Improve Social and Nature Connectedness with Meditation

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Improve Social and Nature Connectedness with Meditation

 

By John M. de Castro, Ph.D.

 

“Loving-kindness meditation is a contemplative practice focused on self-generated emotions of compassion, love, and goodwill toward oneself and others. . . individuals who regularly practiced loving-kindness meditation for approximately 2 months experienced significant increases in self-reported positive emotions, such as joy, awe, and gratitude. . .  they also reported a stronger sense of social connectedness. . . individuals in the loving-kindness meditation group perceived themselves as being closer and more “in tune” with others during social interactions.” – Laura Schenck

 

We are social animals. Alone we are weak and vulnerable and would not have fared well in evolution. But, in concert with others we have dominated our world. By working together in organized societies, we have not only been able to provide for a vast population but create technical wonders expanding interpersonal interaction possibilities. It is obvious that we are connected to and depend upon one another and that, in general, is a good thing. All that the species has accomplished resulted from the ability to work together cooperatively and build upon the work of others.

 

Beyond, the importance of the group, interactions with other people are fundamental to personal well-being. People need to be with and connected with others. Social connections are crucial to our health and happiness. Hence, it is very important for the individual to have effective satisfying social relationships. Unfortunately, interacting with other people is extremely complex and many find it very difficult to effectively engage with others. Some are better than others, but everyone struggles with human connections to some extent. Hence it is important for us to find ways to improve how we connect with other people.

 

Loving Kindness Meditation (LKM) is specifically designed to develop positive feelings toward the self and others.  In LKM the meditator focuses on repeatedly wishing positive things, wellness, safety, happiness, health etc. for oneself and toward multiple other people from loved ones to enemies. LKM and other mindfulness practices have been shown to improve positive mood and improve social interactions. In today’s Research News article “Mindfulness and Loving-Kindness Meditation.” (See summary below). Aspy and Proeve examine the effectiveness of mindfulness meditation and Loving Kindness Meditation (LKM) to improve connectedness to others and to nature.

 

They recruited college students who were occasional meditators and randomly assigned them to complete either a 15-minute recorded guided mindfulness meditation, Loving Kindness Meditation (LKM), or relaxation session. Before and after the session they completed measures of positive and negative emotions, social connectedness, and connectedness to nature. The entire study was conducted over the internet. So, they included objective questions regarding the recordings to insure that the participants actually completed the appropriate 15-minute session. 24% of the original participants were excluded for providing incorrect answers.

 

They found that the two meditation groups had significantly higher social connectedness, and connectedness to nature than the relaxation group. But, there were no significant differences between the mindfulness meditation and Loving Kindness Meditation (LKM) groups. In addition, there were no significant differences between the three groups in positive and negative emotions. Hence, brief meditations appear to increase connectedness socially and to nature without altering mood.

 

It has been well established that both mindfulness meditation and Loving Kindness Meditation (LKM) increase positive emotions and decrease negative emotions. It is likely that a single brief meditation is not sufficient to improve mood. But, it is interesting that connectedness was improved. This makes sense for Loving Kindness Meditation (LKM) as it includes thoughts about others. But mindfulness meditation does not, focusing on the breath and bodily sensations. But, mindfulness meditation has been shown previously to improve social behavior. So, although the two types of meditation have the same effect on connectedness, they may do so in different ways.

 

So, improve social and nature connectedness with meditation.

 

“Loving-Kindness meditation focuses on developing feelings of goodwill, kindness and warmth towards others. . . compassion, kindness and empathy are very basic emotions to us. Research shows that Loving Kindness Meditation has a tremendous amount of benefits ranging from benefitting well-being, to giving relief from illness and improving emotional intelligence.” – Emma Seppälä

 

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

 

Denholm J. Aspy, Michael Proeve. Mindfulness and Loving-Kindness Meditation. Psychological Reports, Vol 120, Issue 1, pp. 102 – 117, 2017. 10.1177/0033294116685867

 

Abstract

An experiment involving 115 undergraduate students (74.8% females; mean age = 20.5 years, SD = 4.3) was conducted to explore effects of meditation on social connectedness, nature connectedness, and affect. Participants listened to one of three brief guided meditation Mp3 recordings via the internet, which involved mindfulness meditation (MM), loving-kindness meditation (LKM), or progressive muscle relaxation (active control group). Participants in the MM and LKM groups reported greater social and nature connectedness at post-test than those in the control group. There were no significant differences in connectedness between the MM and LKM groups, suggesting they are both effective for enhancing connectedness. There were no significant changes in negative or positive affect at post-test due to the interventions. Recommendations for future research are provided.

Reduce Mind Wandering and Negative Mood with Mindfulness

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Reduce Mind Wandering and Negative Mood with Mindfulness

 

By John M. de Castro, Ph.D.

 

“being in a mind-wandering state – instead of aware of present moment activities – is not such a happy state. We are generally happier when we are not mind-wandering.” – Susan Smalley

 

We spend a tremendous amount of waking time with our minds wandering and not on the present environment or the task at hand. We daydream, plan for the future, review the past, ruminate on our failures, exalt in our successes. In fact, we spend almost half of our waking hours off task with our mind wandering. Mindfulness is the antithesis of mind wandering. When we’re mindful, we’re paying attention to what is occurring in the present moment. In fact, the more mindful we are the less the mind wanders and mindfulness training reduces mind wandering.

 

You’d think that if we spend so much time with the mind wandering it must be enjoyable. But, in fact research has shown that when our mind is wandering we are actually less happy than when we are paying attention to what is at hand. There are times when mind wandering may be useful, especially in regard to planning and creative thinking. But, for the most part, it interferes with our concentration on the present moment and what we’re doing and makes us unhappy. Hence, it makes sense to study the relationship of mindfulness to mind wandering and negative emotions.

 

In today’s Research News article “Does Mind Wandering Mediate the Association Between Mindfulness and Negative Mood? A Preliminary Study.” (See summary below). Wang and colleagues recruited meditation naïve college students. They completed measures of mindfulness, positive and negative moods, and mind wandering during a 15-minute breath following meditation period. Correlations and sophisticated mediation model analysis were conducted on the students’ responses.

 

They found that the higher the levels of mindfulness the higher the levels of positive emotions and the lower the levels of mind wandering and negative emotions. Hence, more mindful students had more positive and less negative emotions and less mind wandering. The mediation analysis revealed that mind wandering partially mediated the relationship between mindfulness and negative emotions but not positive emotions. In other words, mindfulness was directly related to less negative emotions and also indirectly by being related to less mind wandering which in turn was related to less negative emotions.

 

This is a correlational study, so no conclusions can be reached about causation. But there is evidence from other studies that mindfulness training improves mood. So, it is likely that mindfulness caused the greater positive emotions and lower negative emotions in the students in this study. These are interesting results that add to the understanding of how mindfulness affects human emotions. They show that mindfulness influences mood directly and also improves negative mood via reduced mind wandering.

 

So, reduce mind wandering and negative mood with mindfulness.

 

“mindfulness training may have protective effects on mind wandering for anxious individuals. . . . meditation practice appears to help anxious people to shift their attention from their own internal worries to the present-moment external world, which enables better focus on a task at hand.” – Mengran Xu

 

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

 

Yuzheng Wang, Wei Xu, Capella Zhuang, Xinghua Liu. Does Mind Wandering Mediate the Association Between Mindfulness and Negative Mood? A Preliminary Study. Psychological Reports, Vol 120, Issue 1, pp. 118 – 129, 2017. 10.1177/0033294116686036

 

Abstract

The aim of this study was to assess the relationship between trait mindfulness and mood and to examine whether the relationship is mediated by mind wandering. Eighty-two individuals (M age = 24.27 years, SD = 5.64, 18 men, 22%) completed a series of measures including the Five-Facet Mindfulness Questionnaire, the Profile of Mood States Questionnaire, and Meditation Breath Attention Exercise. Results showed that the level of mindfulness was significantly correlated with positive and negative mood, and the association between mindfulness and negative mood was mediated by mind wandering. This study indicated the important role of mind wandering in the relation between mindfulness and negative mood. Limitations and future research directions are discussed.

Improve Fatigue and Multiple Sclerosis Psychological Symptoms with Mindfulness

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Improve Fatigue and Multiple Sclerosis Psychological Symptoms with Mindfulness

 

By John M. de Castro, Ph.D.

 

“mindfulness may help people better respond to stress by fostering healthier coping strategies. For example, study participants who reported higher levels of mindfulness were less likely to rely on coping strategies, such as denial, disengagement and self-blame. They were also more likely to use more-positive strategies, such as information gathering, planning and seeking out social support. Mindfulness practice appears to be a safe, drug-free approach to coping with stress and anxiety, which may in turn help reduce your MS symptoms.” – Amit Sood

 

Multiple Sclerosis (MS) is a progressive demyelinating disease which attacks the coating on the neural axons which send messages throughout the body and nervous system. It affects about 2 million people worldwide and about 400,000 in the U.S. It is most commonly diagnosed in people between the ages of 20 and 50 years.  Unfortunately, there is no cure for multiple sclerosis. There are a number of approved medications that are used to treat MS but are designed to lessen frequency of relapses and slow the progression of the disease, but they don’t address individual symptoms.

 

Although there is a progressive deterioration, MS is not fatal with MS patients having about the same life expectancy as the general population. Hence, most MS sufferers have to live with the disease for many years. So, quality of life becomes a major issue. Quality of life with MS is affected by fatigue, cognitive decrements, physical impairment, depression, and poor sleep quality. There is a thus a critical need for safe and effective methods to help relieve the symptoms of MS and improve quality of life. Mindfulness has been previously shown to improve depression, sleep quality, cognitive impairments, emotion regulation, and fatigue. It has also been shown to improve the symptoms of multiple sclerosis.

 

In today’s Research News article “Mindfulness-based cognitive therapy severely fatigued multiple sclerosis patients: A waiting list controlled study.” See summary below or view the full text of the study at: https://www.medicaljournals.se/jrm/content/html/10.2340/16501977-2237, Hoogerwerf and colleagues recruited patients with multiple sclerosis and kept them on a waiting list for 10 weeks and then provided them with 10 weeks of Mindfulness-Based Cognitive Therapy (MBCT) in groups of 12. MBCT involves mindfulness training, containing sitting and walking meditation and body scan, and cognitive therapy to alter how the patient relates to the thought processes that often underlie and exacerbate psychological symptoms. They were measured at baseline after the 10-week waiting period, after treatment and 3 months later for fatigue, mindfulness, anxiety, depression, quality of life, sleeping problems, daily cognitive mistakes, catastrophizing, coping styles, and cognitive ability.

 

They found that during the 10-week waiting period symptoms generally did not significantly change, but after the MBCT training there were significant improvements in fatigue, mindfulness, anxiety, depression, daily cognitive mistakes, catastrophizing, and emotion focused coping styles. These improvements were sustained at the 3-month follow-up. Hence, MBCT training appeared to produce marked and lasting improvements in the psychological symptoms of multiple sclerosis. There is a need to repeat this study with a stronger randomized controlled clinical trial. The positive results make a compelling case for such a trial.

 

Mindfulness training has been shown to produce improvements in fatigue, emotion regulation, anxiety, depression, cognitive performance, coping strategies, worry and catastrophizing, and of course mindfulness. The present study confirms that these benefits also accrue to patients with multiple sclerosis and are maintained. This suggests that MBCT training or other mindfulness trainings may be helpful in relieving the symptoms of this life-long progressive neurological disease. This will hopefully allow them to cope better with their disease and generally make their lives better

 

So, improve fatigue and multiple sclerosis psychological symptoms with mindfulness.

 

“Studies in multiple sclerosis, these have shown that mindfulness can improve quality of life and help people cope better with their MS. The studies also found that it decreased stress, anxiety and depression.” – MS Trust

 

 

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

 

Hoogerwerf AEW, Bol Y, Lobbestael J, Hupperts R, van Heugten CM. Mindfulness-based cognitive therapy severely fatigued multiple sclerosis patients: A waiting list controlled study. J Rehabil Med. 2017 Jun 8. doi: 10.2340/16501977-2237

 

Abstract

BACKGROUND:

Fatigue is the most common symptom in multiple sclerosis. Evidence-based treatment options are scarce.

OBJECTIVE:

To study the feasibility and potential effectiveness of mindfulness-based cognitive therapy in severely fatigued multiple sclerosis patients.

METHODS:

Non-randomized pilot study with a wai-ting list control period including 59 multiple sclerosis patients with severe fatigue.

PRIMARY OUTCOME MEASURE:

fatigue severity subscale of the Checklist Individual Strength-20. Secondary measures: Hospital Anxiety and Depression Scale, Life Satisfaction Questionnaire, subscale sleep of the Symptom Checklist-90, Cognitive Failure Questionnaire, Fatigue Catastrophizing Scale, Coping Inventory of Stressful Situations, and Five Facet Mindfulness Questionnaire-Short Form. Measurements were taken before treatment (double baseline), after treatment, and at follow-up (3 months).

RESULTS:

Adherence rate was 71%. Eight out of 10 participants who completed the intervention were satisfied with the intervention. Significant time effects were found for 7 out of 11 outcome measures (p = 0.006 to < 0.001). The effect size was moderate for all outcome measures that were significant post-treatment and/or at follow-up (Ƞ² = 0.10-0.17). Improvements were maintained at follow-up. Of the completers, 46% showed a clinically relevant change regarding fatigue.

CONCLUSION:

Mindfulness-based cognitive therapy is feasible in severely fatigued multiple sclerosis patients and has positive results in the reduction of severe fatigue and several psychological factors.

https://www.medicaljournals.se/jrm/content/html/10.2340/16501977-2237

Improve Mental Health in the Elderly with Mindfulness

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Improve Mental Health in the Elderly with Mindfulness

 

By John M. de Castro, Ph.D.

 

“The interconnectedness of mind and body lies at the heart of mindfulness and this makes it highly relevant to older people who are more likely to experience physical health problems with associated psychological issues ­ such as reduced mobility and depression. It is thought that mindfulness can be particularly empowering to older people as it focuses on abilities rather than difficulties which may help older people to feel more engaged in decisions about their care.” – MyAgingParent.com

 

Human life is one of constant change. We revel in our increases in physical and mental capacities during development, but regret their decline during aging. As we age, there are systematic progressive declines in every system in the body, the brain included. This includes our mental abilities and results in impairments in memory, attention, and problem solving ability. It is inevitable and cannot be avoided. Aging also results in changes in mental health. Depression is very common in the elderly. The elderly cope with increasing loss of friends and family, deteriorating health, as well as concerns regarding finances on fixed incomes. All of these are legitimate sources of worry. In addition, many elderly experience withdrawal and isolation from social interactions. But, no matter how reasonable, the increased loneliness, worry and anxiety add extra stress that can impact on the elderly’s already deteriorating physical and psychological health.

 

Mindfulness appears to be effective for an array of physical and psychological issues that occur with aging. It appears to strengthen the immune system and reduce inflammation. It has also been shown to be beneficial in slowing or delaying physical and mental decline with aging. and improve cognitive processes. It has also been shown to reduce anxiety, worry, and depression and improve overall mental health. Since the global population of the elderly is increasing at unprecedented rates, it is imperative to investigate safe and effective methods to slow physical and mental aging and improve mental health in the elderly.

 

In today’s Research News article “Meditation in Stressed Older Adults: Improvements in Self-Rated Mental Health Not Paralleled by Improvements in Cognitive Function or Physiological Measures.” (See summary below). Oken and colleagues recruited health elderly between the ages of 50-85 (average age = 60 years) who did not evidence cognitive decline and who were at least mildly stressed. They were randomly assigned to either receive 6 weeks of mindfulness meditation practice or to a wait-list control condition. Mindfulness meditation practice included one-on-one instruction in body scan, sitting meditation, and breathing exercises. The participants were measured before and after training for mindfulness, perceived stress, positive and negative emotions, neuroticism, fatigue, quality of life, self-efficacy, sleep, executive function, memory, attention, physiological vital signs, and salivary cortisol levels.

 

They found that the mindful meditation group in comparison to the wait-list group and the baseline measures showed significant reductions in negative emotions, neuroticism, and perceived stress following training and significant increases in mindfulness, vitality, self-efficacy, agreeableness and conscientiousness. Hence, mindfulness meditation produced significant improvements in the overall mental health of the participants, but did not alter physical health or cognitive abilities.

 

These are important results that suggest that mindfulness meditation practice produces major improvements in the mental health of the elderly. The participants, however, were relatively young elderly with an average age of 60 and only one participant over 75. They were all in good health and demonstrated no cognitive issues. Hence, the failure to demonstrate any effects of mindfulness meditation on the physical health or cognitive ability of this group may have been due to the fact that they were high functioning at the beginning making it difficult to produce further improvements. Regardless, the results clearly show large and important effects of mindfulness meditation on the overall mental health of these young elderly. This suggests that mindfulness meditation should be incorporated into the lives of the elderly to improve their psychological state during their declining years.

 

So, improve mental health in the elderly with mindfulness.

 

“Mindfulness practice has a definite positive impact on issues such as recurrent depression, stress, anxiety, chronic physical pain and loneliness. For elderly people, loneliness is a major risk factor for health problems-such as cardiovascular disease and Alzheimer’s. Mindfulness meditation training can be used as a novel approach for reducing loneliness and the risk of disease. Research suggests that mindfulness meditation training is a promising intervention for improving the health of older adults.” – Bláthnait Ní Mhurchú

 

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

 

Oken, B.S., Wahbeh, H., Goodrich, E. et al. Meditation in Stressed Older Adults: Improvements in Self-Rated Mental Health Not Paralleled by Improvements in Cognitive Function or Physiological Measures. Mindfulness (2017) 8: 627. doi:10.1007/s12671-016-0640-7

 

Abstract

To determine if mindfulness meditation (MM) in older adults improves cognition and, secondarily, if MM improves mental health and physiology, 134 at least mildly stressed 50–85-year olds were randomized to a 6-week MM intervention or a waitlist control. Outcome measures were assessed at baseline and 2 months later at visit 2. The primary outcome measure was an executive function/attentional measure (flanker task). Other outcome measures included additional cognitive assessments, salivary cortisol, respiratory rate, heart rate variability, Positive and Negative Affect Schedule (PANAS), Center for Epidemiologic Studies Depression (CESD), Perceived Stress Scale (PSS), Neuroticism-Extraversion-Openness (NEO) personality traits, and SF-36 health-related quality of life. One hundred twenty-eight participants completed the study though visit 2 assessments. There was no significant change in the primary or other cognitive outcome measures. Even after statistical adjustment for multiple outcomes, self-rated measures related to negative affect and stress were all significantly improved in the MM intervention compared to waitlist group (PANAS-negative, CESD, PSS, and SF-36 health-related quality of life Vitality and Mental Health Component). The SF-36 Mental Health Component score improved more than the minimum clinically important difference. There were also significant changes in personality traits such as Neuroticism. Changes in positive affect were not observed. There were no group differences in salivary cortisol or heart rate variability. These moderate-sized improvements in self-rated measures were not paralleled by improvements in cognitive function or physiological measures. Potential explanations for this discrepancy in stress-related outcomes are discussed to help improve future studies.

Improve Parkinson’s Disease with Mindfulness

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Improve Parkinson’s Disease with Mindfulness

 

By John M. de Castro, Ph.D.

 

“A practical and powerful way to reduce stress is to become more mindful which, simply put, means being present in the moment rather than agonizing over the past or anticipating the future. Once stress levels are well under control, symptoms of Parkinson’s will have enormous difficulty presenting themselves. When people experience stress, their symptoms get much worse. When stress levels are under control, symptoms subside.” – Robert Rogers

 

Parkinson’s Disease (PD) is an incurable progressive degenerative disease of the central nervous system. The condition is caused by the death of nerve cells in the brain that produce the neurotransmitter dopamine. There are around seven million people worldwide and one million people in the U.S. living with PD and about 60,000 people are diagnosed with PD every year. PD is associated with aging as the vast majority of patients are diagnosed after age 50. In fact, it has been speculated that everyone would eventually develop PD if they lived long enough.

 

Its physical symptoms include resting tremor, slow movements, muscle rigidity, problems with posture and balance, loss of automatic movements, and slurring of speech. PD itself is not fatal but is often associated with related complications which can reduce life expectancy, such as falls, choking, and cardiovascular problems. Parkinson’s Disease (PD) also has psychological effects, especially anxiety and depression. All of these symptoms result in a marked reduction in the quality of life.

 

Mindfulness training has been found to improve the psychological symptoms and the quality of life with PD patients. In addition, stress is known to exacerbate the symptoms of PD. So, it would make sense that Mindfulness-Based Stress Reduction (MBSR), a mindfulness training that was developed specifically for stress reduction, would be effective for relieving some of the symptoms of PD. In today’s Research News article “Mindfulness-based stress reduction in Parkinson’s disease: a systematic review.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5433018/, McLean and colleagues review the published research literature on the effectiveness of an 8-week program of  MBSR for patients with PD.

 

As it turns out, the research is sparse. They were only able to identify 3 published articles which described 2 controlled trials, both of small size and with non-active control groups. The studies reported that MBSR participants, in comparison to controls, had improved motor ability, mindfulness, and quality of life with PD, and decreases in depression. One study found potentially beneficial changes in the patients’ brains in the MBSR group.

 

The scarce published research to date is promising and suggests that MBSR may be a beneficial treatment for patients with Parkinson’s Disease (PD) producing improvements in motor ability, psychological well-being, and quality of life. There is obviously a need for larger and better controlled trials. But, the research suggests that such research is warranted. Mindfulness training may be helpful in easing some of the symptom burden that plagues PD sufferers.

 

So, improve Parkinson’s disease with mindfulness.

 

“Mindfulness training, as taught by qualified and experienced teachers, may offer a more participatory medicine, empowering the individual by engagement to learn how to strengthen internal resources to help cope with chronic disease. Mindfulness training may help to restore some degree of self-determination in the experience of living with PD.” – Margaret Tuchman

 

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

 

McLean, G., Lawrence, M., Simpson, R., & Mercer, S. W. (2017). Mindfulness-based stress reduction in Parkinson’s disease: a systematic review. BMC Neurology, 17, 92. http://doi.org/10.1186/s12883-017-0876-4

 

Abstract

Background

Mindfulness based stress reduction (MBSR) is increasingly being used to improve outcomes such as stress and depression in a range of long-term conditions (LTCs). While systematic reviews on MBSR have taken place for a number of conditions there remains limited information on its impact on individuals with Parkinson’s disease (PD).

Methods

Medline, Central, Embase, Amed, CINAHAL were searched in March 2016. These databases were searched using a combination of MeSH subject headings where available and keywords in the title and abstracts. We also searched the reference lists of related reviews. Study quality was assessed based on questions from the Cochrane Collaboration risk of bias tool.

Results

Two interventions and three papers with a total of 66 participants were included. The interventions were undertaken in Belgium (n = 27) and the USA (n = 39). One study reported significantly increased grey matter density (GMD) in the brains of the MBSR group compared to the usual care group. Significant improvements were reported in one study for a number of outcomes including PD outcomes, depression, mindfulness, and quality of life indicators. Only one intervention was of reasonable quality and both interventions failed to control for potential confounders in the analysis. Adverse events and reasons for drop-outs were not reported. There was also no reporting on the costs/benefits of the intervention or how they affected health service utilisation.

Conclusion

This systematic review found limited and inconclusive evidence of the effectiveness of MBSR for PD patients. Both of the included interventions claimed positive effects for PD patients but significant outcomes were often contradicted by other results. Further trials with larger sample sizes, control groups and longer follow-ups are needed before the evidence for MBSR in PD can be conclusively judged.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5433018/

Stay Abstinent from Smoking Mindfully

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Stay Abstinent from Smoking Mindfully

 

By John M. de Castro, Ph.D.

 

“I liken it to having weeds in your garden. Standard treatments—for example, avoiding triggers such as ashtrays and lighters or using substitutes such as eating carrot sticks and chewing on your pen—just pull the heads off the weeds, so they grow back. These treatments don’t uproot the craving itself. In contrast, mindfulness really gets in there and pulls up the roots.” – Judson Brewer

 

“Tobacco use remains the single largest preventable cause of death and disease in the United States.” (Centers for Disease Control and Prevention). So, treating nicotine addiction and producing smoking cessation could greatly improve health. But, smoking has proved devilishly difficult to treat. There are a wide variety of methods and strategies to quit smoking which are to only a very limited extent effective. According to the National Institutes of Health, about 40% of smokers who want to quit make a serious attempt to do so each year, but fewer than 5% actually succeed. Most people require three or four failed attempts before being successful.

 

One problem is that nicotine is one of the most addictive substances known and withdrawal from nicotine is very stressful, producing many physical and psychological problems, including negative emotional states and depression. In essence, the addict feels miserable without the nicotine. This promotes relapse to relieve the discomfort. Better methods to quit which can not only promote quitting but also prevent relapse are badly needed. Mindfulness practices have been found to be helpful in treating addictions, including nicotine addiction, and reducing the risk of relapse.

 

In today’s Research News article “Dispositional Mindfulness Predicts Enhanced Smoking Cessation and Smoking Lapse Recovery.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4867253/, Heppner and colleagues recruited African American smokers who smoked at least 5 cigarettes per day for at least one year and enrolled in a smoking cessation treatment program. They were measured 19 and 5 days before quitting smoking and 3 days, 31 days, and 26 weeks after quitting for cigarettes smoked per day, smoking abstinence, mindfulness, positive and negative emotions, dependence and withdrawal symptoms, self-efficacy, and social support.

 

They found that the number of participants remaining abstinent dropped precipitously over 26 weeks but mindfulness mattered. Abstinence dropped to around 7% of participants who were low in mindfulness but to only 14% of participants who were high in mindfulness. Of those participants who relapsed at day 3 after treatment high mindfulness participants were significantly more likely to recover abstinence by day 31 and week 26. They also found that the improvement in abstinence at day 3 produced by mindfulness occurred primarily as a result of mindfulness producing lower levels of sadness, anger, and depression, lower use of smoking to control emotions, and more social support which in turn were associated with better abstinence rates.

 

These results are interesting but correlational, so causation cannot be determined. But, prior research has shown that mindfulness training improves treatment for nicotine addiction. So, it is likely that the relationships between mindfulness and smoking cessation observed in the present study were due to mindfulness causing the improved abstinence. Mindfulness acted through intermediaries of improved emotion regulation and improved social support to support abstinence. These results suggest that mindfulness is very helpful in remaining abstinent after quitting smoking and should become a component of all smoking cessation treatment packages.

 

So, stay abstinent from smoking mindfully.

 

“each time the individual does not succumb to the craving, the craving becomes weaker until eventually it no longer gets triggered. Moreover, with each moment of mindfulness, the smoker regains a sense of control and understanding regarding their mind and body, which can be empowering.” – Azadeh Aalai

 

 

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

 

Heppner, W. L., Spears, C. A., Correa-Fernández, V., Castro, Y., Li, Y., Guo, B., … Wetter, D. W. (2016). Dispositional Mindfulness Predicts Enhanced Smoking Cessation and Smoking Lapse Recovery. Annals of Behavioral Medicine : A Publication of the Society of Behavioral Medicine, 50(3), 337–347. http://doi.org/10.1007/s12160-015-9759-3

 

Abstract

Background

Although mindfulness has been hypothesized to promote health behaviors, no research has examined how dispositional mindfulness might influence the process of smoking cessation.

Purpose

The current study investigated dispositional mindfulness, smoking abstinence, and recovery from a lapse among African American smokers.

Methods

Participants were 399 African Americans seeking smoking cessation treatment (treatments did not include any components related to mindfulness). Dispositional mindfulness and other psychosocial measures were obtained pre-quit; smoking abstinence was assessed 3 days, 31 days, and 26 weeks post-quit.

Results

Individuals higher in dispositional mindfulness were more likely to quit smoking both initially and over time. Moreover, among individuals who had lapsed at day 3, those higher in mindfulness were more likely to recover abstinence by the later time points. The mindfulness-early abstinence association was mediated by lower negative affect, lower expectancies to regulate affect via smoking, and higher perceived social support.

Conclusions

Results suggest that mindfulness might enhance smoking cessation among African American smokers by operating on mechanisms posited by prominent models of addiction.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4867253/

Sat Chit Ananda 3 – Bliss

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Sat Chit Ananda 3 – Bliss

 

By John M. de Castro, Ph.D.

 

“Ananda is that bliss which is eternal, uncaused and unexcelled. It is the real nature.” – Swami Sivananda

 

In previous posts we discussed the first two components of the classic phrase from Hinduism, “Sat Chit Ananda”. The phrase means “being, consciousness, bliss” and is a description of a sublimely blissful experience of the boundless, pure consciousness, a glimpse of ultimate reality.

 

The third component “Ananda” is translated as bliss, but also implies love and happiness. Bliss is often thought of as an ecstatic state of extraordinary joy and exhilarating happiness. But this does not capture the true meaning of “Ananda”. It is much subtler and richer, but devilishly difficult to capture in words. It is probably better to simply conceive of it as the feelings one has when “Sat” and “Chit” are fully realized, when one has fully awakened. Paramhansa Yogananda, described bliss as, “a transcendental state of superior calm including within itself the consciousness of a great expansion and that of ‘all in One and One in all.’”

 

Bliss is a continuous state of inner joy that is constant and undisturbed by outward gain or loss or by external circumstances whether positive or negative or happy or sad. It is a feeling of oneness and connection with all of creation. Bliss is where happiness, meaning, and truth converge.

 

Bliss is found in every religion. It is the ultimate state of consciousness that every religion holds as its highest goal and achievement, though each uses different terminology to explain it. Whether we are Christian or Hindu, Jewish or Muslim, Buddhist or atheist, Wiccan or animist, Taoist or Native American, we all strive for bliss.

 

Bliss arises when the mind becomes quiet and calm naturally and effortlessly. A fully awakened individual does not need to “think good thoughts” to feel good. Feeling good is our natural state when the mind is calm and open. So “Ananda” is as natural and inherent as Pure Being and Consciousness; “Sat” and “Chit”.

 

We can catch a glimpse of “Ananda” in our everyday unawakened state. When we quiet the mind and simply watch a sunset or a sunrise, Bliss arises naturally. Awakened ones simply experience this regardless of eternal circumstances. But, by simply letting go, and paying attention to what is always present naturally we can experience the state of “Ananda”.

 

So don’t strive to become blissful. Don’t try to make it happen. It already is happening. Simply practice deeply, quiet and calm the mind, and you will understand the meaning of “Ananda”.

 

“Sat is divine Existence, Chit is divine Consciousness, Ananda is divine Bliss. When we go deep within we feel these three together, and when we acquire the inner vision to perceive them all at once, we live verily in the Kingdom of Heaven. Otherwise, Existence is at one place, Consciousness is somewhere else and Bliss is nowhere near the other two. When we see and feel Existence-Consciousness-Bliss on the selfsame plane, each complementing and fulfilling the others, we can say that we live in the Kingdom of Heaven. Yes, the Kingdom of Heaven is within us. Not only can we feel it, but without the least possible doubt, we can become it.” – Sri Chinmoy

 

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

 

Improve Anxiety in Adolescents with Mindfulness

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Improve Anxiety in Adolescents with Mindfulness

 

By John M. de Castro, Ph.D.

 

“Mindfulness also helps us to get to know our real self which is never a bad thing! People suffering from social anxiety are often marred by an exaggerated perception of their shortcomings which leads them to believe that they are inadequate and that everybody must be noticing. Practicing mindfulness based cognitive therapy will help them to reestablish a more realistic self-image.” – Kyle MacDonald

 

Anxiety disorders are the most common mental illness in the United States, affecting 40 million adults, or 18% of the population. Anxiety Disorders affects about 3.1% of the U.S. population. Severe anxiety affects about 6% of adolescents. Physically, anxiety sufferers will often show excessive fatigue, irritability, muscle tension or muscle aches, trembling, feeling twitchy, being easily startled, trouble sleeping, sweating, nausea, diarrhea or irritable bowel syndrome, and headaches.

 

Anxiety disorders in adults have generally been treated with drugs. It has been estimated that 11% of women in the U.S. are taking anti-anxiety medications. But, there are considerable side effects and these drugs are often abused. The drugs are also not appropriate for children and adolescents with developing nervous systems. So, there is a need to develop alternative treatments. Recently, it has been found that mindfulness training can be effective for anxiety disorders. Mindfulness-Based Cognitive Therapy (MBCT) has been shown to be effective in treating anxiety in adults. Mindfulness training has also been shown to produce changes in the nervous system. It is not known, however, what changes in the nervous system underlie the effect of MBCT on anxiety.

 

In today’s Research News article “Neural Function Before and After Mindfulness-Based Cognitive Therapy in Anxious Adolescents at Risk for Developing Bipolar Disorder.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876535/, Strawn and colleagues examine the effects of Mindfulness-Based Cognitive Therapy (MBCT) on the nervous systems of youth with high levels of anxiety. They recruited children and adolescents, aged 9 to 16 years, who were diagnosed with an anxiety disorder and who were at risk for developing bipolar disorder. They were treated with a 12-week program of MBCT. Before and after the treatment they were measured for anxiety, clinical symptoms, and mindfulness and also underwent functional Magnetic Resonance (f-MRI) brain scans while performing a continuous processing task with emotional and neutral distractors.

 

They found that following MBCT there was a significant increase in activity of the insula, lentiform nucleus, and thalamus, and anterior cingulate cortex with the presentation of emotional pictures. So, MBCT produces changes in the brains of children and adolescents similar to those seen in adults. They also found that the greater the reduction in anxiety resulting from MBCT the greater the decrease in activity of the insula and anterior cingulate cortex.

 

The insula and the anterior cingulate cortex have been shown to be involved in emotional processing and MBCT is aimed at altering the thought processes revolving around the interpretations of emotions. So, the changes in the functional activity of these structures following MBCT are commensurate with the changes in emotionality. Hence, MBCT appears to change the brains of children and adolescents with anxiety disorders to improve emotional processing.

 

It should be noted that this was a pilot study with a very small number of participants and no control group. So, the findings must be interpreted with caution. But the findings are sufficiently interesting to justify conducting a larger randomized clinical trial in the future.

 

“If you have unproductive worries, you can train yourself to experience those thoughts completely differently. ‘You might think ‘I’m late, I might lose my job if I don’t get there on time, and it will be a disaster!’ Mindfulness teaches you to recognize, ‘Oh, there’s that thought again. I’ve been here before. But it’s just that—a thought, and not a part of my core self,‘” – Elizabeth Hoge

 

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

 

Strawn, J. R., Cotton, S., Luberto, C. M., Patino, L. R., Stahl, L. A., Weber, W. A., … DelBello, M. P. (2016). Neural Function Before and After Mindfulness-Based Cognitive Therapy in Anxious Adolescents at Risk for Developing Bipolar Disorder. Journal of Child and Adolescent Psychopharmacology, 26(4), 372–379. http://doi.org/10.1089/cap.2015.0054

 

Abstract

Objective: We sought to evaluate the neurophysiology of mindfulness-based cognitive therapy for children (MBCT-C) in youth with generalized, social, and/or separation anxiety disorder who were at risk for developing bipolar disorder.

Methods: Nine youth (mean age: 13 ± 2 years) with a generalized, social, and/or separation anxiety disorder and a parent with bipolar disorder completed functional magnetic resonance imaging (fMRI) while performing a continuous processing task with emotional and neutral distractors (CPT-END) prior to and following 12 weeks of MBCT-C.

Results: MBCT-C was associated with increases in activation of the bilateral insula, lentiform nucleus, and thalamus, as well as the left anterior cingulate while viewing emotional stimuli during the CPT-END, and decreases in anxiety were correlated with change in activation in the bilateral insula and anterior cingulate during the viewing of emotional stimuli (p < 0.05, uncorrected; p < 0.005 corrected; cluster size, 37 voxels).

Conclusions: MBCT-C treatment in anxious youth with a familial history of bipolar disorder is associated with increased activation of brain structures that subserve interoception and the processing of internal stimuli—functions that are ostensibly improved by this treatment.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876535/

Improve Executive Function with Mindful Movement

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Improve Executive Function with Mindful Movement

 

By John M. de Castro, Ph.D.

 

“Tai Chi may just be a form of exercise that will preserve a sharp mind!” – Tai Chi and Health

 

Human life is one of constant change. We revel in our increases in physical and mental capacities during development, but regret their decreases during aging. Over time there is a systematic progressive decline in every system in the body, the brain included. This includes our mental abilities which decline with age including impairments in memory, attention, and problem solving ability. It is inevitable and cannot be avoided. Using modern neuroimaging techniques, scientists have been able to view the changes that occur in the nervous system with aging. In addition, they have been able to investigate various techniques that might slow the process of neurodegeneration that accompanies normal aging. They’ve found that mindfulness practices reduce the deterioration of the brain that occurs with aging restraining the loss of neural tissue.

 

Mindfulness practices have been shown to improve cognitive processes and mood while gentle mindful movement exercises such as Tai Chi, Qigong and Baduanjin mind-body training have been shown to slow age related cognitive decline. But, most studies of mindful movement effects on cognitive decline and mood, are performed in the elderly. Hence, the effectiveness of these practices with younger people to enhance cognitive function and mood have not been extensively studied. In today’s Research News article “Baduanjin Mind-Body Intervention Improves the Executive Control Function.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5233682/, Chen and colleagues studied the effects of Baduanjin mind-body practice on mood and cognitive function of college students.

 

They recruited college students and randomly assigned them to receive either 8 weeks, 5 days per week, for 90 minutes per day of Baduanjin mind-body training or progressive muscle relaxation training. The Baduanjin mind-body training consisted of 8 movements for limbs, body-trunk, and eye movements. The participants were measured before and after training for mood and cognitive executive function with a flanker task. The flanker task required the participants to respond to the direction of an arrow when distracting arrows were present alongside the target arrow. This test for attention and filtering of irrelevant information. During the flanker task their brain activity was measured with near-infrared spectroscopy which measures blood flows in the brain.

 

They found that following Baduanjin mind-body training, but not relaxation training, there was a significant decrease in the levels of depression and increase in flanker task performance with incongruous distracting stimuli. The flanker task improvement demonstrated that the Baduanjin mind-body training participants were better able to filter out distracting material. In addition, during the flanker task, with distracting incongruent stimuli present, the Baduanjin mind-body training group had an increase in blood flow in the left prefrontal cortex while the relaxation group did not. This suggests that the Baduanjin mind-body training produced a change in the brain that may underlie the improvements in mood and executive function.

 

It has been demonstrated that increases in the activity and size of the prefrontal cortex occurs with improved executive function ability. This suggests that Baduanjin mind-body training changes the brain to improve cognitive function. It is quite remarkable that such a gentle practice can produce neural changes resulting in such beneficial effects. It is also important that these effects were produced in young participants. So, the benefits of participation in mindful movement programs are not restricted to the elderly and do not just protect against cognitive decline but can improve cognitive function even for those at the peak of their abilities.

 

Baduanjin mind-body training is a gentle practice, completely safe, can be used by anyone, including the elderly and sickly, is inexpensive to administer, can be performed in groups or alone, at home or in a facility or even public park, and can be quickly learned. In addition, it can also be practiced in social groups without professional supervision. This can make it fun, improving the likelihood of long-term engagement in the practice.

 

So, improve executive function with mindful movement.

 

“A comparison of the effects of regular sessions of tai chi, walking, and social discussion, has found tai chi was associated with the biggest gains in brain volume and improved cognition.” – About Memory

 

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

 

Chen, T., Yue, G. H., Tian, Y., & Jiang, C. (2016). Baduanjin Mind-Body Intervention Improves the Executive Control Function. Frontiers in Psychology, 7, 2015. http://doi.org/10.3389/fpsyg.2016.02015

 

Abstract

This study aims at comparing the effects of the Baduanjin mind-body (BMB) intervention with a conventional relaxation training program on enhancing the executive function. The study also attempts to explore the neural substrates underlying the cognitive effect of BMB intervention using near-infrared spectroscopy (NIRS) technique. Forty-two healthy college students were randomly allocated into either the Baduanjin intervention group or relaxation training (control) group. Training lasted for 8 weeks (90 min/day, 5 days/week). Each participant was administered the shortened Profile of Mood States to evaluate their mood status and the flanker task to evaluate executive function before and after training. While performing the flanker task, the NIRS data were collected from each participant. After training, individuals who have participated in BMB exercise showed a significant reduction in depressive mood compared with the same measure before the intervention. However, participants in the control group showed no such reduction. The before vs. after measurement difference in the flanker task incongruent trails was significant only for the Baduanjin intervention group. Interestingly, an increase in oxygenated hemoglobin in the left prefrontal cortex was observed during the Incongruent Trails test only after the BMB exercise intervention. These findings implicate that Baduanjin is an effective and easy-to-administering mind-body exercise for improving executive function and perhaps brain self-regulation in a young and healthy population.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5233682/

Tai Chi is Better than Physical Therapy for Knee Osteoarthritis

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Tai Chi is Better than Physical Therapy for Knee Osteoarthritis

 

By John M. de Castro, Ph.D.

 

“Tai chi helps patients preserve and improve function by increasing strength, flexibility and coordination while avoiding aggravation of arthritic pain and inflammation. Tai chi is a particularly appealing form of exercise, as it is very low impact and emphasizes balance, coordination and strength. Tai chi is safe and has been shown to reduce falls in the elderly. Moreover, patients who practice tai chi often report an increased sense of wellness.” – Matthew Hepinstall

 

Osteoarthritis is a chronic degenerative joint disease that is the most common form of arthritis. It produces pain, swelling, and stiffness of the joints. It is the leading cause of disability in the U.S., with about 43% of arthritis sufferers limited in mobility and about a third having limitations that affect their ability to perform their work. In the U.S., osteoarthritis affects 14% of adults over 25 years of age and 34% of those over 65. Knee osteoarthritis effects 5% of adults over 25 years of age and 12% of those over 65. It is painful and disabling. Its causes are varied including, hereditary, injury including sports injuries, repetitive stress injuries, infection, or from being overweight.

 

There are no cures for knee osteoarthritis. Treatments are primarily symptomatic, including weight loss, exercise, braces, pain relievers and anti-inflammatory drugs, corticosteroids, arthroscopic knee surgery, or even knee replacement. Gentle movements of the joints with exercise and physical therapy appear to be helpful in the treatment of knee osteoarthritis. This suggests that alternative and complementary practices that involve gentle knee movements may be useful in for treatment. Indeed, yoga practice has been shown to be effective in treating arthritis. Various forms of traditional Chinese exercises, such as Tai Chi, Qigong, and Baduanjin involve slow gentle movements of the limbs and mindfulness and have been shown to reduce the physical symptoms of knee osteoarthritis. So, it would seem reasonable to look further into the effectiveness of Tai Chi relative to physical therapy in treating knee osteoarthritis.

 

In today’s Research News article “Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4960454/, Wang and colleagues recruited patients who were 40 years or older with knee osteoarthritis who had never practiced Tai Chi or received physical therapy before. They were randomly assigned to receive either 60 minutes, 2 times per week for 12 weeks of Tai Chi or 30 minutes, 2 times per week for 6 weeks of physical therapy. All patients continued to practice at home for an additional 12 weeks. They were measured before treatment and 12, 24, and 52 weeks later for osteoarthritis symptoms, physical function, stiffness, depression, arthritis self-efficacy, walk test, and expectations regarding intervention effectiveness.

 

They found that both groups had large significant improvements in osteoarthritis pain, and physical function that remained significant 1 year after training. Most of the other outcome measures were also significantly improved in both groups. The Tai Chi group demonstrated significantly greater improvements in depression and physical quality of life than the physical therapy group and also had greater but non-significant improvements in all measure than the physical therapy group. So, both Tai Chi and physical therapy were effective in improving the symptoms of knee osteoarthritis, but Tai Chi was superior particularly for depression and quality of life.

 

These are interesting and important results. While both Tai Chi and physical therapy were effective, Tai Chi appeared to have some better results. This is particularly important because this ancient gentle practice is completely safe, can be used with the elderly and sickly, is inexpensive to administer, can be performed in groups or alone, at home or in a facility or even public park, and can be quickly learned. In addition, it can also be practiced in social groups without professional supervision. This can make it fun, improving the likelihood of long-term engagement in the practice. Hence, Tai Chi would appear to be an excellent treatment for the symptoms of knee osteoarthritis.

 

So, improve knee osteoarthritis with Tai Chi.

 

“For the uninitiated, tai chi may be a little daunting. The ancient Chinese exercise is hardly as mainstream as aerobics or the treadmill, but with its gentle, fluid movements and proven health benefits, it’s a natural arthritis workout.” – Mary Jo DiLonardo

 

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

 

Wang, C., Schmid, C. H., Iversen, M. D., Harvey, W. F., Fielding, R. A., Driban, J. B., … McAlindon, T. (2016). Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial. Annals of Internal Medicine, 165(2), 77–86. http://doi.org/10.7326/M15-2143

 

Abstract

Background

Few remedies effectively treat long-term pain and disability from knee osteoarthritis. Studies suggest that Tai Chi alleviates symptoms, but no trials have directly compared Tai Chi with standard therapies for osteoarthritis.

Objective

To compare Tai Chi with standard physical therapy for patients with knee osteoarthritis.

Design

Randomized, 52-week, single-blind comparative effectiveness trial. (ClinicalTrials.gov: NCT01258985)

Setting

An urban tertiary care academic hospital.

Patients

204 participants with symptomatic knee osteoarthritis (mean age, 60 years; 70% women; 53% white).

Intervention

Tai Chi (2 times per week for 12 weeks) or standard physical therapy (2 times per week for 6 weeks, followed by 6 weeks of monitored home exercise).

Measurements

The primary outcome was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 12 weeks. Secondary outcomes included physical function, depression, medication use, and quality of life.

Results

At 12 weeks, the WOMAC score was substantially reduced in both groups (Tai Chi, 167 points [95% CI, 145 to 190 points]; physical therapy, 143 points [CI, 119 to 167 points]). The between-group difference was not significant (24 points [CI, −10 to 58 points]). Both groups also showed similar clinically significant improvement in most secondary outcomes, and the benefits were maintained up to 52 weeks. Of note, the Tai Chi group had significantly greater improvements in depression and the physical component of quality of life. The benefit of Tai Chi was consistent across instructors. No serious adverse events occurred.

Limitation

Patients were aware of their treatment group assignment, and the generalizability of the findings to other settings remains undetermined.

Conclusion

Tai Chi produced beneficial effects similar to those of a standard course of physical therapy in the treatment of knee osteoarthritis.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4960454/