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Answers, or solutions

An inconsequential year lapses

One would hope to have one’s reflections crystallised following mute introspection but, sorry… yeah nahh.

I went to a church to farewell friends before my Indian sojourn and, whoopsed on the address so arrived at an evangelical Anglican. After cackling yesterday at the puerile and contrived setups in a putdown of revivalist religion, https://www.sbs.com.au/ondemand/movie/salvation-boulevard/2225598531732 *, the unanswered question of just what exactly are we mocking ensured that I sit it out.

Singalongs lacked the depth of fervour in classic hymns, but tunes were easier to hold. The sermon/reflection was lengthy and, though loathe to prolong the repetition of cliches and slogans, I simply had to put my hand up to question a premise. This was problematic, as half the crowd had a palm aloft. A wicked notion to growl out: “In the name of Beelzebub I command thee…” was suppressed, since they’re lovely people – much like my Uncle Ken, servants to humanity. Most troubling was a putdown of other Christian franchises, playing to our tribalism in claiming to have the one true Way.

Affinity to nascent, booming born-agains sits will with ex-PM Morrison and his previous advertising career. Simplify and repeat, in ecstatic mantras, are the new divide and conquer. The lectionary on this day was Jesus’ instruction to Nicodemus that entry to the Kingdom was predicated on being born again. This Pharisee, at the pinnacle of their power, had to firstly be humbled. This is little different from Buddhism’s exhortation to have ‘beginners mind’, Taoism’s Pu or ‘uncarved block’ (from whence came inspiration for Winnie the Pooh), or elsewhere in the gospels eg Matt 18:2-5 teaching to first become childlike.
Start over again! That’s hardly in accord with our instant gratification craving; handover to consultants of complex issues; highly evolved society.
Enlightenment wasn’t meant to be easy, but this pastor stressed his interpretation of being reborn ‘from above’ gave a miraculous shortcut. But one, in accord with advertising fundamentals, had exclusivity. Becoming a chosen one is actually as easy as taking advantage of any ‘limited time special offer’. Walking into a shop with money or showroom prepared to commit has similar simplicity to the contractual acceptance of godly grace through baptism.

Interestingly, there are no contemporaneous reports of Jesus or his miracles, yet John the Baptist does appear in the historical record. The concept of re-living life from a fresh start received attention, and endures. This lesson was fleshed out in the characters of the gospel, and sadly most Christians focus on the personality but paying scant attention to the teachings. Even fortunate Nicodemus, supposedly given exclusive audience, ignored the advice to relinquish his privilege and success – according to theologian Laurence Cantwell [The Quest for the Historical Nicodemus, 1980]. He attempted to leverage his position within the Sanhedrin authority to advocate for Jesus… but of course both players are fictional, allegorical. The reality of their conversation is no less fanciful than the bible’s private prayers of Jesus. The biblical wisdom, which holds up a mirror to humanity, is that nobody wants to forgo any power or influence they’ve achieved. There endeth the lesson.

* Salvation Boulevard was punished at the Us & Canadian box offices, recouping 0.5% of production costs. Needless to say, if Americans failed to find it funny that says more about the audience than the gags.

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Bad Medicine (part 5)

Martin Seligman’s 2018 ‘The Hope Circuit’ is his autobiographical account of the field of Positive Psychology’s (PP) evolution. As a popularly elected President of the American Psychology Ass’n (APA), despite being unpopular with legacy professorial clinicians, his object was usurp of the American Psychiatric Assn’s cornerstone: mental disorders. This other APA manages the Diagnostic & Statistical Manual (DSM), which establishes thresholds of ‘what’s normal’ in behavior and perception. The DSM pigeon-holes us, much like the museum pins taxonomy labels on insects, but PP refutes the idea of correcting faults. Better that we play to strengths, and let the defects be.

Nailed to a diagnosis

The last chapter is his epiphany – in his seventies, he realizes that he’s been wrong all along. His theory of learned helplessness had been proven in the labs – beat an animal down with inescapable suffering, and they’ll lose the will to fight their way out of the predicament. But his colleague Steve Maier turned that upside down. Our vulnerable infants are nurtured through their helplessness, but based upon success against adversity they build a neural circuit, simple neuroplasticity, that gives resilience. I repeat: we learn to thrive from achieving, else feebly succumb and remain dependent for life.

To be fair to Marty, the neuroscience had only recently matured so as to enable Maier & Watkins’ breakthrough. Though the seminal work is a dozen years old, it’ll be awhile yet before its significance drives psychotherapy dinosaurs into extinction. My personal enthusiasm is kindled by Linda Watkins’ other, amazing insight into fibromyalgia, where along with Prof Younger and Adelaide Uni’s Prof Mark Hutchinson this autoimmune disorder was attributed to the brain’s innate defence mechanism – glial response to perceived viral attack* . Sufferers can’t yet take comfort from that breakthrough, there’s more Randomised Control Trials of an anti-viral combo (IMC-1) to be done over many years.

Back to the ‘hope circuit’. By default the brainstem’s DRN produces serotonin, which calms down the ‘fight or flight’ sympathetic nervous system – but also amplifies anxiety driven by the amygdala in the limbic system. I’ll re-word that for emphasis: serotonin treats panic attacks, but worsens fear. One could ponder the backlash of research, through the likes of David Healy’s Rxisk.org, asking why antidepressants that elevate serotonin have side-effects such as increased suicidality. The simple ‘chemical imbalance’ theory has been thrown out awhile ago (don’t get me started as to whether bloods to review serotonin levels in patients should be analysed, before being handed the happy pills on a presumption of necessitating boost via an SSRI), because we’re not machines but rather systems. Tinker with one process and another will compensate. All this isn’t in the pharmaceutical company brochures, though it’s been well-known for two decades. And the growth market is for teenagers, despite halting the formation of circuits required for later resilience.

DRN hijack of emotions is dampened by previous cognitive rewards from the Pre-Frontal Cortex (PFC, the learning brain) using successful control over situations to increase kinase proteins – described as an ‘immunization’. In animal models the dissected brains are tested for a change to successfully build resilience, and in the last few years studies have been designed for humans using fMRI. Do-it-yourself at home is a no-brainer. PP gives all the tools you need to focus on success, and protect your brain: simply do the survey to ascertain strengths, then determine how best to use them. If that fails, then seek professional help… being prescribed an anti-depressant isn’t the worst possible outcome from a trip to the doctor – script for Lyrica holds that ignominy.

The 2009 Stanford study damning Lyrica as blocking formation of new synapses, connections between neurons, has been cited a further 245 times. The most recent further investigation ‘The α2δ-1–NMDA receptor coupling is essential for corticostriatal long-term potentiation and is involved in learning and memory’ describes how gabapentinoids break the hope circuit (nasty biochem, but Lyrica and Neurontin are designed to block α2δ-1 Calcium subchannels, and the PFC pathway to moderate the DRN is via ERK->NMDA Calcium channels. Please don’t ask for an explanation).

This fresh knowledge has no commercial application, PP will never be packaged in a pill (picrotoxin is used in research as an ‘anti-gabapentinoid’ to artificially create PFC->DRN control, but is deadly!). Worse, the accreditation Master of Applied PP is only taught in Australia at Melbourne Uni – where it’s sequestered away in the School of Education, not Health. An inceptual program is underway centred on Heathmont College, which follows Geelong Grammar’s wonderful work. It’s unlikely that the medical industry’s stranglehold on wellbeing will loosen without generational change through these schoolkids achieving professorship. TheMindfulGap was a partnership with my then wife, doing all we could to prepare the way for chronic illness sufferers to escape helplessness. Hopefully someday someone’s children will value those efforts.

Good luck in the meantime, Geoff

 

* So what? Well to measure societal suffering through subscribers to forum PatientsLikeMe.com, where the medically disenfranchised seek answers to their condition, 106 thousand fibromites vastly outnumber Major Depressive Disorders 2:1, or backpain 100:1, or arthritics 4:1. Great research tackles great problems.

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2015 blog cont’d…. Another massive campaign to discredit the authors of the PACE study into three ME/CFS interventions is underway. Over 12,000 signed the first petition to request retraction of supposed claims that some one quarter ‘recovered’ – even though the Lancet paper clearly states potential to just ‘moderately improve outcomes’, specified per the Mayo Clinical Significance Consensus. Another lobbying is underway, so far 6,300 have signed a demand to the GMC regulators that the study doctors be disciplined – suggesting 10 years custodial penalty for the crime of Fraud. The gist of concerns is than consequent to PACE report practitioners have distressed sufferers from ME/CFS with callous disregard. Claim is even made of “… harm done to children being forced to go to school and being subject to child protection plans“. This irrational outburst references the Tymes Trust’s Jane Colby regarding the potential for healthcare authorities to intervene so as to enforce adherence to clinical guidelines after PACE recommendations.

First in GP Sarah Myhill’s complaints beginning on pg 7 of 25 are that PACE “has effectively determined CFS/ME as a psychological condition“. Recall that the interventions detailed in the Lancet article were: Cognitive Based Therapy (CBT) with a psychologist; Graded Exercise Therapy (GET) with a physio; Adaptive Pacing (APT) with an Occupational Therapist (OT); and against a control group receiving standard care from a CFS specialist. CBT and GET were significantly better for fatigue and functioning, while APT was no better than the control/placebo. The authors state clearly: “The effectiveness of behavioural treatments does not imply that the condition is psychological in nature.” Dr Myhill’s 2012 reprimand by GMC and recently concluded cautionary period must be considered in grading her opinions, when the disciplinary ruling declared: “statements in relation to contraception and breast cancer screening that were factually incorrect; clinically unsubstantiated; and contrary to national guidelines. In so doing she used her position as a registered practitioner to exploit patients’ lack of medical knowledge by arousing ill found fears for their health.” Myhill’s website promotes powerlifting as High Intensity Training – but not for ME/CFS, where diet and detox are advised. And vaccinating is discouraged.

Another line of advocacy comes from Tuller, Geraghty, Wilshire et al. The link has a number of articles, including the PACE authors’ refuting of complaints re research quality. More telling is the activist’s collated manuscript ‘Rethinking the treatment of chronic fatigue syndrome’, which begins with an allegation that the Randomised Controlled Trial did not control nuisance variables, such as contact hours. This is alarming. ‘Control’ in this situation means that the intervention was compared with a control group, not their idea that control be applied so as to enforce participant compliance. The scientific complaints differ over time, but this paper zeroes in on statistical analysis in that the published protocol considers every possible comparison between therapies, and the Bonferroni principle requires stronger levels of proof ie the more permutations (ie 6 pairwise comparisons), the greater likelihood of a random fluke (odds of 1 in 125 actually) supporting the hypothesis of a therapy being better than the control ie standard care. The pairwise tests were a change to the stats plan, by dropping consideration of combo-therapy eg is APT and GET better than GET alone etc….explained as being overly convoluted.

Access to raw data was achieved by activist’s FoI request. Looking at their re-analysis of supplied data in Table1, people improved most under two therapies. No argument. The control group also did over time, where a placebo or Hawthorne effect can result from the satisfaction of working with supportive professionals towards a solution.

To the impartial eye, CBT and GET worked ‘better’

 

 

Expert opinions and agendas at play

Independent commentators are worth noting: OT Bronnie Thompson admires the study, but is concerned that their APT protocol failed to set goals to work towards. Their envelope of maximal activity was fixed within a ‘disabled identity’ focused on what COULDN’T be achieved, a problem noticed by Prof Leonard Jason. His Energy Envelope Theory relies upon success in avoiding crashes being inducement to better achievements in future. This is similar to Feldenkrais practice, progressing away from fear of movement through progressive challenges. Medical journalist Dr Norman Swan discusses the unprecedented outrage in the patient community with a study author and journal editor, but only considers the absence of harm during the trial (1% of all treatment arms reported worsening conditions). They suggest that activists hijacking the CFS community does them harm, without stopping to think about why there is even an outcry and whether their GPs are at fault.

It is obvious that distress results from unsympathetic doctors who’ve simplified the study conclusion as “get active, get counseling, and get out of my practice“. Indeed, practitioners proudly state conviction in their ability to discern CFS patient agendas. “I often use it as a diagnostic tool for MUPS (Medically Unexplained Physical Symptoms), that I get irritated by patients.” A vulnerable population then becomes prey to peddlers of solutions that are accompanied by rather more sympathetic caring. At a patient forum Dr Daniel Lewis agreed with Tuller’s complaint that the participant inclusion criteria of ‘Oxford Research’, rather than ‘Canadian Consensus’, was the problem. They weren’t suffering real ME/CFS, whatever that is. He sells meditation courses targeting chronic fatigue or pain in general however, without quibbling about specific diagnoses in attendees. Likewise a clinician’s summit unanimously supported their client’s grievances against PACE conclusions being given as guidance to doctors.

Personal injury specialist legal firm Maurice Blackburn sponsors Australia’s Emerge ME/CFS foundation, and seeks litigants who’ve been refused disability payment. They also advertise on SBS TV, who have requested patient’s stories for a program. CFS guru Dr Jacob Teitelbaum initially took a rational stance that PACE results were being misinterpreted in the media, but five years later joined the herd by stating in his blog: “… the PACE trial that wrongly concluded that CFS patients should be treated with psychotherapy.” Other experts such as Jose Montoya just focus on their research.

The study team took the controversy onboard, replying with rational argument to editorial letters. It then seemed that the time was ripe to shoot themselves in the foot. Perhaps the declared conflicted interest of team member’s consulting to insurance companies, presumably over disability payouts, made the Lancet article just a testing of the waters. Another writeup appeared, declaring ‘Recovery is possible!’ much as Chamberlain did in saying “Peace in our time”. And war broke out.

This wasn’t the only investigation into exercise as therapy for CFS. Last year’s update to the meta-analysis of 7 trials affirmed the results, every one of them showing benefit for reported Fatigue. But once again, researchers do themselves no favours with clinicians or patients: the publishing/editorial group is Cochrane’s ‘Common Mental Disorders’ .

My thoughts

CFS is an unmet challenge to medicine. There’s no fix, only symptom relief. LowDose Naltrexone relieves the brain fog (presumed to result from glial inflammatory response), beta-blockers may be used against POTS in orthostatic intolerance (light-headedness upon arising), and supplements such as CoQ10 or D-Ribose aid mitochondrial energy production. Post-exertional malaise is a constant however, which reinforces the lost sense of identity that was once based upon our function. Patient experience is of an invariant, and lifelong struggle. For anyone else we experience affliction as mostly transitory, even chronic illness can go into remission upon treatment. They who experience anxiety attacks, also know there’s moments of achievement. Joy counters sadness, emotions rise and fall again. It is possible to mentally step back and observe thoughts and sensations that may come and go, without attaching identity or sense of self to such temporary states. This is infinitely harder when the disease is so poorly understood.

CBT and GET offer slight improvement, a readiness for future solutions rather than idling whilst deconditioning – where practitioner’s pushing of anti-depressant meds worsens weight gain. Meanwhile however, you’re powerless prey to commercialism.

Right of Reply & Disclosure

Dr Lewis’ office has never replied to my correspondence. SBS passed a message on to their producer. David Tuller wrote back that the trial authors assumption of the CFS sufferer’s [de]reconditioning biased their choice of interventions offered, which is fair comment. If only there were better answers to this perplexing problem.

I’m married to a MUPS, and like others I know well, am struck by their hitherto overachieving.

 

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Are you a morning person?

Series 7 episode 1 of Michael Mosley’s BBC program ‘Trust Me, I’m a Doctor’ featured a study comparing gardening against yoga against mindful meditation in beating stress. The outcome was an objective measure – salivary cortisol, for which the latter activity outscored all others. 😮 Wow! But sadly, this trial hasn’t ever been written up for publication, and furthermore the premise of showing increased cortisol awakening response (CAR)  as indicative of de-stressing  is counter to the evidence. Trust me, I’m a skeptic.

Dr Mosley as coach for the Rat Race

From the beginning. Cortisol is a restorative hormone – the benefits of the synthetic corticoid, prednisolone, in suppressing auto-immune response are well understood. In evolutionary terms it’s a clever output from an activated fight/flight HPA axis, halting anti-inflammatory effects so as to concentrate energy and strength. Focus on survival, consequences be damned. It shows a strong peak half an hour into the morning, the CAR, as we prepare to take on the world. It’s so consistent, that it’s been analysed for decades. The CAR peak is flattened when in pain, or fatigued – that makes sense. “Think I’ll sit this battle out, Genghis  – tell the truth, I’m pretty knackered“. But there’s half a dozen studies showing that CAR is boosted in stressful circumstances, such as angrier teachers preparing for work or ‘Perceived work overload and chronic worrying predict weekend-weekday differences in the cortisol awakening response‘.

The Mosley program had results consistent with another, scientifically rigorous trial of yoga. The CAR peak indeed up-regulates after gentle ‘Yoga as Awareness’ classes, just as it does when making ready for battle. Though counter-intuitive, this is the lesson. Meditation isn’t just avoidance, a cozy retreating into a safe place. It’s a pep talk for the body, giving gratitude for past valour, ready for a call of “Once more unto the breech, good friends” (Henry V). A similar increase in morning cortisol resulted from an 8-week Mindfulness program delivered to military helicopter pilots – complementing and enhancing their readiness for a stressful workday.

Humans are not deterministic – the feedback mechanisms are a workaround to any change. To take a pill, or supplement, on the simplistic basis that it has a directly measurable effect shown in clinical studies overlooks the complexity of the body systems that maintain our balance (homeostasis). Mindful meditation and stress both alter CAR in identical ways, yet have opposite effects on your wellbeing. To navigate the contradictory claims there’s only one answer – treat mind&body holistically. Integrative Medicine practitioners are being supplanted by accredited wellness coaches, providing lifestyle counsel but without reliance on a script pad. America’s healthcare travails have fostered two dozen accredited university courses, and the same from private suppliers, for Health & Wellness Coaching. theMindfulGap.com.au is also servicing this need.

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The influx of Chinese to the Californian goldfields brought with them homegrown remedies for the pain and inflammation of their labour. So impressive was the effectiveness of their snake-oil, that an entrepreneur also made extracts from the local rattlesnakes. It was ineffectual, and sales events were followed by the salesman’s hasty exit. But Chinese water-snake’s oil is 20% EPA – more than that from our preferred source of omega-3, salmon. It’s vital for the species in the cold conditions, whereas the rattlesnake’s blood has no issue with glugging up in the desert.

Why the history lesson?

It’s because Harvard Med School has just blogged that fish-oil supplements are worthless as preventatives. This surprised me, since my BP reduces markedly on the minimal dosage of 2000mg fish oil, twice that obtained from an ACE inhibitor. Sure, that’s just a surrogate outcome and not reflective of survival into senility. So is the research from American Heart Association to be trusted? Our Heart Foundation’s never untangled themselves from industry ties, so….

The detailed article needs to be read from bottom to top, starting with declarations of conflicted-interest. Dariush Mozaffarian has received no grants or support from industry? That’s not what Mozza’s CV says on pg8&10: $83k from Pfizer to trial Lipitor in ’02, and $5.1m from GSK & SigmaTau pharmaceutical companies to trial fish oil on cardiac patients. His collaborator on that one, Jason Wu also forgot to disclose same in the article. He’s done a lot of work with the George Institute, a partner in the Australian public’s generously sponsoring of a $5m NHMRC trial of Lipitor. Pfizer and SigmaTau also ran a 5 year trial of omega-3 supplements on twelve and a half thousand elderly patients having cardiovascular risk factors, finding no advantage conferred to survival rates. That’s a big study, and pretty generous of Pfarma.

You have to wonder: why do we pay to study Pfarma’s meds, and they pay to study the competition?

The Harvard expert Eric Rimm’s quoted in their blog: “Taking fish oil… may not only have no benefit, it may even have some risks that we don’t realize because we haven’t studied them.” And they’re the ones dismissing complementary medicine for its supposed lack of evidence base to claimed benefits! Dr Rimm’s Pfizer-sponsored study on erectile dysfunction is a rerun of the  Heart Foundation’s apologists Grenfell and Banks advisories to take Pfizer’s infamous blue pills OR DIE. Despite this geek’s degree being Computer Sc, he’s pulled $400k to study floppys, and is now a Professor of Medicine.

In the movie ‘Dope’, drug-hustling Malcolm is fixated on Harvard. For the easy money?

It’s ironic to think that better treatments were available in the Wild West, and those cowboys had no problems with shooting their gun.

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We’re all crazy now

PRO-logue. It’s telling that an identical German study to PRO-HEART was shutdown early. Comments by psychiatrist Andreas Ströhle and Nina Rieckmann from their Institute of Public Health : “Dr Angermann and colleagues reported that escitalopram did not reduce all-cause death or hospitalization… It is not clear why the authors expected that it would, as it does not reduce mild to moderate levels of depression… Rather, it adds to the mounting evidence that questions the risk-benefit ratio of prescribing antidepressants to patients with less than severe depression.”

Once upon a time, psychs drew a distinction between depression originating from within (endogenous) or that which arose due to circumstances (reactive). The former was treated by meds, but the market for anti-depressants has grown as the two-type concept has fallen out of favour. Pills manipulating neurotransmitter levels are a simple solution with scrip from your GP, one that doesn’t require psych expertise. The American Psychiatric Association aren’t blameless, since the criteria for mental illnesses is loosened with every release of the DSM. That manual has also expanded in order to inform practitioners of the complexity of the complex. But they have lost control in this non-infectious pandemic. Prof Peter Gotzsche is fanatical in advocating that prescriptions of such meds be reduced 50-fold, but for a less emotive perspective I suggest you follow psychiatrist Professor David Healy, or read his ‘Pharmageddon’.

Followon book to 'Deadly Medicines and Organised Crime'

Followon book to ‘Deadly Medicines and Organised Crime’

Earlier posts have complained at the fabricated conclusion that chronic pain is  manifestation of a mental illness. It was a researcher’s invented report that then conveniently led into a publicly funded trial for anti-depressants in osteoarthritis. It’s to the Royal Aust & NZ College of Psychiatry’s credit that their submission  against Medicine Aust code-of-misconduct application to regulatory authority ACCC was the only one to address perversion of research by industry. If they’re to be believed, academics are corrupted. And if Gotzsche is right, you can’t trust Patient Organisations for … “having done absolutely nothing to stop the blatant abuse of patients in industry-sponsored trials“, citing Dr Ben Goldacre’s book ‘Bad Pharma’ of 2012. It’s worse than that, as you’ll find out.

Heart Foundation Vic CEO Jennifer Johns has earlier come in for ridicule over statins, echoing her disgraced NSW President’s associations with the refined sugar industry. An Austin hospital cardiologist, in 2010 she funded her colleague David Hare and Baker IDI’s Prof Krum to trial  Lexapro as treatment for the depression that their heart failure patients are presumed to suffer, PRO-HEART. Also in this year the manufacturer’s promotion of such off-label usage cost them $USD313m in fines, with civil actions continuing. Such as 03-10395-NMG for wrongful dismissal of sales rep and whistleblower Chris Gobble, who complained to supervisors of “illegal kickbacks (i.e. paying doctors for no other reason than to induce them to prescribe Celexa and Lexapro)”. The marketing budget disclosed in the Confidential plan provided to the US Senate was $35m on speakers fees, and $36m on lunches. In one year. In one country.

The drug is also associated with hyponatremia, ie it worsens heart failure risk. None of the team answered this concern, but they were defended by the Heart Foundation’s Deidre Cope: “In regard to its Research Program, the Heart Foundation follows the NHMRC guidelines around disclosure of interest. The research funded by the Heart Foundation undergoes a rigorous peer review process involving assessment by independent, external reviewers. All funding decisions are scrutinised by an external committee to ensure that all aspects of the peer review process are consistent, transparent and ethical.” Affirming that they’re just as utterly corrupt as the NHMRC, as evidenced by Cicuttini and Wluka’s impunity.

The other half of the $820,000 raised by door-knockers and tin-shakers that PRO-HEART is costing was from Beyond Blue. No responses to approaches were provided at all. It’s too early to allege misconduct – the trial is running three years behind schedule, and a staffer thought late 2017 would see a report released. But it already stinks like something’s died. [Sep 2017 update: 2018 perhaps? BB CEO Georgie Harman states that she’s happy with the study progress – seven years after the first patient was enrolled in the 6month study]

There’s often a trite closing disclaimer in articles that if you suffer from depression, there’s phone support available at these numbers…… who’ll suggest medical advice. I’m more of the opinion that you think carefully, so have linked further material on happiness or absence thereof at http://themindfulgap.com.au/2016/02/05/the-blue-bird-and-the-black-dog/

 

 

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This hipster showed us infinitely cool back in 1848, which is totally 0K 😉

Science geek jokes aside *, learning has three aspects. The tuition, the practise, and the assessment. Measurement is not simply to verify competence, but it’s vital to correcting and enhancing understanding.

hipsterMetrics
Athletes seeking peak performance are being joined by all and sundry seeking motivation for exercise, in usage of metrics. Simple weight and repetitions, or distance and times logged, or biometrics such as heart rate (to keep inside a safe envelope of effort). Recently heartrate variability (HRV) sensing has been adopted to inform the decision of whether to train today. Or sleep in. To explain: fight & flight is from the sympathetic nervous system causing endocrine outputs such as adrenalin (epinephrine). It’s a survival response arising in the reptilian depths of our brain, around 6 times faster than rational thought process in the cortex. DON’T STEP ON THAT SNAKE ………………………………………………… no, wait up – it’s just a stick. Heightened arousal has already set off neuroransmitter and hormone cascades however. Chemical affect upon the heart ticker has a delay in effecting increase, which means that the beat-to-beat changes are subtle but steady. Rest & digest parasympathetic ying balances autonomic control of yang‘s panic, and is entirely effected by the vagus nerve. This electrical moderation of rate took time to formulate, but works near instantaneously. This means that beat-beat (R-R, or NN) intervals change markedly. Reporting on R-R through an HRV check is being suggested by coaches, to ensure the exercise activities are undertaken with the right mindset, mindfully.

HRV training uses biofeedback to display this measure of autonomic balance (or Vagal tone) in realtime, and seeks to amplify your increases in rate with the in-breath – a natural observation known as Respiratory Sinus Arrhythmia. Gevirtz and Lehrer provide many journal articles and video explanations, and a few months ago ‘Treating the mind to improve the heart‘ appeared in Frontiers in Psychology journal announcing studies underway at a US Veteran’s Affairs medical centre. The simplicity of the measure means it’s already quantified, thus a useful assessment. Neurofeedback training adds a level of complexity, by selecting EEG leads on the scalp to quantify, and visually report focus in regions of the brain responsible for control – such as sensorimotor for chronic pain. The history of training by reward for helpful brainwaves goes back to Sherman’s meditating cats in ’65. This is the second aspect, a practise.

Finally, the didactic beginning: tuition. Educational courses in mindfulness abound, this is a no-brainer!

Practicalities. HRV is supported by many cheststraps which very accurately measure the electrical R-R interval, and upload this to smartphone apps capable of Bluetooth LE e.g. Polar H7 and Zephyr HxM. Rather than BLE, Garmin uses Ant+ wireless as does 60Beat – SweetBeat for iOS interfaces on both these protocols. iThlete have a simple sensor to detect blood pulsing in the finger,  in a medical rather than sports context and this has been validated against the gold standard of ECG as a tool for developing countries.

* Zero degrees Kelvin (0°K) is very cold – the theoretical absolute minimum.

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The butterfly emblem is frequently chosen by carefree souls, which suits my care-less persona also! My attention has flitted to continued controversy over two chronic pain studies – PACE for chronic fatigue, and Auckland University’s Stroke and Applied Neurosciences report: ‘Daytime napping associated with increased symptom severity in fibromyalgia syndrome’. Blogs and commentaries frequently generate traffic by highlighting controversy (but not mine, of course). Digging out the truth is easier by discarding any opinionated article which doesn’t link the original study for scrutiny, since both were published in open publicly accessible forums. If it matters, it’s usually in PublicLibraryofScience or the like. If hidden behind the commercial barrier of a medical journal, then it was probably just an extension of Pfarma’s marketing (if the statement by past editor of the unimpeachable British Medical Journal is to be believed). The late, great Dr Dave Sackett tickled my humours with his Clinical Trial Organisation HARLOT (How to Achieve positive Results without actually Lying to Overcome the Truth).

Linked study PACE was of very high quality. UK govt sponsored and large enough to be powerfully conclusive, it randomised sufferers from chronic fatigue into four arms:- standard medical care alone, or in combination with either of Cognitive-Based Therapy (CBT), Graded Exercise Therapy (GET), or Adaptive Pacing Therapy (APT). The outcome published in The Lancet in 2011 showed improvements in fatigue and physical functioning scores for CBT and GET, but not APT. An outraged patient community expressed alarm that doctors would prescribe exercise to reverse lack of physical condition resulting from illness. A planned followup investigation this year re-ignited the furore, explaining that CBT and GET mediate changed belief and citing a Belgian study “…the role of beliefs in chronic fatigue syndrome and fibromyalgia, which suggested that fear and avoidance of movement were associated with poorer outcomes.” Criticisms include the PACE protocol’s broad inclusion criteria, that their participant’s syndrome wasn’t real CFS are quite ironic given the difficulties experienced by anyone seeking validation for their own sero-negative invisible illness. Emotive catastrophisation reflects the shame felt at being stricken to bed – when the reality uncovered by another Belgian team is that CFS suffferers were hitherto over-achievers. This study isn’t published for the public, but I’m grateful for someone breaching Elsevier© copyright. It also seems free from bias.

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All the evidence is clearly presented in the links, so I won’t insult by advising what you ought to think of it all. Complaints will have to be made to the 640 who presented their results. However, the failure of APT bears editorialising. It was a program delivered by experienced Occupational Therapists per PaceTrial.org published manuals . APT wisely directs diarising of activity and subsequent post-exertional malaise to establish baselines of safe achievement, thus the salient lesson of ‘you play, you pay’ is documented in order to inform self-management. Advice is given on the need to inform work, family or friends on limited capacity to give of oneself. Diaphragm breathing exercises are explained with the importance of control over fight/flight responses. How could this not improve wellbeing? The answer awaits further analysis, but clearly deficient is any strategy for activity which may increase the envelope of energy. The therapist manual requires joint devising with the client of goals and aims  in CBT and GET only, and instructs not to motivate for an improvement in function in APT. Emphasis on self-compassion  without guidance for rehabilitation will leave patients stuck where they are. Mindfulness of the condition without movement to actively re-engage with the world, is analogous to theory without the practical. <continues Mar 2018>

Onto psychologist Alice Theadom and her survey. The implication is of causality between resting up and worsening symptoms, under the heading of Results: “Daytime napping was significantly associated with increased pain, depression, anxiety, fatigue, memory difficulties and sleep problems.” Worsened relationship with one’s boss too, I’d reckon. If the order of words was changed, one would presume that fibromites suffering worsened symptoms take more naps. But in each presentation of facts uncovered, the order is naps -> bad outcome. Briefly consider the impact to sleep, and the difference reported by nappers being an average of 17 minutes less each night. Mmm ‘kay. When strong pain hits, hit the couch and make up for that lost quarter hour. Incidentally, table 4 shows that the use of opioids is as strong a predictor of likelihood to nap as is gender. That one’s overlooked in the text, and close behind come gabapentin and pregabalin for sending you to sleep.

mackey

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How to Breathe

The mindfulness teachings of Jon Kabat-Zinn in his book ‘Full Catastrophe Living’ aren’t new. Among palliative counselor Stephen Levine’s books is ‘A Year To Live’, wherein he advises living each day as if it’s your last. If it’s not too late to learn to breathe for the dying (drawing upon his work with Elizabeth Kübler-Ross), then offering to the healthy a soft-belly breathing meditation is all the more valuable. This idea recognises that grief, and tension are held in a guarded, rigid stomach. A simple check is to place a hand on your belly, and the other on the lower half of your chest. Looking down, inhale deeply through your nose. If the hands move apart, you’re a stomach breather … and the studies show, probably male.

chest-pain-fig1

Our two choices for getting air in are rarely explained, but the implications of a tight tummy are that the diaphragm muscle can’t flatten down. This means a chest heave is required, to expand the lung cavity by lifting the ribs outwards. These muscles work against the cartilage joining the ribs to your sternum, flexing that which has become harder with aging. Voice teacher and opera singer Dominique Oyston suggests that women generally conform to societal expectations of first, a flat tummy, and second, having a petite voice that’s raised in pitch. This means pinching off your breath, instead of letting your voice boom out from deeper down (which scares off men who’re insecure about their masculinity!).

The acute pain of early stages of childbirth is countered by conscious, patterned breathing in antenatal classes. A clinical trial for those suffering the archetypal pain caused by fibromyalgia (Zautra and Davis et al) reported in Pain 2010 that slower, deeper breathing reduced pain intensity due to external stimuli, suggesting in explanation an enhanced parasympathetic nervous system tone – overcoming fight/flight of the sympathetic response.

Much like medicating is not just a matter of forcing up hormone or neurotransmitter level, better breathing is not a simple matter of getting more oxygen through to tissues. A trial of 40 sessions in a diver’s hyperbaric chamber to allow normally toxic 100% oxygen delivery as treatment for fibromyalgia used SPECT imaging to determine areas of the brain where activity was changed by the therapy. The magenta section is the Anterior Cingulate cortex (ACC), previously showing less activity than is considered normal, had become enhanced after the 8 week course. This is the area where emotions lead to regulation of heartrate and registering pain (the greatest improvement was in the Brodmann Area 24, for those into neural mapping). The authors concluded the therapy induced neuroplasticity, proposing the effect as due to suppressed glial auto-immune response reducing neuroinflammation. The oxygen overdose’s reasoning can be described as triggering anti-oxidant pathways.

image002 - CopyDelivered by way of a more practical channel, EEGs after an 8 week Breathworks mindfulness course showed changes in the same ACC as pictured in the inset, increasing activity before administration of a painful stimuli. The ability to prepare oneself for suffering isn’t an easy skill to grasp. The course’s first task focuses meditation on a single point, observing one’s breathing.This interoception of bodily sensation is processed by spindle neurons, a type restricted to only two brain regions – the cognitive-emotional area of the insular cortex and the ACC. Lessons progress onto body scans, creating patterns associating feelings and senses, so as to effect mindful recollection for self-control (as discussed previously).

Handling pain better doesn’t make the pain go, straight away. However these regions interface to the endocrine system, and the hypothalamus-pituitary-adrenal (HPA axis) glands release old friends adrenalin, cortisol, and immune system regulator prolactin. If big changes need to be made, it’s best to start at the top – instead of swallowing chemicals in the hope of a quicker fix.

Soften the belly to receive the breath, to receive sensation, to experience life in the body,

Soften the muscles that have held the fear for so long. (Levine, 1997)

 

6

The smarter way to a 6-pack

Working the obliquus muscles by crunching won’t help back strength anyway. For more, read http://www.yogajournal.com/article/practice-section/forget-six-pack-abs/

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Previous blog postings on mindful meditation had focused on the science, but the complexities of innate immunity and autonomic response may be so overwhelming that the wise approach would be to simply try for yourself.  On the other hand, eastern spirituality provides explanations of health benefits which are heavily laden with Sanskrit language – probably equally offputting. A key learning is the concept of impermanence, the notion that All Things Must Pass (borrowing from Timothy Leary’s LSD inspired interpretation of Tao philosophy). Change, as an all-encompassing and irresistible force, and often unwelcome predicament creates a sense of loss if it won’t pass. The difficulty is managing the change, in order to avoid a worsening due to remorse or seeking of retribution. The Buddha wrote of the second arrow of anguish compounding the suffering of pain. The business world relies upon change as a path to growth, so has embraced mindfulness as a management of the inevitable. Individuals however, too often associate Buddhist notions such as impermanence with religious dogma rather than a philosophic understanding.

A middle way, between medical science and faithful belief is to be desired. At an International Yoga Day gathering, surgeon Ranjit Rao promoted “the higher echelons of Yoga, culminating into meditation. The ability to bring the sympathetic nervous system under control by reducing adrenal hormones is a great boon…”, and anyone who practices sufficient self-control to write a blog every single day on holistic approaches has my respect immediately*. Professor Jayashri Kulkarni, President-elect of the International Association of Women’s Mental Health said that “Finding individual mental peace through the practices of yoga and mindfulness can restore balance in physical and mental health“. Many other bridges can be found, and I found works from Arogyadhama to be eye-opening.  But there’s one language which crosses all cultures.$worship

Money speaks most persuasively throughout history, dwarfing the thousands of years that Ayurvedic therapies have been evolving. Researchers from the UK’s Bangor University reviewed the health economic justifications and issues in the medical journal of Mindfulness this year. The obvious bonus arising from a group session as compared with personal psychotherapy is a monetary one, due to economies of scale. The quandary arises in testing the benefit of a public health initiative delivered to groups of participants, whereas testing the efficacy of an  intervention has always focused on an individual’s complaint. Cost-effectiveness reports for health funding are typically consequent to successful trials of a therapy conducted under rigorous research protocols such as blinding of assessors. For a medication, this is easy – commitment to take a pill bears no burden. But to undertake 8 weeks of intense  focus requires a degree of commitment from a patient who’d presume the therapy to have merit, and thus reported outcomes may be biased.

Even more complex is compliance with medicine’s gold standard test – the Randomised Control Trial (RCT). The control or comparator group is either standard care or a placebo/sham treatment, but neither conform to our requirements. There is unfortunately no standard in care for fibromites (just as well for courts workload, else judging from social media narratives then 100% of their time would be booked by medical malpractice litigants for whom nothing is being done!), although consensus opinion endorses a multi-disciplinary approach.  And duping the controls with a fake course of unhelpful training is a nonsense too. A Cochrane review in April evaluating RCT attempts for mind and body therapies reports a standardised mean difference in Quality of Life score of 0.43 for psychotherapy, and a corrected figure for Mindfulness Based Stress Reduction (MBSR) of 0.39 (corresponding to an improvement of 9.5  points on a scale of 100). Another previous meta-analysis on MBSR for fibromyalgia by Lauche & Schmidt et al calculated score of 0.35 for QoL is very much in accord.  These results are significant, but insufficient.

One avenue for better results is the means of delivery – an individual therapy session vs group. Jon Kabat-Zinn’s MBSR launch a quarter of a century ago with publication of ‘Full Catastrophe Living’ has been adapted in this manner as Mindfulness Based Cognitive Therapy. Doctors reporting good results such as Craig Hassed, or Unlearn Your Pain’s Howard Schubiner may have benefitted from their clinical credibility when transforming client thinking. The timescale for achieving results also deserves further study – yogis put in years to attain insight, whereas a pharmacy can plaster over problems in a quick transaction. Understanding progress through diaries is to be encouraged, and biofeedback also holds promise. This could be respiratory testing (breathing.com offers some simple tools) or heartrate monitoring in order to understand autonomic nervous system balance between fight&flight and rest&digest. Your opinions and experiences are sought, as this solution continues to evolve.

* Admirable achievement even before considering he also authored ‘Meditation and Martini: the subtle cocktail of balance’

 

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