Helene Langevin is a professor at Harvard Medical School and at The University of Vermont College of Medicine. She is also the director for the Osher Center for Integrative Medicine. Her lab has conducted a lot of interesting research on connective tissue. I’ve summarised some of the findings that relate to the effects of stretching on connective tissue (fascia).
Studies from her lab have shown that stretching had beneficial effects on chronic inflammation in rats. They noted increases in stride length, decreased pain and decreased macrophages (inflammatory cells). Both active and passive stretching were effective and had an effect on acute and chronic phases of inflammation. Stretching decreases pro-inflammatory mediators and increases pro-resolving mediators such as Resolvin, which is synthesised from omega-3 fatty acids.
A thicker thoracolumbar fascia has been identified in some people with low back pain. And the decreased mobility of the fascial layers is thought to stem from adhesions between the layers. Stretching can decrease connective tissue adhesions (fibrosis) by decreasing collagen formation.
Additionally, links have been found between chronic inflammation, fibrosis and cancer. In summary, stretching can have beneficial effects on inflammation, pain, function and even the predisposition to certain types of cancer!
A few months ago Ural et al, from Yildirim Beyazit University Medical School in Ankara, published an interesting paper looking into the effects of acupuncture on carpal tunnel syndrome (CTS). Their work was published in Evidence-Based Complementary and Alternative Medicine.
CTS affects more women than men and has a prevalence of 1-5%. Causes include overuse of the hand, diabetes, rheumatoid arthritis, hypothyroidism and pregnancy. Symptoms can include pain numbness and tingling of the first 3-4 fingers, as well as weakness and wasting of the hand muscles supplied by the median nerve. Some of the commonly used treatments are rest, non-steroidal anti-inflammatory drugs, splinting, steroid inject injections, vitamin B6 supplementation, physiotherapy and eventually surgery. The cross-sectional area (CSA) of the median nerve has been found to increase in association with the severity of CTS. In fact, this increase in CSA is so reliable that it can be used to diagnose CTS or predict the need for surgery.
Ural et al recruited 27 female patients with mild to moderate CTS. On average, their symptoms had lasted about 1.5 years. They were randomised into an acupuncture group and a control group. Both groups wore a night wrist splint for 4 weeks. In addition to the night splint, the acupuncture group received 10 sessions of acupuncture over 4 weeks. Nine acupuncture points were used and the needles were retained for 25 minutes. Evaluations of hand function (DHI and DASH) and pain (VAS), electrophysiological tests and ultrasound measurements of CSA were taken before and after treatment.
The results showed that symptom severity, hand function and electromyographic measurements improved in both groups but improvements were significantly greater in the acupuncture group. In the acupuncture group, pain decreased by just under 50% (from 9/10 to less than 5/10), and hand function measurements improved by 15-22%. These are impressive results when we consider that they took place over a month and that patients had been symptomatic for 1.5 years prior to that. CSA of the median nerve was unchanged in the control group but significantly reduced in the acupuncture group (8% reduction). The authors believe that this is the first time the effect of acupuncture on median nerve CSA in patients with CTS has been demonstrated.
Ural et al conclude that “acupuncture improves not only clinical and electrophysiological findings but also morphological features in patients with CTS”, however “the relationship between change of CSA and electrophysiological changes was not correlated. The small sample size of our study may cause this result”. They suggest confirming the results in future studies with larger sample and long-term monitoring.
Last month Groessl et al., from the San Diego School of Medicine, published the results of their study examining the benefits of yoga on military veterans with chronic low back pain. Of the 150 participants in the study, 35% were unemployed or disabled and the mean back pain duration was 15 years. The mean age was 53 years. The group was generally thought to have “fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously”.
Hatha yoga classes, designed specifically for people with low back pain, were held twice a week for 12 weeks. They were led by an experienced certified instructor. Home practice (15-20 mins/day) was encouraged. The classes consisted of yoga postures, movement sequences, breathing exercises and brief meditation.
The veterans that completed the study had less disability and less pain. Although the decreases in pain were small, they happened in spite of reduced opioid use.
Yu et al recently published the results their study on the effects of acceptance and commitment therapy (ACT) in people with chronic pain. The article appeared in last month’s issue of Journal of Pain. ACT “is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility. The objective of ACT is not elimination of difficult feelings; rather, it is to be present with what life brings us and to “move toward valued behavior”. Acceptance and commitment therapy invites people to open up to unpleasant feelings, and learn not to overreact to them, and not avoiding situations where they are invoked” (Wikipedia).
The study involved over 400 hundred adults referred to a pain management clinic. Treatment significantly improved pain acceptance, pain-related interference, work and social adjustment and depression. This was true immediately post-treatment as well as at a 9-month follow-up. ACT also changed something known as “self-as-context” (SAC). SAC can be described as “the you that is always there observing and experiencing and yet distinct from one’s thoughts, feelings, sensations, and memories” (Wikipedia). Of note was the fact that positive changes in “self-as-context” were associated with positive changes in outcomes.
It’s really interesting how acceptance and commitment therapy has incorporated Buddhist principles and techniques such as mindfulness, acceptance and the self. In fact, it seems that the use of Buddhist philosophy and principles are becoming more common within therapy nowadays.
A study by Whitlock et al from the University of California, published in this month’s Jama Internal Medicine, looked into the relationship between persistent pain, memory decline and dementia. Over 10,000 senior citizens (median age of 73 years) from the Health and Retirement Study were followed for 12 years.
At baseline, persistent pain affected 11% of participants and was linked with more restrictions in daily activities and more symptoms of depression. Those with persistent pain had a greater risk (9%) of having a more rapid memory decline than those without pain. They also had a smaller increase in risk (2%) of developing dementia. These changes significantly increased the chances of being unable to manage medications (16%) or finances (12%).
What’s the causal connection between chronic pain, memory decline and dementia? The authors believe the severity of pain can decrease attention capacity and impair memory consolidation. Additionally, pain leads to stress, and stress has been shown to promote cognitive decline, mainly through hypotrophy of the hippocampus. In my opinion, the disruption of sleep can also contribute to poor memory and a decline in cognitive ability because, as we know, sleep is involved in memory processing and consolidation.
Fortunately, physiotherapy, rehabilitation, relaxation and mindfulness meditation are effective at addressing chronic pain.
This month a fascinating report was published in Annals of the Rheumatic Diseases. It was a collaborative study between Tufts University (Boston) and the University of Manchester. Dai et al looked into the link between dietary fibre and knee osteoarthritis (OA). They used data from the Osteoarthritis Initiative (4796 participants) and the Framingham Offspring Osteoarthritis Study (1268 participants). The first group was followed for 4 years and the second group was reassessed after 9 years. The findings consistently showed that higher total fibre intake was related to a lower risk of symptoms of knee osteoarthritis (pain, stiffness, and swelling). It was unclear whether fibre had an effect on the result of knee x-rays.
The authors note that “there is increasing evidence suggesting that OA shares similar metabolic characteristics including obesity, dyslipidaemia and inflammation with cardiovascular diseases and diabetes”. Clinical trials have already shown the beneficial effect of dietary fibre on reducing body weight, blood pressure, blood sugar and in reducing circulating C reactive protein (a marker of inflammation). Increasing our intake of fibre can help improve musculoskeletal problems in addition to bettering our overall health. Fibre can be found in cereal grains, fruits, vegetables, nuts and legumes.
Earlier this year Billington et al. from the University of Liverpool published the results of their study looking at the effects of shared reading (SR) on people with chronic pain. The shared reading model they used was the one employed by the charity “The Reader“. “The Reader is an award-winning charitable social enterprise working to connect people with great literature through shared reading. We’re here to bring books to life, creating welcoming environments in which personal feeling is recognised and valued, forming vital connections between people and literature through which everyone can feel more alive.”
The researchers concluded “Qualitative evidence indicates SR’s potential as an alternative or long-term follow-up or adjunct to CBT in bringing into conscious awareness areas of emotional pain otherwise passively suffered by patients with chronic pain. In addition, quantitative analysis, albeit of limited pilot data, indicated possible improvements in mood/pain for up to 2?days following SR. Both findings lay the basis for future research involving a larger sample size.”
The preliminary findings are encouraging. There may be other factors such as distraction, social bonding and the benefits of having regular scheduled activities that may also play a part in improving the well-being of the participants.
Mild cognitive impairment (MCI) is a condition where a person has minor problems with things like memory, thinking, attention, language or visual depth perception. The problems are usually not severe enough to affect activities of daily living. But some people with MCI go on to develop dementia – Alzheimer’s in particular. A new study published in the Journal of the American Geriatrics Society by Mavros et al from the University of Sydney has looked into the effects of strength training on cognitive function. The researchers selected 100 people with MCI aged 55 or over. Part of the subjects were put through progressive resistance training (PRT) 2x/week for 6 months. Unsurprisingly, the resistance training led to increases in strength but interestingly the strength increases were linked to improvements in mental ability. The researchers conclude that the link between strength gains and cognitive function merits further study.
New research by Romani et al. from The John Hopkins University in Baltimore has been published in The Knee and has shown that testosterone levels can have an impact on the strength of the anterior cruciate ligament (ACL). Romani’s previous research has shown that estrogen could reduce ACL strength.
The most recent study was performed on male rats. The ACLs of normal rats were compared to those of castrated rats. The testosterone levels in the castrated rats was close to zero. The researchers concluded that “rats with normal circulating testosterone had higher ACL load-to-failure and ultimate stress, indicating that testosterone may influence ACL strength and the injury rate of the ligament“. The results suggest that testosterone may help to strengthen the ACL. If coupled with the findings that estrogen could weaken the ACL, we can start to understand some of the reasons behind the differences in prevalence of ACL injuries between the sexes. Obviously, this only holds if these findings are the same in humans as well. It would also be interesting to know if these findings apply to other ligaments.
It’s been known for a while that smoking decreases blood flow and hence reduces the transport of oxygen and other nutrients to tissues. But recent research by Ava Hosseinzadeh et al from the University of Umea in Sweden has looked into its effects on inflammation. Their findings were published in the Journal of Leucocyte Biology. They found that nicotine induces neutrophils to release neutrophil extracellular traps (NETs). NETs surround and destroy microbial pathogens but they can also lead to excessive inflammation and tissue damage. Obviously, it’s the excessive inflammation and tissue damage that’s of concern and it provides yet another reason to stop smoking.