Exploring the relationship between disease-related pain and cortisol levels in women with osteoarthritis

Autonomic nervous system and endocrine system response to upper or lower cervical spine mobilization in males with persistent post-concussion symptoms: a proof-of-concept trial

INTRODUCTION

The peripheral stress response, consisting of the autonomic nervous system (ANS) and hypothalamic pituitary adrenal-axis (HPA-axis), functions to maintain homeostasis in response to stressors. Cervical spine manual therapy has been shown to differentially modulate the stress response in healthy populations. No study has investigated whether cervical spine mobilizations can differentially modulate the stress response in individuals with persistent post-concussion symptoms (PPCS), a population characterized by a dysfunctional stress response.

METHODS

A randomized, controlled, parallel design trial was performed to investigate whether upper or lower cervical spine mobilization can differentially modulate components of the stress response in individuals with PPCS. The outcomes were salivary cortisol (sCOR) concentration (primary) and the HRV metric, rMSSD, measured with a smartphone application (secondary). Nineteen males diagnosed with PPCS, aged 19-35, were included. Participants were randomly assigned into either intervention group, upper (n = 10) or lower (n = 9) cervical spine mobilization. Each outcome was collected at different time points, pre- and post-intervention. Statistical analyses were performed using the Friedman's Two-Way ANOVA, Mann-Whitney U test, and Wilcoxon Signed Rank Test.

RESULTS

There was a statistically significant within-group reduction in sCOR concentration 30 minutes following lower cervical spine mobilizations and statistically significant within-group increase in rMSSD 30 minutes following upper cervical spine mobilizations.

CONCLUSION

The results of this trial provide preliminary evidence for cervical spine mobilizations to differentially modulate components of the stress response at specific time points. Understanding the mechanisms of the effect of cervical spine mobilizations on the stress response provides a novel rationale for selecting cervical spine mobilizations to rehabilitate individuals with PPCS.

Balneotherapy and cortisol levels: an updated systematic review and meta-analysis

The main objective of this review is to examine the impact of balneotherapy on serum and salivary cortisol concentrations. A systematic search was conducted in PubMed, Scopus, Web of Science, PEDro, and Google Scholar. The databases were screened from inception up until April 2024. After screening the scientific literature, 845 articles were retrieved and 17 studies, involving a total of 765 participants, were eventually included in the review. Among them, four were randomized controlled trials, five were non-randomized studies, and eight were pre-post studies with no control group. The evidence gathered in this review indicates a significant short-term reduction in cortisol levels in healthy individuals undergoing balneotherapy, particularly those experiencing high levels of stress. Conversely, in patients with rheumatic conditions (especially if elderly), increases in cortisol levels induced by balneotherapy can act as beneficial hormetic stress, reducing inflammatory mediators and improving pain and functional quality of life. The meta-analysis shows an overall trend of reduction in stress hormone levels, more pronounced in the intervention group undergoing mud-balneotherapy compared to the control group, a finding that, however, does not reach statistical significance (g=-0.11 [95% CI: -0.30; 0.08]; p > 0.05). Current scientific evidence demonstrates that balneotherapy has a positive impact on the regulation of cortisol levels. The regulation of the hypothalamic-pituitary-adrenal axis and the beneficial effects observed on health parameters and quality of life allow mud-balneotherapy to be classified as eustressful stimuli useful in preventing stress-related pathologies in healthy individuals and in alleviating symptoms in patients with chronic conditions. Future research on the topic is advised.

Examining Reactivity and Recovery Patterns of Pain-Evoked Cortisol and Alpha-Amylase Trajectories: Relations Between Psychological Markers of Risk and Resilience

Chronic low back pain (cLBP) is one of the leading causes of disability globally and represents an enormous burden to aging adults. While numerous factors contribute to cLBP, dysregulation in the hypothalamic-pituitary-adrenal axis and autonomic nervous system functioning have been implicated in its pathogenesis. It is well documented that negative psychological states can modulate biological stress responsivity in chronic pain; however, little is known regarding the influence of positive psychological factors in this relationship. The aim of this study was to examine the association between psychological risk and resilience factors with patterns of physiological stress reactivity and recovery in 60 older adults with cLBP. Participants completed measures of hope, optimism, pain catastrophizing, and perceived stress, and underwent psychophysical pain testing assessing responses to painful pressure, heat, and cold stimuli. Salivary samples were obtained prior to pain induction and at 7 time points spanning 90 minutes after pain testing terminated. To examine reactivity and recovery profiles in hypothalamic-pituitary-adrenal axis and autonomic nervous system function, samples were assayed for cortisol and alpha-amylase, respectively. Results revealed higher levels of hope and optimism were associated with increased cortisol reactivity (p's < .003) and more rapid recovery (p's = .001). Further, pain catastrophizing and perceived stress were associated with cortisol reactivity, with lower levels of these factors predicting larger increases in cortisol from baseline to peak levels (p's < .04). No significant differences in reactivity or recovery patterns emerged for alpha-amylase. Overall, findings highlight the role of psychological risk and resilience factors in modulating physiological stress reactivity. PERSPECTIVE: This article investigated whether psychosocial risk and resilience factors were associated with stress reactivity and recovery in response to laboratory-based pain testing in older adults with chronic low back pain. Results indicate that high resilience factors may be protective by modulating adrenocortical reactivity and recovery profiles.

Autonomic nervous system and endocrine system response to upper and lower cervical spine mobilization in healthy male adults: a randomized crossover trial

BACKGROUND

Cervical spine mobilizations may differentially modulate both components of the stress response, consisting of the autonomic nervous system and hypothalamic pituitary adrenal-axis, depending on whether the target location is the upper or lower cervical spine. To date, no study has investigated this.

METHODS

A randomized, crossover trial investigated the effects of upper versus lower cervical mobilization on both components of the stress response simultaneously. The primary outcome was salivary cortisol (sCOR) concentration. The secondary outcome was heart rate variability measured with a smartphone application. Twenty healthy males, aged 21-35, were included. Participants were randomly assigned to block-AB (upper then lower cervical mobilization, n = 10) or block-BA (lower than upper cervical mobilization, n = 10), separated by a one-week washout period. All interventions were performed in the same room (University clinic) under controlled conditions. Statistical analyses were performed with a Friedman's Two-Way ANOVA and Wilcoxon Signed Rank Test.

RESULTS

Within groups, sCOR concentration reduced thirty-minutes following lower cervical mobilization (p = 0.049). Between groups, sCOR concentration was different at thirty-minutes following the intervention (p = 0.018).

CONCLUSION

There was a statistically significant reduction in sCOR concentration following lower cervical spine mobilization, and between-group difference, 30 min following the intervention. This indicates that mobilizations applied to separate target locations within the cervical spine can differentially modulate the stress response.

Associations Among Knee Osteoarthritis Severity, Body Mass Index, and Physical Functions in Saudi Arabian Adults: A Multi-Center Cross-Sectional Study

Background The purpose of this study was to investigate the associations among knee osteoarthritis severity, body mass index, and physical functions in Saudi Arabian adults. Methodology In this multi-center, cross-sectional study, we performed a secondary data analysis that included 189 adults aged 55 years or above with doctor-diagnosed knee osteoarthritis enrolled in five hospitals in Riyadh, Saudi Arabia, between March 2016 and March 2017. According to knee osteoarthritis severity, all of the individuals were divided into the following three groups: mild (n = 36), moderate (n = 75), and severe (n = 78). A high body mass index was defined as a body mass index score of >25 kg/m2. Physical function was evaluated using the 36-item physical functioning subscale. Results Severe knee osteoarthritis had a significantly 6.47-fold (95% confidence interval (CI) = 2.95-14.22, p < 0.0001) higher risk of physical function than those with mild knee osteoarthritis after adjusting for age, sex, educational status, occupational status, affected knee with osteoarthritis, knee pain, and body mass index. However, moderate knee osteoarthritis had a 1.22-fold higher risk of physical function, but the association was not statistically significant (95% CI = 0.60-2.49, p = 0.578). Conclusions Severe but not moderate knee osteoarthritis was more likely to have the worst physical function than mild knee osteoarthritis among adults with a high body mass index in Saudi Arabia.

Role of the Sympathetic Nervous System in Mild Chronic Inflammatory Diseases: Focus on Osteoarthritis

The sympathetic nervous system (SNS) is a major regulatory mediator connecting the brain and the immune system that influences accordingly inflammatory processes within the entire body. In the periphery, the SNS exerts its effects mainly via its neurotransmitters norepinephrine (NE) and epinephrine (E), which are released by peripheral nerve endings in lymphatic organs and other tissues. Depending on their concentration, NE and E bind to specific α- and β-adrenergic receptor subtypes and can cause both pro- and anti-inflammatory cellular responses. The co-transmitter neuropeptide Y, adenosine triphosphate, or its metabolite adenosine are also mediators of the SNS. Local pro-inflammatory processes due to injury or pathogens lead to an activation of the SNS, which in turn induces several immunoregulatory mechanisms with either pro- or anti-inflammatory effects depending on neurotransmitter concentration or pathological context. In chronic inflammatory diseases, the activity of the SNS is persistently elevated and can trigger detrimental pathological processes. Recently, the sympathetic contribution to mild chronic inflammatory diseases like osteoarthritis (OA) has attracted growing interest. OA is a whole-joint disease and is characterized by mild chronic inflammation in the joint. In this narrative article, we summarize the underlying mechanisms behind the sympathetic influence on inflammation during OA pathogenesis. In addition, OA comorbidities also accompanied by mild chronic inflammation, such as hypertension, obesity, diabetes, and depression, will be reviewed. Finally, the potential of SNS-based therapeutic options for the treatment of OA will be discussed.

Non-Invasive Objective Markers to Measure Pain: A Direction to Develop a Pain Device - A Narrative Review

Objective

To review the literature regarding non-invasive objective measurements of pain. Measuring pain is of uttermost importance, but it can be an inconvenient task, especially in terms of the interpretation of patient's information. Reiterating, there is no "standard" that provides the physician with a method to objectively quantify this problem of patient's pain. For assessing the pain, physician relies solely on unidimensional assessment tools or questionnaire-based pain assessment. Although pain is a subjective experience of the patient, but there is a need to measure pain sometimes in the individuals who cannot communicate their quality and severity of pain.

Material and Methods

The articles from PubMed and Google Scholar without any year and age limit were searched in the current narrative review. A total of 16 markers were searched and their relation to pain was studied.

Results

Studies have shown that these markers change in relation to pain and it can be considered a valuable tool for pain measurement but there are multiple factors like psychological and emotional factors which affect these markers.

Conclusion

There is lack of evidence to show which marker can be used for measuring pain accurately. This narrative review is an attempt to look into the various pain-related markers that can be used and it calls for further studies including clinical trials with different diseases and taking into accounts different factors affecting pain to give an accurate measurement of pain.

Sex-specific effects of calving season on joint health and biomarkers in Montana ranchers

BACKGROUND

Agricultural workers have a higher incidence of osteoarthritis (OA), but the etiology behind this phenomenon is unclear. Calving season, which occurs in mid- to late-winter for ranchers, includes physical conditions that may elevate OA risk. Our primary aim was to determine whether OA biomarkers are elevated at the peak of calving season compared to pre-season, and to compare these data with joint health survey information from the subjects. Our secondary aim was to detect biomarker differences between male and female ranchers.

METHODS

During collection periods before and during calving season, male (n = 28) and female (n = 10) ranchers completed joint health surveys and provided samples of blood, urine, and saliva for biomarker analysis. Statistical analyses examined associations between mean biomarker levels and survey predictors. Ensemble cluster analysis identified groups having unique biomarker profiles.

RESULTS

The number of calvings performed by each rancher positively correlated with plasma IL-6, serum hyaluronic acid (HA) and urinary CTX-I. Thiobarbituric acid reactive substances (TBARS), a marker of oxidative stress, was significantly higher during calving season than pre-season and was also correlated with ranchers having more months per year of joint pain. We found evidence of sexual dimorphism in the biomarkers among the ranchers, with leptin being elevated and matrix metalloproteinase-3 diminished in female ranchers. The opposite was detected in males. WOMAC score was positively associated with multiple biomarkers: IL-6, IL-2, HA, leptin, C2C, asymmetric dimethylarginine, and CTX-I. These biomarkers represent enzymatic degradation, inflammation, products of joint destruction, and OA severity.

CONCLUSIONS

The positive association between number of calvings performed by each rancher (workload) and both inflammatory and joint tissue catabolism biomarkers establishes that calving season is a risk factor for OA in Montana ranchers. Consistent with the literature, we found important sex differences in OA biomarkers, with female ranchers showing elevated leptin, whereas males showed elevated MMP-3.

Cross-Disorder Genomics Data Analysis Elucidates a Shared Genetic Basis Between Major Depression and Osteoarthritis Pain

Osteoarthritis (OA) and major depression (MD) are two debilitating disorders that frequently co-occur and affect millions of the elderly each year. Despite the greater symptom severity, poorer clinical outcomes, and increased mortality of the comorbid conditions, we have a limited understanding of their etiologic relationships. In this study, we conducted the first cross-disorder investigations of OA and MD, using genome-wide association data representing over 247K cases and 475K controls. Along with significant positive genome-wide genetic correlations (r g = 0.299 ± 0.026, p = 9.10 × 10-31), Mendelian randomization (MR) analysis identified a bidirectional causal effect between OA and MD (βOA → MD = 0.09, SE = 0.02, z-score p-value < 1.02 × 10-5; βMD → OA = 0.19, SE = 0.026, p < 2.67 × 10-13), indicating genetic variants affecting OA risk are, in part, shared with those influencing MD risk. Cross-disorder meta-analysis of OA and MD identified 56 genomic risk loci (P meta ≤ 5 × 10-8), which show heightened expression of the associated genes in the brain and pituitary. Gene-set enrichment analysis highlighted "mechanosensory behavior" genes (GO:0007638; P gene_set = 2.45 × 10-8) as potential biological mechanisms that simultaneously increase susceptibility to these mental and physical health conditions. Taken together, these findings show that OA and MD share common genetic risk mechanisms, one of which centers on the neural response to the sensation of mechanical stimulus. Further investigation is warranted to elaborate the etiologic mechanisms of the pleiotropic risk genes, as well as to develop early intervention and integrative clinical care of these serious conditions that disproportionally affect the aging population.

Osteoprotegerin changes in saliva and serum of patients with knee osteoarthritis

OBJECTIVE

The scope of this study was to assess salivary and serum osteoprotegerin (OPG) levels in knee osteoarthritis (OA).

METHODS

Serum and saliva OPG levels of 30 knee OA and 30 matched healthy controls in this cross-sectional study was assessed by ELISA. Knee pain was assessed by WOMAC. Data were analyzed by Student's t-test, Spearman correlation test and ROC.

RESULTS

The mean serum but not saliva OPG level was lower in knee OA than that of the healthy group. WOMAC negatively correlated with serum OPG (r=-0.501; P=0.000). The serum OPG cutoff value was 237.5pg/ml for the diagnosis of knee OA.

CONCLUSIONS

As serum OPG was lower in knee OA and negatively correlated with WOMAC, it seems that detection of OPG in serum but not in saliva may be a probable marker to the diagnosis of knee OA.

KEY MESSAGES

Osteoprotegerin decreases in knee osteoarthritis.

Individual variation in diurnal cortisol in patients with knee osteoarthritis: Clinical correlates

BACKGROUND

The cortisol awakening response (CAR) is a core biomarker of hypothalamic-pituitary-adrenal (HPA) axis regulation. To date, however, studies of HPA-axis function among patients with chronic pain are scarce and show equivocal results. The objectives of this study were to investigate the association between CAR and pain-related outcomes and to investigate potential sex differences in patients with knee osteoarthritis (KOA).

METHODS

In this cross-sectional study, KOA patients (N = 96) completed self-report questionnaires assessing pain and psychosocial factors and underwent Quantitative Sensory Testing (QST) to assess pressure pain threshold (PPT). Additionally, salivary cortisol samples (N = 60) were collected to assess HPA-axis function at 6 time points (awakening, 15- and 30-minute post-awakening, 4 PM, 9 PM and bedtime). The CAR was calculated by examining increases in salivary cortisol from awakening to 30 min post awakening and the total post-awakening cortisol concentration by calculating the lower areas under the curve of cortisol with respect to ground (AUC_G).

RESULTS

Patients with a relatively blunted CAR had significantly higher anxiety levels and lower PPT than patients with relatively normal CAR. Similarly, patients with a relatively reduced AUC_G had significantly higher pain interference and anxiety levels compared to patients with relatively normal AUC_G. PPT was positively correlated with CAR and AUC_G and negatively correlated with pain severity and anxiety_. Men with KOA had significantly lower anxiety, higher PPT and higher CAR and AUC_G than women with KOA. Mediation analysis results revealed a significant indirect effect of PPT on the relationship between sex and AUC_G. CONCLUSIONS: The findings of this study suggest that neuroendocrine factors such as CAR and AUC_G may contribute to individual differences in pain-related outcomes in patients with KOA. Additionally, our results show sex differences in the magnitude of morning HPA activation and pain-related outcomes. Finally, our findings are suggestive of a sex-dependent relationship between post-awakening cortisol concentrations and pain perception. Future research should examine these associations across various pain populations.

Arthritis and the role of endogenous glucocorticoids

Rheumatoid arthritis and osteoarthritis, the most common forms of arthritis, are chronic, painful, and disabling conditions. Although both diseases differ in etiology, they manifest in progressive joint destruction characterized by pathological changes in the articular cartilage, bone, and synovium. While the potent anti-inflammatory properties of therapeutic (i.e., exogenous) glucocorticoids have been heavily researched and are widely used in clinical practice, the role of endogenous glucocorticoids in arthritis susceptibility and disease progression remains poorly understood. Current evidence from mouse models suggests that local endogenous glucocorticoid signaling is upregulated by the pro-inflammatory microenvironment in rheumatoid arthritis and by aging-related mechanisms in osteoarthritis. Furthermore, these models indicate that endogenous glucocorticoid signaling in macrophages, mast cells, and chondrocytes has anti-inflammatory effects, while signaling in fibroblast-like synoviocytes, myocytes, osteoblasts, and osteocytes has pro-inflammatory actions in rheumatoid arthritis. Conversely, in osteoarthritis, endogenous glucocorticoid signaling in both osteoblasts and chondrocytes has destructive actions. Together these studies provide insights into the role of endogenous glucocorticoids in the pathogenesis of both inflammatory and degenerative joint disease.

Exploring the relationship between chronic pain and cortisol levels in subjects with osteoarthritis: results from a systematic review of the literature

OBJECTIVE

Several reports in the literature have identified an association between cortisol levels and the presence of chronic pain in conditions such as rheumatoid arthritis, low back pain or whiplash. In contrast, few have examined the association of cortisol and pain in people with osteoarthritis (OA). The purpose of this systematic review was to verify the association between cortisol and pain in the OA population.

DESIGN

The databases MEDLINE, CINAHL, EMBASE were searched systematically for human studies written in English up to December 2018. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Articles were included if they measured the cortisol levels in adults with pain in the OA population. Methodological quality was assessed using Methodological Index for non-randomized Studies (MINORS) score.

RESULTS

Seven studies reporting on 415 patients were included in this review. The MINORS scale yielded mean scores of 8.6 of 16 and 17.5 of 24, for the cohort and case-control studies respectively. In general, the studies were of poor quality. A discrepancy of noteworthy associations between cortisol level comparison and pain was found.

CONCLUSIONS

This study shows that there is a discrepancy in the relationship between cortisol and pain dependent on how and when cortisol is measured. Evidence from three low-quality studies suggest increased cortisol levels in patients with pain but the conclusions have a high risk of bias. It was not possible to make a quantitative analysis comparing the relationship between cortisol and pain in the OA population.

Level of obesity is directly associated with the clinical and functional consequences of knee osteoarthritis

Obesity is one of the most important risk factors of knee osteoarthritis (KOA), but its impact on clinical and functional consequences is less clear. The main objective of this cross-sectional study was to describe the relation between body mass index (BMI) and clinical expression of KOA. Participants with BMI ≥ 25 kg/m² and KOA completed anonymous self-administered questionnaires. They were classified according to BMI in three groups: overweight (BMI 25-30 kg/m²), stage I obesity (BMI 30-35 kg/m²) and stage II/III obesity (BMI ≥ 35 kg/m²). The groups were compared in terms of pain, physical disability, level of physical activity (PA) and fears and beliefs concerning KOA. Among the 391 individuals included, 57.0% were overweight, 28.4% had stage I obesity and 14.6% had stage II/III obesity. Mean pain score on a 10-point visual analog scale was 4.3 (SD 2.4), 5.0 (SD 2.6) and 5.2 (SD 2.3) with overweight, stage I and stage II/III obesity, respectively (p = 0.0367). The mean WOMAC function score (out of 100) was 36.2 (SD 20.1), 39.5 (SD 21.4) and 45.6 (SD 18.4), respectively (p = 0.0409). The Knee Osteoarthritis Fears and Beliefs Questionnaire total score (KOFBEQ), daily activity score and physician score significantly differed among BMI groups (p = 0.0204, p = 0.0389 and p = 0.0413, respectively), and the PA level significantly differed (p = 0.0219). We found a dose-response relation between BMI and the clinical consequences of KOA. Strategies to treat KOA should differ by obesity severity. High PA level was associated with low BMI and contributes to preventing the clinical consequences of KOA.

The CNS theory of osteoarthritis: Opportunities beyond the joint

Osteoarthritis (OA) is a leading cause of global disability that affects more than half of the population over 65. It is not a single disease but a progressive, inflammatory- and immune-altering multi-disease that affects the whole joint. OA has many risk factors including age, obesity, gender, lifestyle, joint morphology, metabolic dysfunction and genetic disposition. A major stumbling block in treating clinical OA has been the inability to detect its early onset and disease progression. This gap in understanding may arise from our failure to recognize that the OA patient exhibits a vulnerability to dysregulation of central feedback circuits that control sympathetic tone, inflammation, circadian rhythms (central and peripheral clocks), gut microbiome, metabolic redox and whole joint pathology. Early detection of OA and slowing its progression may come from discoveries outside the joint targeting these potentially modifiable upstream targets. We argue that future treatments may benefit from moving from a knee-centric viewpoint to a more systems-based, whole-body approach. The challenge, however, will be to better characterize these key circuits and apply this knowledge to develop new therapies and interventions.

Effects of stress on the corticolimbic system: implications for chronic pain

Stress has multifaceted effects on pain. On the one hand, it is a powerful inhibitor of nociception and inflammation; on the other hand, it contributes to enhanced pathological states including the establishment and continuation of chronic pain. These seemingly paradoxical effects can be better understood by investigating how stress-induced plasticity in particular brain circuitry contributes to the chronic pain state. This review presents the rationale and evidence for the interactions between stress and pain, emphasizing underlying mechanisms and putting forth the hypothesis that stress partly mediates the deleterious effects of pain on the corticolimbic system. First, a general description of the corticolimbic circuitry predisposing and amplifying chronic pain will be discussed, followed by an overview of the neurotoxic effects of stress hormones on this circuitry. Recent studies show that the resulting perturbations to these brain circuits have significant consequences both for chronic pain and for general regulation of the stress response, primarily through feedback mechanisms controlling the hypothalamic-pituitary-adrenal axis. This overlap in effected circuitry provides a key point of comparison between stress and pain, and the similarities between the plasticity induced by chronic pain and chronic stress will be examined here. Chronic pain patients have been shown to exhibit maladaptive stress responses in general and in response to pain; the cause of this response and its consequence on pain severity will then be reviewed. Finally, factors that have been shown to lead to resilience or vulnerability for chronic pain and maladaptive stress responses will be summarized.

Treatment of Osteoarthritis With Low-level Laser Therapy, Acupuncture, and Herbal Therapy: A Case Report

Osteoarthritis is a challenging diagnosis to navigate and treat. Management options range from nonpharmacological agents to surgical repair. No specific combination of therapies has yet been identified for optimal management although a variety of therapeutic options have been studied. This case report details the use of low-level laser therapy, acupuncture, and herbal medicine in a 64-y-old female with radiographically confirmed osteoarthritis. Near-complete resolution of her symptoms was associated with the multiple therapies outlined in this case report.