Medscape
Laird Harrison
Gerry Gajadharsingh writes:
“The other night I was having a chat, to an internal medicine doctor from the US, lamenting the death of “evidence-based medicine” because of what’s happened during the pandemic. Many of us did not feel that governments around the world “followed the science”. I read a lot of research and I can often find research papers which support one particular viewpoint and research papers which gives a completely opposite viewpoint. Therefore, what are patients and clinicians supposed to make of it?
The philosophy of Osteopathy (a 140-year old system of medicine founded in the USA), in my opinion the original practice of functional medicine, bases a lot of its understanding, on anatomy and physiology and we will often work from first principles. An understanding of pathology (and pathophysiology, which is the mechanism behind how disease is caused) is important but functional approaches to medicine are increasingly important in this era of complex patient presentations.
When I look at research, I tend to look at the principles behind that research and think about how I can apply that research principle, to practical ways of helping patients.
The below article focuses on the inflammatory gastrointestinal disease, Crohn’s.
Psychological and social factors affect the gut and vice versa. Yet many inflammatory bowel disease clinics overlook psychological interventions.
Odes and colleagues developed cognitive-behavioral– and mindfulness-based stress reduction (COBMINDEX) training “The patient learns to relax,” Odes told MDedge News. “He learns not to fight his condition.
Odes and colleagues reported that patients who learned the technique showed improvement on a variety of psychological and quality-of-life measures, accompanied by changes in inflammatory cytokines and cortisol.
The importance of these findings is not only did patients feel better, but there was evidence of biochemical change, as measured by inflammatory cytokines and cortisol, after adopting CBT and mindfulness-based stress strategies.
So often, what is lacking in research, is the mechanism behind how an intervention causes an effect, in this case a positive effect on patients suffering from Crohn’s.
So why would CBT and mindfulness have a positive effect?
Many patients exist in a state of chronic up regulation of the stress part of the autonomic nervous system. We call this sympathetic up regulation. The autonomic nervous system or the subconscious or automatic nervous system takes up about 90% of the activity of the nervous system and controls many of our internal functions.
There has been some research recently and over the past few years, looking into so-called vagal stimulation devices or techniques. The Vagus nerve is probably the most important verve in the parasympathetic or relaxation part of the nervous system. And this nerve has the main innovation to the gastrointestinal tract.
So what exactly is the Vagus nerve?
It’s also known as the 10th cranial nerve and is the longest mixed cranial nerve and although we think of it as a nerve it’s actually a pair of nerves, which emerge from the left and right side of the medulla oblongata of the brain stem. From there it branches out in multiple directions to the neck and lower down the body. It’s interesting to note that the literal translation of the Vegas nerve is as the “wanderer”, which aptly represents the numerous connections between the cortex. Brainstem, hypothalamus and the body. From an Osteopathic manual therapy perspective working on the neck is much more than improving mechanics! Depending on where and how one works it can influence vagal function.
During the recent few years there’s been a significant shift in our understanding of what we now call the gut brain axis. The Microbiome which is being increasingly recognised as playing an important part in many disease processes, communicates through the Microbiome gut brain access in a bi directional way that involves the autonomic nervous system. So, it’s not just the good and bad bacteria that we all have within our gut that’s important it’s the fact that the autonomic nervous system has a significant impact on this. The Vagus nerve is able to sense the gut Microbiome metabolites through its afferent fibres which make up 80% of the nerve. Then transfers this gut information to the central nervous system, where it gets integrated in the central autonomic network and then generates a response.
A cholinergic anti-inflammatory pathway has been described through the Vagus nerve fibres which is able to dampen peripheral inflammation and to decrease intestinal permeability (leaky gut), and very probably modulating Microbiome composition.
Stress inhibits the Vagus nerve and has a negative effect on the gastrointestinal tract and Microbiome and is often involved in the pathophysiology of many gastrointestinal disorders, including this particular research on Crohn’s disease.
Because the gut Microbiome has such important effects on our immune system one can see how important good autonomic control can have on having a robust immune system.
Another important anti-inflammatory pathway mediated via the vagus nerve, is the hypothalamic pituitary adrenal (HPA) axis which is stimulated by vagal afferent fibres and leads to release of cortisol by the adrenal glands. Cortisol is an interesting hormone as it’s implicated in stress and carbohydrate metabolism (via insulin), but also happens to be an important anti-inflammatory. It’s one of the reasons that synthetic prednisolone (the steroid hormone that mimics cortisol), is often used in many chronic inflammatory conditions including Crohn’s disease.
By the way recent research looking at ways of stimulating the Vagus nerve, include the reduction of TNF alpha a pro inflammatory cytokine in rheumatoid patients and more recently in the British media, a device that targets branches of the Vagus nerve around the ear and its effect on lowering blood pressure. I guess over the coming years we will continue to see an increasing number of research papers backing up interventions to influence the autonomic nervous system, which will be brilliant as it will bring it much more mainstream, hopefully contributing to a reduction in medication that patients are prescribed and the topic of my recent blog last week.
https://www.thehealthequation.co.uk/gps-increase-side-effects-risks-with-a-pill-for-every-ill/
Chronic ongoing stress switches the autonomic nervous system to target the systems that we need in stress usually the heart, the lungs, the muscles and the liver, these are the systems that are needed in the so-called fight and flight response. This is what it is designed to do in fight and flight. However modern life, which often leads to persistent ongoing stress, tends to continue to divert the system away from the necessary functions organised by the parasympathetic nervous system, into chronic stress or “alert”, upregulating the sympathetic or stress part of the nervous system.
Therefore, with many functional problems, including functional problems of the gastrointestinal tract, targeting techniques that down regulate the overactive stress nervous system, leading the patient to relax and supporting the parasympathetic nervous system, will often lead to improvement in gastrointestinal function.
The important bit, is that it’s not about just making the patient feel relaxed, as I suspect relaxation contributes to well-being on so many different levels. But the fact that this research and others points to a change in biochemical markers such as inflammatory cytokines and cortisol, increases our understanding that much more is going on, than just relaxing. This is important because medicine focuses so much on pathology and sometimes can make quite binary decisions in deciding whether a condition is pathological or more functional, where indeed they often coexist and, on a spectrum, sometimes mostly pathological where medication and medical interventions are necessary and sometimes mostly functional, where functional medical approaches such as Osteopathy are probably more appropriate, but a whole crossover in the middle where in my opinion an integrated approach would be much better. If it’s possible to reduce the actual pathology and in the case of Crohn’s disease, decrease the active inflammation going on, this gives us scope to reduce or even stop medication, assuming the functional factors are being addressed.
Incorporated in many relaxing techniques and mindfulness is a degree of breathing behaviour. Whilst this is often thought of as a simple thing to do, in my experience it is not. Many patients have dysfunctional breathing patterns which have been going on for years, generally as a consequence to physical and emotional stress. I tend to measure their breathing pattern via capnometry and measure their autonomic nervous system response via Heart Rate Variability, in particular breathing Heart Wave which measures HRV in relation to breathing patterns. Having a high heart rate variability implies better balance in the autonomic nervous system between the sympathetic and parasympathetic parts. Increasing HRV is often an important part of my treatment interventions and we can do this in numerous ways put an important one is helping the patient adopt a more relaxed breathing pattern.
As well as optimising End Tidal CO2 (ETCO2), the peak C02 measured as we breathe out, this optimises oxygen delivery on a cellular level and helps balance pH, in fact breathing is the thing that has the major effect on pH, compared to any other intervention such as so-called dietary approaches, eg alkalising diets, and as I have said, a significant effect on the autonomic nervous system.
The other important point from a more mechanical perspective, is the movement of the diaphragm the large muscle of breathing at the lower part of a rib cage. Many patients and I really mean many patients, do not really know how to use their diaphragms. They tend to over to recruit the accessory muscles of respiration and use the upper rib cage. This significantly contributes to increasing patterns of soft tissue tension and dysfunction through these structures, which because of those anatomical connections can contribute to autonomic dysregulation. Proper diaphragmatic movement is important for normal gut peristalsis (the mechanism behind which food is moved through the gastrointestinal tract.
One of the principles in Osteopathic medicine is to think about the nerve and blood supply or whatever part of the bod, that we think may not be working properly and this of course can include internal organs such as the viscera.
Whilst much of Osteopathic medicine, as practised in the UK tends to focus on pain management, and Osteopathy is incredibly good at managing acute and chronic pain especially in the musculoskeletal system, the application of the philosophy of Osteopathy can be really helpful in so many conditions, and using research like the focus of this article, helps us understand why this can be the case.
It’s important not to confuse Osteopathy with the application of Osteopathic technique. The interventions that Osteopaths choose, can often be from using a variety of manual treatment approaches but also approaches to relaxation, breathing, stress management, optimising nutrition et cetera. It simply depends on the diagnosis or evaluation of the patient, which is where everything starts from and the understanding from that clinician as to how their interventions can work and how they and the patient would like them to intervene.”
https://www.thehealthequation.co.uk/breathing-therapy-and-techniques/
SAN DIEGO — A combination of cognitive-behavioral therapy and mindfulness meditation could reduce pain and fatigue from Crohn’s disease, researchers say.
Patients who followed the program not only felt better but were also more often able to show up for work and leisure activities, compared with a control group assigned to a wait list, said Shmuel Odes, MD, a professor of internal medicine at Ben-Gurion University of the Negev in Beersheba, Israel. He presented the finding at Digestive Diseases Week (DDW) 2022.
Psychological and social factors affect the gut and vice versa, Odes said. Yet many inflammatory bowel disease clinics overlook psychological interventions.
To address these issues, Odes and colleagues developed cognitive-behavioral– and mindfulness-based stress reduction (COBMINDEX) training, which can be taught by clinical social workers over the Internet. “The patient learns to relax,” Odes told MDedge News. “He learns not to fight his condition.”
In a previous paper, published in the journal Inflammatory Bowel Diseases, Odes and colleagues reported that patients who learned the technique showed improvement on a variety of psychological and quality-of-life measures, accompanied by changes in inflammatory cytokines and cortisol.
In a follow-up analysis presented here, the researchers looked at measures of pain and fatigue and then examined whether these were associated with productivity at work and other daily activities.
The study investigators randomly assigned 72 patients to an intervention group who got COBMINDEX training right away, and another 70 to a control group assigned to a wait list of 12 weeks before they could get the training. At baseline, the two groups were not significantly different in any demographic or clinical variable the researchers could find.
Social workers provided COBMINDEX training for the patients in seven 60-minute session over 12 weeks. Five of the sessions were devoted to cognitive-behavioral therapy and two to mindfulness-based stress reduction. The social workers asked the patients to do exercises at least once a day and report outcomes through an app.
Twelve patients dropped out of the COBMINDEX group and four dropped from the wait-list group because of lack of interest, time constraints, pregnancy, or illness.
The researchers created a composite score with a 0-15 scale (with higher scores indicating greater pain) from three pain items from the Harvey-Bradshaw Index for Crohn’s Disease, the Short Inflammatory Bowel Disease Questionnaire, and the 12-Item Short Form Survey.
To measure fatigue, they used the Functional Assessment of Chronic Illness Therapy-Fatigue, which has a 0-52 scale, with lower scores indicating greater fatigue.
To measure impairment while working and other daily activities, they used the Work Productivity and Activity Impairment Questionnaire: Crohn’s Disease. Scores on this measure are expressed as a percentage, with higher values indicating greater impairment.
Both the COBMINDEX and the wait-list groups improved on all these scales, but the improvements were significantly greater for the COBMINDEX group.
Through statistical analysis, the researchers found that the improvements in pain and fatigue indirectly caused the improvements in work and activity impairment, and that pain and fatigue improvements made independent contributions of similar magnitudes. COBMINDEX did not directly improve work or activity.
Psychological interventions are too often overlooked in Crohn’s disease, said the session comoderator Paul Moayyedi, MD, a professor of gastroenterology at McMaster University in Hamilton, Ont. “We need to realize how important this is to patients and urgently make this available,” he told MDedge.
A variety of interventions are being researched, and this study makes an important contribution, he said. However, he questioned whether people on a wait list can serve as an adequate control. “If you have to wait for something, you tend to have more pain, and you could have less productivity just because of waiting,” he said. “Ideally they should do a randomized trial with a sham intervention, not a wait list.”
Odes responded that it is very difficult to recruit people to a trial if they only have a 50% chance of getting a real treatment. And he noted that the people on the wait list in this trial did not show any signs of increased symptoms.
Physicians wanting to provide psychological help to their Crohn’s disease patients can refer them to social workers or psychotherapists, Odes said, but these professionals may lack training for applying cognitive-behavioral therapy and mindfulness-based stress reduction to patients with Crohn’s disease. His team hopes to make an app publicly available soon.