a mind-body practice that typically combines physical postures, breathing techniques and meditation. Yoga has been shown to have neuroprotective effects on the brain, possibly even reversing the effects of chronic pain. Patients with chronic pain can be hesitant to start yoga due to the public’s view of needing to be flexible and fit in order to do yoga. People with chronic pain may also fear exercise due to past experiences that flared their pain. There are many different schools and types of yoga available, making it confusing to choose a class to attend. Therefore, we developed an 8 week “yoga for chronic pain” program to introduce the benefits of yoga and modify the yoga practice for patients with chronic pain. There is a weekly didactic on how yoga can be helpful for various aspects of chronic painfatigue, sleep, improved mood. This is followed by a gentle guided posture, breathing and meditation practice. Participants are given a variety of resources, encouraged to start a home practice and log their minutes of practice each week. In 2018, we had two groups of patients complete our 8-week yoga program and we measured their pain interference, sleep, mood, and pain medication usage at the start, end and 3 months following completion of our program. In this poster, we will present our findings (currently under analysis). (Villemure, et al, Cerebral Cortex 2014)