Month: June 2021

Improve Pain, Sleep, and the Mental Health of Chronic Pain Patients with Internet Mindfulness Training

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Improve Pain, Sleep, and the Mental Health of Chronic Pain Patients with Internet Mindfulness Training

 

By John M. de Castro, Ph.D.

 

“In the context of chronic pain . . . meditation can help you to stop your mind wandering back to your pain when you are trying to focus on something else, therefore improving your ability to give your entire attention to the task at hand and in turn, improve your level of functioning. It gives you the power to take your mind off your pain and refocus it, therefore aiding you in replacing unhelpful, behaviours with healthy ones which can reduce your pain and allow you to take better care of your health.” – Ann-Marie D’arcy-Sharpe

 

We all have to deal with pain. It’s inevitable, but hopefully it’s mild and short lived. For a wide swath of humanity, however, pain is a constant in their lives. At least 100 million adult Americans have chronic pain conditions. The most common treatment for chronic pain is drugs. These include over-the-counter analgesics and opioids. But opioids are dangerous and highly addictive. Prescription opioid overdoses kill more than 14,000 people annually. So, there is a great need to find safe and effective ways to lower the psychological distress and improve the individual’s ability to cope with the pain.

 

There is an accumulating volume of research findings that demonstrate that mindfulness practices, in general, are effective in treating pain. A therapeutic technique that contains mindfulness training and Cognitive Behavioral Therapy (CBT) is Acceptance and Commitment Therapy (ACT). It focuses on the individual’s thoughts, feelings, and behavior and how they interact to impact their psychological and physical well-being. It then works to change thinking to alter the interaction and produce greater life satisfaction. ACT employs mindfulness practices to increase awareness and develop an attitude of acceptance and compassion in the presence of painful thoughts and feelings. ACT teaches individuals to “just notice”, accept and embrace private experiences and focus on behavioral responses that produce more desirable outcomes.

 

Acceptance and Commitment Therapy (ACT) requires a scheduled program of sessions with a trained therapist. This results in costs that many clients can’t afford. In addition, the participants must be available to attend multiple sessions at particular scheduled times that may or may not be compatible with their busy schedules and at locations that may not be convenient. As an alternative, mindfulness training over the internet have been developed. These have tremendous advantages in decreasing costs, making training schedules much more flexible, and eliminating the need to go repeatedly to specific locations. In addition, research has indicated that mindfulness training online can be effective for improving the health and well-being of the participants.

 

In today’s Research News article “Internet‐delivered acceptance and commitment therapy as microlearning for chronic pain: A randomized controlled trial with 1‐year follow‐up.” (See summary below or view the full text of the study at: https://onlinelibrary.wiley.com/doi/10.1002/ejp.1723 ) Rickardsson and colleagues recruited adult chronic pain patients and randomly assigned them to either a wait-list control condition or to receive an 8-week program of Acceptance and Commitment Therapy (ACT) delivered over the internet. ACT was delivered in daily microlearning short learning interactions. There was a 74% completion rate of the modules. The participants were measured before and after training and at 3-, 6-, and 12-month follow-ups for psychiatric problems, pain interference, pain intensity, anxiety, depression, psychological inflexibility, values, and health-related quality of life.

 

They found that compared to baseline and the wait-list control group, the group that received internet-delivered Acceptance and Commitment Therapy (ACT) had significant decreases in pain interference, pain intensity, anxiety, depression, psychological inflexibility, value obstruction, and insomnia. These improvements were long-lasting as they were maintained at the 12-month follow-up.

 

These are impressive improvements in the pain and psychological health of these diverse chronic pain patients. These results correspond with the frequent prior observations that mindfulness training produces reductions in pain, anxiety, depression, psychological inflexibility, and insomnia in a wide range of patient types and normal individuals. These results are particularly impressive as Acceptance and Commitment Therapy (ACT) was delivered over the internet. in daily microlearning short learning interactions. This was very convenient for the patients and required only 12.4 minutes per week of therapist time per week and was thus very inexpensive to deliver. Yet ACT was highly effective and lasting in relieving the suffering of these chronic pain patients.

 

So, improve pain, sleep, and the mental health of chronic pain patients with internet mindfulness training.

 

“What we want to do as best as we can is to engage with the pain just as it is. It’s not about achieving a certain goal – like minimizing pain – but learning to relate to your pain differently.” – Elisha Goldstein

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Jenny Rickardsson, Charlotte Gentili, Linda Holmström, Vendela Zetterqvist, Erik Andersson, Jan Persson, Mats Lekander, Brjánn Ljótsson, Rikard K. Wicksell. Internet‐delivered acceptance and commitment therapy as microlearning for chronic pain: A randomized controlled trial with 1‐year follow‐up, European Journal of Pain, 2021;00:1–19, https://doi.org/10.1002/ejp.1723

 

Abstract

Background

Studies of Internet‐delivered acceptance and commitment therapy (ACT) for chronic pain have shown small to moderate positive effects for pain interference and pain acceptance. Effects on pain intensity, depression, anxiety and quality of life (QoL) have been less favourable, and improvements for values and sleep are lacking. In this randomized controlled trial iACT – a novel format of Internet‐ACT using daily microlearning exercises – was examined for efficacy compared to a waitlist condition.

Methods

Adult participants (mean age 49.5 years, pain duration 18.1 years) with diverse chronic pain conditions were recruited via self‐referral, and randomized to iACT (n = 57) or waitlist (n = 56). The primary outcome was pain interference. The secondary outcomes were QoL, depression, anxiety, insomnia and pain intensity. The process variables included psychological inflexibility and values. Post‐assessments were completed by 88% (n = 100) of participants. Twelve‐month follow‐up assessments were completed by 65% (iACT only, n = 37). Treatment efficacy was analysed using linear mixed models and an intention‐to‐treat‐approach.

Results

Significant improvements in favour of iACT were seen for pain interference, depression, anxiety, pain intensity and insomnia, as well as process variables psychological inflexibility and values. Between‐group effect sizes were large for pain interference (d = 0.99) and pain intensity (d = 1.2), moderate for anxiety and depressive symptoms and small for QoL and insomnia. For the process variables, the between‐group effect size was large for psychological inflexibility (d = 1.0) and moderate for values. All improvements were maintained at 1‐year follow‐up.

Conclusions

Internet‐ACT as microlearning may improve a broad range of outcomes in chronic pain.

Significance

The study evaluates a novel behavioral treatment with positive results on pain interference, mood as well as pain intensity for longtime chronic pain sufferers. The innovative format of a digital ACT intervention delivered in short and experiential daily learnings may be a promising way forward.

https://onlinelibrary.wiley.com/doi/10.1002/ejp.1723

 

jenny.rickardsson@ki.se

 

University Leaders and Teachers Mindfulness are Associated with Lower Emotional Exhaustion in Teachers

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University Leaders and Teachers Mindfulness are Associated with Lower Emotional Exhaustion in Teachers

 

By John M. de Castro, Ph.D.

 

“leader mindfulness significantly reduces the emotional exhaustion of university teachers.” – Beini Liu

 

Work is very important for our health and well-being. We spend approximately 25% of our adult lives at work. How we spend that time is immensely important for not only to productivity in the workplace but also to our psychological and physical health. Mindfulness practices have been implemented in the workplace and they have been shown to markedly reduce the physiological and psychological responses to stress. This, in turn, improves productivity and the well-being of the employees. As a result, many businesses have incorporated mindfulness practices into the workday.

 

Mindfulness may also help to promote leadership in the workplace. It can potentially do so by enhancing emotion regulation, making the individual better able to recognize, experience, and adaptively respond to their emotions, and making the leader better able to listen to and to understand the needs and emotion of the workers they lead. Hence, the mindfulness of the leader may well be associated with University teachers’ well-being.

 

In today’s Research News article “Influence of Leader Mindfulness on the Emotional Exhaustion of University Teachers: Resources Crossover Effect.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7959755/ ) Liu and colleagues recruited public university leaders and teachers and had them complete a questionnaire measuring leader mindfulness and teacher mindfulness, workplace telepressure, emotional exhaustion, self-efficacy, working hours, and years in current position.

 

They found that with gender, age, tenure, and hours worked statistically controlled that the higher the level of the leader’s mindfulness the lower the level of the teacher’s emotional exhaustion and the lower the levels of telepressure. A mediation analysis revealed the leader’s mindfulness was associated with lower teacher emotional exhaustion directly and also indirectly by being associated with lower telepressure and telepressure was associated with higher levels of teacher emotional exhaustion. This association between the leader’s mindfulness and the lower teacher’s emotional exhaustions was significantly stronger when the teachers had high levels of mindfulness. Finally, they found that the higher the levels of the teacher’s self-efficacy the weaker the relationship between telepressure and emotional exhaustion.

 

The study was correlational so no conclusions regarding causation can be reached. Nevertheless, the associations between the variables are interesting. It is clear that mindfulness is important both within the individual teacher and also in the leader for being associated with lower teacher emotional exhaustion. It has previously been shown that mindfulness decreases burnout. So, the relationships observed here probably results from a causal connection.

 

Workplace telepressure “is a psychological state in which employees are constantly concerned about urgently responding to work-related ICTs [Information and Communications Technologies] during non-working hours.” These communications appear to be associated with higher levels of emotional exhaustion and these, in part, appear to mediate the effects of mindfulness on emotional exhaustion. In addition, when the teachers had high self-efficacy, telepressure had less of an impact on emotional exhaustion.

 

Preventing teacher burnout is important not only for the teacher’s well-being but also for the students’ education. It is clear that mindful academic leadership is important, suggesting that mindfulness training for leaders may improve the workplace environment for the teachers. The teacher’s level of mindfulness and self-efficacy appear also to be important, suggesting that mindfulness and self-efficacy training for the teachers would also likely improve their well-being. The results also suggest that communications to the teachers should be limited and less urgent. Being cognizant of the importance of these relationships can help to improve the environment, psychological health, and performance of university teachers.

 

So, university leaders’ and teachers’ mindfulness are associated with lower emotional exhaustion in teachers.

 

“administrators and school leaders can increase retention and efficacy by seeking out ways to support teachers’ self-care and learning of mindfulness techniques.” – Kelsey Milne

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Liu, B., Zhang, Z., & Lu, Q. (2021). Influence of Leader Mindfulness on the Emotional Exhaustion of University Teachers: Resources Crossover Effect. Frontiers in psychology, 12, 597208. https://doi.org/10.3389/fpsyg.2021.597208

 

Abstract

This study combined conservation of resources theory with the job demands-resources model to explore the influence of leader mindfulness on the emotional exhaustion of university teachers Using a time-lagged research design, 388 paired data sets were gathered. Multiple regression and bootstrapping were used to test each hypothesis. The results showed that first, leader mindfulness significantly reduces the emotional exhaustion of university teachers. Second, the results showed that workplace telepressure partially mediates the relationship between leader mindfulness and the emotional exhaustion of university teachers. Third, university teacher mindfulness positively moderates the relationship between leader mindfulness and workplace telepressure. Finally, the results of this study indicate that self-efficacy in managing negative emotions negatively moderates the relationship between workplace telepressure and the emotional exhaustion of university teachers. This study empirically examined the interpersonal influence of leader mindfulness and the initial resources effect of university teacher mindfulness and self-efficacy in managing negative emotions from the bilateral perspective of leaders and university teachers.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7959755/

 

A Supportive Environment is Necessary for Mindfulness to Lower Stress and Increase Well-Being at Work

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A Supportive Environment is Necessary for Mindfulness to Lower Stress and Increase Well-Being at Work

 

By John M. de Castro, Ph.D.

 

“Mindfulness is not about living life in slow motion. It’s about enhancing focus and awareness both in work and in life. It’s about stripping away distractions and staying on track with individual, as well as organizational, goals.” –  Rasmus Hougaard

 

Work is very important for our health and well-being. We spend approximately 25% of our adult lives at work. How we spend that time is immensely important for our psychological, social, and physical health. But, nearly 2/3 of employees worldwide are unhappy at work. This is partially due to work-related stress which is epidemic in the western workplace. Almost two thirds of workers reporting high levels of stress at work. This stress can result in impaired health and can result in burnout; producing fatigue, cynicism, and professional inefficacy.

 

To help overcome unhappiness, stress, and burnout, mindfulness practices have been implemented in the workplace. Indeed, mindfulness practices have been shown to markedly reduce the physiological and psychological responses to stress. As a result, it has become very trendy for business to incorporate meditation into the workday to help improve employee well-being, health, and productivity. These programs attempt to increase the employees’ mindfulness at work and thereby reduce stress. The research is accumulating. So, it makes sense to step back and summarize what has been learned.

 

In today’s Research News article “Mindfulness-based programmes to reduce stress and enhance well-being at work: a realist review” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986896/ )  Micklitz and colleagues review and summarize the published research on the effectiveness of mindfulness training to improve the psychological well-being of employees. They identified 75 published research studies.

 

They report that the published research found that mindfulness-based programs in the workplace significantly reduce employee stress and improve well-being. They report that these benefits appear to occur as a result of mindfulness training producing increases in awareness, self-regulation, acceptance, compassion, permission for self-care, growth, and goal attainment. But, in order for this to work, the employees must feel comfortable sharing with peers their emotional difficulties, see that the program aligns with existing goals and practices, and be comfortable with a potential loss of productivity during training.

 

These findings suggest that mindfulness training at work can be effective in improving the employee’s ability to cope with stress and thereby improve their well-being. But a supportive environment must be present in order for the benefits to occur. These include managements acceptance of the program, employees seeing it as management caring for their well-being, and the programs alignment with the employee’s aspirations.

 

So, a supportive environment is necessary for mindfulness to lower stress and increase well-being at work.

 

“When we constantly flit from one task to another, the quality of our work can suffer. By practicing mindfulness — simply coming back to the present moment over and over again — we can train ourselves to become more focused.” – David Gelles

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Micklitz, K., Wong, G., & Howick, J. (2021). Mindfulness-based programmes to reduce stress and enhance well-being at work: a realist review. BMJ open, 11(3), e043525. https://doi.org/10.1136/bmjopen-2020-043525

Abstract

Objectives

To understand how and why workplace mindfulness-based programmes (MBPs) work or do not work.

Design

A realist review.

Eligibility criteria for selection

We considered any studies (experimental quasi-experimental, observational, qualitative and mixed-methods studies) of workplace MBPs as long as they provided data to explain our programme theories. All MBP formats and delivery modes were included.

Analysis

Consistent with realist review methodology, we systematically screened and analysed data to explain how and why workplace MBPs work or do not work. These explanations were consolidated into a programme theory augmented by theories from organisational literature, such as conservation of resources theory.

Results

Findings from 75 primary studies suggest that workplace MBPs enable participants (including healthcare professionals) to deal more skillfully with stressful events and improve their well-being. The mechanisms involved can be grouped around awareness/self-regulation, acceptance/compassion, feeling permitted to take care of self, sense of growth and promise of goal attainment. In order for professionals to invest in an MBP and benefit from it, it is important that they feel safe to engage with self-care at work and share emotional difficulties among peers. It is also important that employees are able to link the programme and its activities to existing goals and practices. Concerns of being non-productive, of not getting work done or of being exposed in front of colleagues can result in strategic use of brief mindfulness exercises, non-adherence or drop-out.

Conclusions

Simply offering an MBP to (healthcare) professionals in order to reduce stress and enhance well-being does not suffice. A supportive environment must exist in order for the programme’s benefits to be reaped.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986896/

 

Mindfulness is Associated with Forgiveness and Reduced Anger Rumination

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Mindfulness is Associated with Forgiveness and Reduced Anger Rumination

 

By John M. de Castro, Ph.D.

 

“Forgiveness demands presence, reminding us that we are not the same as the feelings we possess in a given situation, nor is the person who we’ve harmed or who has harmed us.” – Sharon Salzberg.

 

Forgiveness is important to happiness and psychological well-being. It allows one to move beyond anger and resentment. It is an adaptive ability to move beyond a perceived transgression by another, not by ignoring or denying it, but by reframing it so the response moves away from negativity. This is true not only of others but also the self. Self-forgiveness is essential for psychological well-being. There is emerging research on forgiveness but much has yet to be explored regarding the processes that lead to and improve forgiveness. Mindfulness has been found to be associated with higher levels of forgiveness. So, it makes sense to explore the processes by which mindfulness is associated with forgiveness.

 

In today’s Research News article “Anger Rumination and Mindfulness: Mediating Effects on Forgiveness.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967311/ ) de la Fuente-Anuncibay and colleagues recruited university students who practiced mindfulness informally and those who were naïve to mindfulness practice. They completed measures of mindfulness, forgiveness, including self-forgiveness, forgiveness towards others and situation-forgiveness subscales, and anger, including angry or rage memories, understanding the causes of the anger, thoughts after the anger and thoughts of revenge subscales.

 

They found that the students who practiced mindfulness had significantly higher levels of forgiveness that those who didn’t. Further they found that mindfulness was associated with higher levels of forgiveness directly and also indirectly by being associated with lower levels of anger rumination which was in turn were associated with smaller reductions in forgiveness. Further analysis using the anger rumination subscales revealed that mindfulness was associated with decreased levels of anger revenge as opposed to anger memories.

 

This study is correlational and as such causation cannot be determined. Nevertheless, the associations are clear. Mindful people are more forgiving than less mindful people, and they also have a lower need for revenge for transgressions This lower revenge is also associated with forgiveness. Future research should investigate the effects of mindfulness training on anger and forgiveness to determine causation.

 

The results demonstrate as has previous research, that mindful people are forgiving people. This makes them better at social interactions as they are less likely to hold grudges. But importantly mindful people are also self-forgiving. This is extremely important for the mental health of the individual. Everyone is imperfect and makes mistakes. If this can be realized and the imperfections forgiven mental well-being can be vastly improved. Hence, mindful forgiveness is an important contributor to the overall happiness and well-being of the individual.

 

So, mindfulness is associated with forgiveness and reduced anger rumination.

 

“the more you practice mindfulness, the more you strengthen your capacity for forgiveness.” – Stefanie Goldstein

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

de la Fuente-Anuncibay, R., González-Barbadillo, Á., Ortega-Sánchez, D., Ordóñez-Camblor, N., & Pizarro-Ruiz, J. P. (2021). Anger Rumination and Mindfulness: Mediating Effects on Forgiveness. International Journal of Environmental Research and Public Health, 18(5), 2668. https://doi.org/10.3390/ijerph18052668

 

Abstract

(1) Background: Different investigations relate mindfulness practice as a strategy to cope with and improve negative repetitive thinking states and forgiveness. (2) Methods: The aim is to analyze the mediating processes of mindfulness as a trait and the changes in the anger rumination on forgiveness. This sample comprised 264 undergraduate students (M = 24.13 years, SD = 11.39). The instruments used were the Anger Rumination Scale (ARS), the Five Facet Mindfulness Questionnaire (FFMQ) and the Heartland Forgiveness Scale (HFS). For data analysis, the spillover effect was calculated using 10,000 bootstrap samples for the bootstrap confidence intervals (CI). (3) Conclusions: The results confirm that the relationship between mindfulness practice and forgiveness is mediated by changes in mindfulness trait and anger rumination. Given the results obtained, it is considered appropriate to extend the study to samples from other countries, as well as to contexts of depressive rumination or anxiety.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967311/

 

rjpizarro@ubu.es

Some Mild Unpleasant Events Occur as a Result of Mindfulness-Based Programs

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Some Mild Unpleasant Events Occur as a Result of Mindfulness-Based Programs

 

By John M. de Castro, Ph.D.

 

“Potential side effects are often front and center when considering taking medicine for physical or mental conditions, but information is less clear with treatments like meditation that don’t come in pill form.” – Marianne Spoon

 

People begin meditation with the misconception that meditation will help them escape from their problems. Nothing could be further from the truth. In fact, meditation does the exact opposite, forcing the meditator to confront their issues. In meditation, the practitioner tries to quiet the mind. But, in that relaxed quiet state, powerful, highly emotionally charged thoughts and memories are likely to emerge. The strength here is that meditation is a wonderful occasion to begin to deal with these issues. But often the thoughts or memories are overwhelming. At times, professional therapeutic intervention may be needed.

 

Many practitioners never experience these negative experiences or only experience very mild states. There are, however, few systematic studies of the extent of negative experiences. In general, the research has reported that unwanted (negative) experiences are quite common with meditators, but for the most part, are short-lived and mild. There is, however, a great need for more research into the nature of the experiences that occur during meditation.

 

In today’s Research News article “Frequency of Self-reported Unpleasant Events and Harm in a Mindfulness-Based Program in Two General Population Samples.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920887/ ) Baer and colleagues recruited teachers who were participating in a study of an 8-week mindfulness training in schools and undergraduate and graduate students enrolled in an 8-week group-based mindfulness courses. The participants completed online measures of anxiety and depression and questions about difficult experiences during or after the mindfulness training including difficult thoughts, emotions, and sensations.

 

They found that 77% of the teachers reported never or occasionally having unpleasant experiences while 22% reported having unpleasant experiences more often. Of those who had unpleasant experiences 88% reported they were not at all or somewhat upsetting while 12% reported them to be quite a bit or extremely upsetting. The unpleasant experiences reported were “difficult emotions, cognitions, or sensations such as frustration, anxiety, distressing thoughts or memories, bodily pain or discomfort, and sleepiness.”

 

The 61% of the students reported never or occasionally having unpleasant experiences while 39% reported having unpleasant experiences more often. Of those who had unpleasant experiences 92% reported they were not at all or somewhat upsetting while 8% reported them to be quite a bit or extremely upsetting. The unpleasant experiences reported “involved difficult thoughts, emotions, and physical sensations; others described recognition of personal patterns” and guilt about not practicing enough.

 

These results suggest that the unpleasant experiences occurring during and after mindfulness training are common but generally mild. The experiences are most often the same as those expected by mindfulness teachers. These experiences are to some extent the goal of mindfulness training to increase awareness of one’s own internal experiences and these can be sometimes upsetting. In rare instances, the experiences are quite upsetting and this is to be expected as some people will discover things about themselves that are difficult to deal with.

 

Psychological therapies in general are designed to uncover and deal with unpleasant thoughts, memories, emotions etc. It is thus not surprising the this is true also of mindfulness training. This suggests that mindfulness teachers, like other therapists, have to be sensitive to these unpleasant experiences in their students and be prepared to deal with extremely difficult experiences.

 

So, some mild unpleasant events occur as a result of mindfulness-based programs.

 

“It’s really important to know the prevalence of people who are having adverse reactions.” – Matt Hirschberg

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Baer, R., Crane, C., Montero-Marin, J., Phillips, A., Taylor, L., Tickell, A., Kuyken, W., & MYRIAD team (2021). Frequency of Self-reported Unpleasant Events and Harm in a Mindfulness-Based Program in Two General Population Samples. Mindfulness, 12(3), 763–774. https://doi.org/10.1007/s12671-020-01547-8

 

Abstract

Objectives

Evidence-based mindfulness programs have well-established benefits, but the potential for harmful effects is understudied. We explored the frequency and severity of unpleasant experiences and harm in two nonclinical samples participating in an adaptation of mindfulness-based cognitive therapy (MBCT) for the general population.

Methods

Study 1 included 84 schoolteachers; study 2 included 74 university students. Both studies were uncontrolled. Participants completed self-report questionnaires about psychological symptoms before and after the 8-week mindfulness course. After the course, they responded to a survey designed for this study that included Likert ratings and free-text questions about unpleasant experiences and harm. All data were collected online.

Results

In both samples, about two-thirds of participants reported unpleasant experiences associated with mindfulness practice during the course. Most participants (85–92%) rated these experiences as not at all or somewhat upsetting; some indicated that difficult experiences led to important learning or were beneficial in some way. The proportion of participants reporting harm from the mindfulness course ranged from 3 to 7%. The proportion showing reliable deterioration on symptom questionnaires ranged from 2 to 7%. Those reporting harm and those showing reliable deterioration on questionnaires were largely separate subgroups; only one participant fell in both.

Conclusions

Findings highlight the need for mindfulness teachers to manage expectations about benefits and difficulties that may occur in mindfulness-based programs and to work skilfully with participants experiencing difficulties. Experiences of harm may not be captured by symptom questionnaires and should be explicitly assessed in other ways.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920887/

 

Improve Psychological Well-Being in Covid-19 Lockdown with Online Mindfulness Training

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Improve Psychological Well-Being in Covid-19 Lockdown with Online Mindfulness Training

 

By John M. de Castro, Ph.D.

 

“mindfulness is one tool that can help promote mental wellness throughout the COVID-19 pandemic and beyond.” – Julie Dunn

 

Mindfulness training has been shown to improve health and well-being in healthy individuals. It has also been found to be effective for a large array of medical and psychiatric conditions, either stand-alone or in combination with more traditional therapies. The COVID-19 pandemic has challenged the mental and physical health of the population. It has created intense stress both for frontline workers but also for people simply isolating at home. Mindfulness is known to decrease the psychological and physical responses to stress. So, mindfulness training may be helpful in coping with the mental and physical challenges resulting from the COVID-19 pandemic.

 

In today’s Research News article “A Brief Online Mindfulness-Based Group Intervention for Psychological Distress Among Chinese Residents During COVID-19: a Pilot Randomized Controlled Trial.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972025/ ) Zhang and colleagues recruited online Chinese adults who were staying at home during the Covid-19 lockdown. They were randomly assigned to a wait-list control condition or to receive online mindfulness training with an abbreviated group version of Mindfulness-Based Stress Reduction (MBSR). The training consisted of a 2-hour training followed by 13 days of 1.5 hours per day of practice separated into 3 30-minute sessions. Once training was complete for the mindfulness group, the wait-list group received the same 2-week mindfulness training. They were measured before and after the training for mindfulness and psychological distress, including somatization, depression, and anxiety.

 

They found that in comparison to baseline and the wait-list control group, the mindfulness training produced significantly higher mindfulness levels and significantly lower levels of psychological distress, including somatization, depression, and anxiety levels. The wait-list group after they received the mindfulness training had similar significant improvements in their psychological well-being.

 

These results are consistent with previous findings that mindfulness training produces decreases in distress, including somatization, depression, and anxiety. But the present study demonstrates that online mindfulness training can produce similar benefits for individuals locked down during a pandemic. Since the training is online, it could be made available to widespread individuals at low cost and thus would be ideal for maintaining the psychological health of people in lock down.

 

So, improve psychological well-being in covid-19 lockdown with online mindfulness training.

 

“In many ways, COVID-19 has shown us just how connected and how much the same we really are. All of us—and some of us more than others—are vulnerable to getting sick and none of us wants to become ill. Viewed through the lens of interconnectedness, practicing mindfulness as the coronavirus spreads is not only a way to care for ourselves but a way to care for everyone around us.” – Kelly Barron

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Hui Zhang, Anao Zhang, Chengbin Liu, Jian Xiao, Kaipeng Wang. A Brief Online Mindfulness-Based Group Intervention for Psychological Distress Among Chinese Residents During COVID-19: a Pilot Randomized Controlled Trial, Mindfulness (N Y) 2021 Mar 18 : 1–11. doi: 10.1007/s12671-021-01618-4

 

Abstract

Objectives

The coronavirus (COVID-19) global pandemic has increased psychological distress among the general population. The objective of this study is to evaluate a mindfulness-based intervention for psychological distress among Chinese residents during COVID-19.

Methods

This study used a switching replications design to test the feasibility and efficacy of a brief online mindfulness-based intervention for Chinese residents’ psychological distress. Fifty-one residents in the Hubei province were randomly allocated to two groups (experimental group and waitlist control group) with three waves of measurement at time 1, time 2, and time 3 for changes in mindfulness and psychological distress.

Results

In addition to significant within-group improvements over time for both groups, OLS linear regression with full information likelihood estimation revealed statistically significant between-group treatment effects across outcome domains, including mindfulness awareness, b = 2.84, p < 0.001, g = 6.92, psychological distress, b = −21.33, p < 0.001, g = 6.62, somatic symptoms, b = −6.22, p < 0.001, g = 4.42, depressive symptoms, b = −7.16, p < 0.001, g = 5.07, and anxiety symptoms, b = −8.09, p < 0.001, g = 6.84.

Conclusions

Results suggest that a brief online mindfulness-based intervention can be a feasible and promising intervention for improving mindfulness and decreasing psychological distress among Chinese residents staying at home during the COVID-19 outbreak. The study used a small convenience sample which led to a concern of external generalizability and with limited evaluation of long-term change.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972025/

 

Improve Adolescent Scoliosis with Select Yoga Poses

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Improve Adolescent Scoliosis with Select Yoga Poses

 

By John M. de Castro, Ph.D.

 

“Yoga can be very helpful for those with scoliosis, particularly given the combination of flexibility and core stabilization needed to perform yoga poses properly.” – Sara Lindberg

 

Scoliosis is a sidewise curvature of the spine that occurs in about 3% of adolescents. It develops most frequently in a growth spurt just prior to puberty. Most cases are mild and can be treated with a brace to stop the curve from increasing. But more serious cases can be disabling and may be treated with surgery.

 

There is a need for safe and effective treatments for scoliosis. Yoga practice combines mindfulness practice with exercise and has been shown to have a myriad of health benefits including the relief of chronic low-back pain. Many forms of yoga focus on the proper alignment of the spine, which could directly address the spinal curvature of scoliosis. But care must be taken as some yoga poses have the potential to exacerbate the spinal curvature.

 

In today’s Research News article “Isometric Yoga-Like Maneuvers Improve Adolescent Idiopathic Scoliosis-A Nonrandomized Control Trial.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917413/ )  Fishman recruited adolescents less than 21 years of age with scoliosis and had them either receive treatment as usual, or yoga practice employing the side-plank pose for a lumbar curve, the half-moon and floating side plank poses for a thoracic curve, and or a side-plank, half-moon, and floating side plank poses for a Thoracolumbar curve. The yoga group was instructed to practice daily for 5 months and hold each pose for as long as they could. Instruction occurred either in person or over the internet. X-rays were taken of their spines before and after treatment.

 

They found that in the yoga group 49% of the lumbar and thoracolumbar curves and 29% of the thoracic curves had significant improvement while none of the control group did. In person and internet instruction were equally effective but compliance was better with in person instruction.

 

These results suggest that practicing a select set of yoga poses appears to be effective in treating scoliosis in adolescents. It is important that the right poses are used. Many yoga poses could well exacerbate the problem. In this study the side-plank, half-moon, and floating side plank poses were found to produce significant improvements.

 

So, improve adolescent scoliosis with select yoga poses

 

 

“But yoga and scoliosis don’t necessarily go hand in hand. While many poses are perfectly safe for scoliotic spines — and some even provide proven benefits — many others can make the curves worse. To safely perform yoga for scoliosis relief, it’s important to differentiate between asanas that can help and those that pose a risk.” – Clayton Stitzel

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Fishman L. M. (2021). Isometric Yoga-Like Maneuvers Improve Adolescent Idiopathic Scoliosis-A Nonrandomized Control Trial. Global advances in health and medicine, 10, 2164956120988259. https://doi.org/10.1177/2164956120988259

 

Abstract

Objective

Assess therapeutic value of specific yoga poses for thoracic and lumbar adolescent idiopathic scoliosis (AIS) taught in office or Internet.

Study Design

Nonrandomized control trial: Fifty-six adolescents (mean age 14.0 years; mean Risser 3.0) were recruited from our clinic; 41 did the side-plank, the half-moon and elevated side plank poses as appropriate (treatment group) and 15 did not (controls). Thirty curves were treated in office, 30 via Internet. Curve change was evaluated by blinded serial Cobb angles, and analyzed using Mann-Whitney U, paired t-tests and χ2.

Results

Mean lumbar and thoracolumbar Cobb angle change was −9.2 (95% CI = −11.8, −6.6) in the treatment group and 5.4 (95% CI = 1.7, 9.0) in controls. Both treatment group improvement and deterioration in controls were significant (treatment group: paired t-test t = −7.1, df = 40, p = .000; controls: t = 3.2, df = 12, p = .008). Mean thoracic Cobb angle change was −7.1 (95% CI = −13.1, −1.2) in the treatment group and 9.3 (95% CI = 4.5, 14.6) in controls. Both changes were significant (paired t-test t = −3.3, df = 21, p = .022 for treatment group; t = 4.5, df = 5, p = .006 for controls). Nine Internet patients were non-compliant vs. 6 office patients. Office patients improved 1.6 degrees/month or 5.5%/month; Internet patients improved .72 degrees/month or 3.3%/month.

Conclusion

These yoga poses show promise for reversing adolescent idiopathic scoliosis. Telemedicine had greater non-compliance and lower efficacy but still produced patient improvement.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917413/

 

Improve Balance and Exercise Capacity in Stroke Patients with Tai Chi

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Improve Balance and Exercise Capacity in Stroke Patients with Tai Chi

 

By John M. de Castro, Ph.D.

 

“With a complete focus on slow, controlled, and repetitive movements, tai chi is effective in improving one’s balance through dynamic motion and coordination, which is crucial to prevent falls. What many people may not know is that stroke survivors endure seven times as many falls each year as healthy adults.” – Henry Hoffman

 

Every year, more than 795,000 people in the United States have a stroke and it is the third leading cause of death, killing around 140,000 Americans each year. A stroke results from an interruption of the blood supply to the brain, depriving it of needed oxygen and nutrients. This can result in the death of brain cells and depending on the extent of the damage produce profound loss of function. Even after recovery from stroke patients can experience residual symptoms. Problems with balance and falling are very common. About 30% of stroke survivors develop spasticity, where the muscles become stiff, tighten up, and resist stretching. Obviously, spasticity can interfere with regaining movement after stroke.

 

The ancient mindful movement technique Tai Chi and Qigong are very safe forms of gentle exercise that appears to be beneficial for stroke victims including improving balance. Tai Chi involves both gentle exercise and mindfulness practice. Much has been learned. So, it makes sense to step back and summarize the research findings.

 

In today’s Research News article “The Influences of Tai Chi on Balance Function and Exercise Capacity among Stroke Patients: A Meta-Analysis.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932789/ ) Zheng and colleagues review, summarize, and perform a meta-analysis of the published randomized controlled trials of the effectiveness of Tai Chi practice for the rehabilitation of stroke survivors. They identified 19 published randomized controlled trials.

 

They found that Tai Chi practice produced a significant improvement in balance. Standing and walking ability, 6-minute walking distance, gravity center swing, and exercise ability. Hence, the published randomized controlled trials make a strong case that Tai Chi practice is a safe and effective non-drug treatment to improve the balance and motor ability of stroke patients. These improvements should reduce the incidence of dangerous falls and improve the overall health and quality of life of these patients.

 

Tai Chi practice is not strenuous, involves slow gentle movements, and is safe, having no appreciable side effects, it is appropriate for all ages including the elderly and for individuals with illnesses that limit their activities or range of motion such as stroke. It can also be practiced without professional supervision and in groups making it inexpensive to deliver and fun to engage in. This makes Tai Chi practice an excellent means to help improve the balance and exercise capacity of stroke patients.

 

“Tai Chi has an overall beneficial effect on activities of daily living, balance, limb motor function, and walking ability among stroke survivors. . . and may also improve sleep quality, mood, mental health, and other motor function.” – Diyang Lyu

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Zheng, X., Wu, X., Liu, Z., Wang, J., Wang, K., Yin, J., & Wang, X. (2021). The Influences of Tai Chi on Balance Function and Exercise Capacity among Stroke Patients: A Meta-Analysis. Evidence-based complementary and alternative medicine : eCAM, 2021, 6636847. https://doi.org/10.1155/2021/6636847

 

Abstract

Objective

This study aims to explore the influences of Tai Chi on the balance function and exercise capacity among stroke patients.

Methods

Databases including PubMed, Embase, WOS (Web of Science), the Cochrane Library, CNKI (China National Knowledge Infrastructure), Wanfang Data, VIP (VIP database), and CBM (China Biology Medicine disc) were retrieved to gather the figures of randomized controlled trials on the balance function and exercise capacity among stroke patients. Then relevant data were input and analyzed in Review Manager 5.3.

Results

Nineteen papers were included and analyzed in this study. According to the combined effect size, the balance function of stroke patients improved significantly: the Berg Balance Function Scale score [MD = 7.67, 95% CI (3.44, 11.90)]; standing and walking test scores [MD = 3.42, 95% CI (4.22, −2.63)]; gravity swing area [MD = 0.79, 95% CI (1.48, 0.10)]; and gravity swing speed [MD = −5.43, 95% CI (−7.79, 3.08)]. In addition, the exercise capacity improved significantly as well: the FMA (Fugl-Meyer Assessment Scale) scale score [MD = 4.15, 95% CI (1.68, 6.63)]. There are no significant influences or changes of other related results.

Conclusions

Stroke patients are able to improve their balance functions and exercise capacities prominently when they do Tai Chi exercise once or twice a week and ≥5 times/week and >30 ≤ 60 min/time.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932789/

 

Reduce Stress and Improve Healthcare Worker Well-Being with Mindfulness

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Reduce Stress and Improve Healthcare Worker Well-Being with Mindfulness

 

By John M. de Castro, Ph.D.

 

“The therapeutic applications of mindfulness are considerable and its impact on clinical practice itself appears to be profound. Indeed, several commentators characterize mindfulness as inciting nothing short of a revolution in the way we conduct our mental lives both within the clinic and without.” – Matias P. Raski

 

Stress is epidemic in the western workplace with almost two thirds of workers reporting high levels of stress at work. In high stress occupations, like healthcare, burnout is all too prevalent. Burnout is the fatigue, cynicism, emotional exhaustion, sleep disruption, and professional inefficacy that comes with work-related stress. It is estimated that over 45% of healthcare workers experience burnout. It not only affects the healthcare providers personally, but also the patients, as it produces a loss of empathy and compassion. Burnout, in fact, it is a threat to the entire healthcare system. Currently, over a third of healthcare workers report that they are looking for a new job. Hence, burnout contributes to the shortage of doctors and nurses.

 

Preventing burnout has to be a priority. Unfortunately, it is beyond the ability of the individual to change the environment to reduce stress and prevent burnout. So, it is important that methods be found to reduce the individual’s responses to stress; to make the individual more resilient when high levels of stress occur. Contemplative practices have been shown to reduce the psychological and physiological responses to stress and improve well-being. Indeed, mindfulness has been shown to be helpful in treating and preventing burnout, increasing resilience, improving sleep and reduce stress.

 

In today’s Research News article “Reducing stress and promoting well-being in healthcare workers using mindfulness-based cognitive therapy for life.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903308/ ) Strauss and colleagues recruited healthy adult healthcare workers and randomly assigned them to either a wait-list control condition or to receive 8 weekly 2-hour group sessions of Mindfulness-Based Cognitive Therapy (MBCT) along with 40 minutes of daily practice.  MBCT involves mindfulness training, containing sitting, walking and body scan meditations, and cognitive therapy that attempts to teach patients to distinguish between thoughts, emotions, physical sensations, and behaviors, and to recognize irrational thinking styles and how they affect behavior. MBCT was developed specifically to treat depression. For this study it was modified to be more appropriate for the general population. The participants were measured before and after training for attendance and practice amounts, stress, anxiety, depression, mental well-being, burnout, presenteeism, compassion, and mindfulness.

 

They found that in comparison to baseline and the wait-list control group after Mindfulness-Based Cognitive Therapy (MBCT) there were significant increases in mindfulness, mental well-being, and self-compassion, and significant decreases in anxiety, depression, and stress. They also found that the greater the increases in mindfulness and self-compassion produced by MBCT the greater the increase in mental well-being and the decrease in stress.

 

These findings are similar to those found in previous research with different groups that Mindfulness training increases well-being and self-compassion, and decreases anxiety, depression, and stress. Hence, mindfulness training improves the psychological well-being of healthcare workers. This should help protect them against burnout and increase their resilience in the face of high workplace stress.

 

So, reduce stress and improve healthcare worker well-being with mindfulness.

 

“As we become more adept at dwelling in the living presence of our own experience, we begin to connect more deeply with patients, as well as co-workers and family members. Mindfulness practice provides a simple and practical way to recapture the calling of healing.” – Penn Medicine

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Strauss, C., Gu, J., Montero-Marin, J., Whittington, A., Chapman, C., & Kuyken, W. (2021). Reducing stress and promoting well-being in healthcare workers using mindfulness-based cognitive therapy for life. International journal of clinical and health psychology : IJCHP, 21(2), 100227. https://doi.org/10.1016/j.ijchp.2021.100227

 

Background/Objective

Healthcare workers play a critical role in the health of a nation, yet rates of healthcare worker stress are disproportionately high. We evaluated whether mindfulness-based cognitive therapy for life (MBCT-L), could reduce stress in healthcare workers and target a range of secondary outcomes. Method: This is the first parallel randomised controlled trial of MBCT-L. Participants were NHS workers, who were randomly assigned (1:1) to receive either MBCT-L or wait-list. The primary outcome was self-reported stress at post-intervention. Secondary variables were well-being, depression, anxiety, and work-related outcomes. Mixed regressions were used. Mindfulness and self/other-compassion were explored as potential mechanisms of effects on stress and wellbeing. Results: We assigned 234 participants to MBCT-L (n = 115) or to wait-list (n = 119). 168 (72%) participants completed the primary outcome and of those who started the MBCT-L 73.40% (n = 69) attended the majority of the sessions. MBCT-L ameliorated stress compared with controls (B = 2.60, 95% CI = 1.63‒3.56; d = -0.72; p < .0001). Effects were also found for well-being, depression and anxiety, but not for work-related outcomes. Mindfulness and self-compassion mediated effects on stress and wellbeing. Conclusions: MBCT-L could be an effective and acceptable part of a wider healthcare workers well-being and mental health strategy.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903308/

 

Reduce Loneliness with Mindfulness

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Reduce Loneliness with Mindfulness

 

By John M. de Castro, Ph.D.

 

“The practice of mindfulness is an invitation to pay attention to the present moment with kindness and curiosity. This means dropping all of the judgments that we have about loneliness and acknowledging the way things are right now. It’s only from this gentle place of acceptance that loneliness can loosen its tight grip.” – Christi-an Slomka

 

Humans are social animals. We are generally happiest when we’re with family and friends. Conversely, being without close social contact makes us miserable. It’s the close relationship that is so important as we can be around people all day at work and still feel deep loneliness. These contacts are frequently superficial and do not satisfy our deepest need. It is sometimes said that we live in “the age of loneliness.” It is estimated that 20% of Americans suffer from persistent loneliness. This even when we are more connected than ever with the internet, text messaging, social media, etc. But these create the kinds of superficial contacts that we think should be satisfying, but are generally not. This has led to the counterintuitive findings that young adults, 18-34, have greater concerns with loneliness than the elderly.

 

The consequences of loneliness are dire. It has been estimated that being socially isolated increases mortality by 14%. Even worse, for people over 60, loneliness increases their risk of death by 45%. When a spouse loses a marital partner there’s a 30% increase in mortality in the 6-months following the death. Hence, loneliness is not only an uncomfortable and unhappy state, but it is also a threat to health and longevity. It is clear that this epidemic of loneliness needs to be addressed.

 

A potential antidote to loneliness is mindfulness which has been shown to reduce loneliness. In today’s Research News article “Can Mindfulness Help to Alleviate Loneliness? A Systematic Review and Meta-Analysis.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947335/ ) Teoh and colleagues review, summarize and perform a meta-analysis of the published randomized controlled trials (RCTs) of the effectiveness of mindfulness to counteract loneliness. They identified 7 RCTs that included a total of 815 participants.

 

They report that the published randomized controlled trials (RCTs) found that mindfulness or compassion training of 8 weeks or longer produced significant reductions in loneliness. The reductions appeared to be larger in younger participants. The majority of the studies, however,  used wait-list controls with no intervention while the mindfulness training occurred in group sessions. It is possible that meeting as a group was the reason for the decrease in loneliness rather than the mindfulness training. Obviously, more research is necessary with better active control conditions occurring in a group setting before definitive conclusions can be reached.

 

“Loneliness is on the rise, despite our interconnected world, but mindfulness training offers a practical intervention for anybody who wishes to decrease their feelings of loneliness and experience greater social connection.” – Christian Rigg

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Teoh, S. L., Letchumanan, V., & Lee, L. H. (2021). Can Mindfulness Help to Alleviate Loneliness? A Systematic Review and Meta-Analysis. Frontiers in psychology, 12, 633319. https://doi.org/10.3389/fpsyg.2021.633319

 

Abstract

Objective: Mindfulness-based intervention (MBI) has been proposed to alleviate loneliness and improve social connectedness. Several randomized controlled trials (RCTs) have been conducted to evaluate the effectiveness of MBI. This study aimed to critically evaluate and determine the effectiveness and safety of MBI in alleviating the feeling of loneliness.

Methods: We searched Medline, Embase, PsycInfo, Cochrane CENTRAL, and AMED for publications from inception to May 2020. We included RCTs with human subjects who were enrolled in MBI with loneliness as an outcome. The quality of evidence was assessed using Cochrane’s Risk of Bias (ROB) tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE). A random-effects model was used for meta-analysis.

Results: Out of 92 articles identified, eight studies involving 815 participants were included in this study. Most (7/8) trials conducted a minimum of 8 weeks of MBI. Most of the trials (5/8) used UCLA-Loneliness Scale. A pooled analysis combining three trials and compared with wait-list showed significant improvement in loneliness score reduction using the UCLA-R scale with MD of −6.33 [95% confidence interval (CI): −9.39, −3.26]. Subgroup analysis with only two Cognitively-Based Compassion Training (CBCT) trials also showed similar MD of −6.05 (95% CI: −9.53, 2.58). The overall quality of evidence (GRADE) was low.

Conclusions: Mindfulness intervention with an average length of 8-week duration significantly improved the population’s loneliness level with no mental health issue. However, this evidence had a low GRADE level.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947335/