Efficacy of Guided Imagery with Relaxation for Osteoarthritis Symptoms and Medication Intake

Enhancing Chronic Non-Cancer Pain Management: A Systematic Review of Mindfulness Therapies and Guided Imagery Interventions

Background and Objectives: There has been an increasing interest in the use of non-pharmacological approaches for the multidimensional treatment of chronic pain. The aim of this systematic review was to assess the effectiveness of mindfulness-based therapies and Guided Imagery (GI) interventions in managing chronic non-cancer pain and related outcomes. Materials and Methods: Searching three electronic databases (Web of Science, PubMed, and Scopus) and following the PRISMA guidelines, a systematic review was performed on Randomized Controlled Trials (RCTs) and pilot RCTs investigating mindfulness or GI interventions in adult patients with chronic non-cancer pain. The Cochrane Risk of Bias Tool was utilized to assess the quality of the evidence, with outcomes encompassing pain intensity, opioid consumption, and non-sensorial dimensions of pain. Results: Twenty-six trials met the inclusion criteria, with most of them exhibiting a moderate to high risk of bias. A wide diversity of chronic pain types were under analysis. Amongst the mindfulness interventions, and besides the classical programs, Mindfulness-Oriented Recovery Enhancement (MORE) emerges as an approach that improves interoception. Six trials demonstrated that mindfulness techniques resulted in a significant reduction in pain intensity, and three trials also reported significant outcomes with GI. Evidence supports a significant improvement in non-sensory dimensions of pain in ten trials using mindfulness and in two trials involving GI. Significant effects on opioid consumption were reported in four mindfulness-based trials, whereas one study involving GI found a small effect with that variable. Conclusions: This study supports the evidence of benefits of both mindfulness techniques and GI interventions in the management of chronic non-cancer pain. Regarding the various mindfulness interventions, a specific emphasis on the positive results of MORE should be highlighted. Future studies should focus on specific pain types, explore different durations of the mindfulness and GI interventions, and evaluate emotion-related outcomes.

Evaluating the Impact of Virtual Reality on the Behavioral and Psychological Symptoms of Dementia and Quality of Life of Inpatients With Dementia in Acute Care: Randomized Controlled Trial (VRCT)

BACKGROUND

Virtual reality (VR) is increasingly considered a valuable therapeutic tool for people with dementia. However, rigorous studies are still needed to evaluate its impact on behavioral and psychological symptoms of dementia (BPSDs) and quality of life (QoL) across care settings.

OBJECTIVE

The primary aim of this study was to evaluate the impact of VR therapy on managing BPSDs, falls, length of stay, and QoL in inpatients with dementia admitted to an acute care hospital. The secondary aim was to evaluate the intervention's feasibility in terms of acceptability, safety, and patient experience.

METHODS

A prospective, open-label, mixed methods, randomized controlled clinical trial was conducted between April 2019 and March 2020. A total of 69 participants (aged ≥65 years with a diagnosis of dementia and who did not meet the exclusion criteria) were randomly assigned to either the control (n=35, 51%) or VR (n=34, 49%) arm. Participants in the experimental (VR) arm were visited by a researcher and watched 360° VR films on a head-mounted display for up to 20 minutes every 1 to 3 days, whereas individuals in the control arm received standard of care. Instances of daily BPSDs and falls were collected from nurses' daily notes. QoL was measured through semistructured interviews and the Quality of Life in Late-Stage Dementia scale. Structured observations and semistructured interviews were used to measure treatment feasibility. The primary outcomes were analyzed at a 95% significance level based on the intention-to-treat method.

RESULTS

VR therapy had a statistically significant effect on reducing aggressiveness (ie, physical aggression and loud vociferation; P=.01). Substantial impact of VR therapy was not found for other BPSDs (eg, apathy), falls, length of stay, or QoL as measured using the Quality of Life in Late-Stage Dementia scale. The average VR therapy session lasted 6.8 (SD 6.6; range 0-20) minutes, and the intervention was overall an acceptable and enjoyable experience for participants. No adverse events occurred as a result of VR therapy.

CONCLUSIONS

Immersive VR therapy appears to have an effect on aggressive behaviors in patients with dementia in acute care. Although the randomized controlled trial was stopped before reaching the intended sample size owing to COVID-19 restrictions, trends in the results are promising. We suggest conducting future trials with larger samples and, in some cases, more sensitive data collection instruments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03941119; https://clinicaltrials.gov/study/NCT03941119.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/22406.

The Effects of Brief Guided Imagery on Patients Suffering From Chronic Back Pain: An A-B Design Study

BACKGROUND

Guided imagery (GI) is a non-pharmacological method used to reduce pain, stress, and anxiety.

AIMS

This study aimed to evaluate the impact of brief GI on symptoms of chronic back pain in adults treated in the Rheumatology clinic.

DESIGN

A-B design study.

SETTINGS & PARTICIPANTS

A sample of 35 women with chronic back pain were recruited at the Rheumatology Outpatient Clinic of Barzilai Medical Center in Ashkelon, Israel.

METHODS

All subjects completed questionnaires at recruitment (T1), and after 8-10 weeks, they completed questionnaires again before the first intervention (T2). The intervention included five brief GI group meetings every 2-3 weeks, one hour each (3-5 subjects per group). Participants learned 6 GI exercises and were asked to practice brief guided imagery exercises at least once daily. Then, questionnaires were completed the third time (T3).

OUTCOME MEASURES

MOQ - Modified Oswestry Low Back Pain Disability Questionnaire, STAI - State-Trait Anxiety Inventory, FABQ - Fear-Avoidance Beliefs Questionnaire, NPRS - Numerical Pain Rating Scale (average pain over the last week).

RESULTS

Compared with the period without intervention, NPRS (Δ = 2.53, standard error [SE] = 0.43, p < .001), STAI (Δ = 8.41, SE = 1.95, p < .001), and MOQ (Δ = 0.06, SE = 0.02, p = .019) reported significantly lower levels after brief guided imagery training. However, no statistically significant change was found in FABQ.

CONCLUSIONS

The brief guided imagery intervention may help alleviate chronic back pain, help decrease anxiety, and improve daily activity in women who suffer from chronic low back pain.

Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article I): a systematic review and description of methods

ABSTRACT

Blinding is challenging in randomised controlled trials of physical, psychological, and self-management therapies for pain, mainly because of their complex and participatory nature. To develop standards for the design, implementation, and reporting of control interventions in efficacy and mechanistic trials, a systematic overview of currently used sham interventions and other blinding methods was required. Twelve databases were searched for placebo or sham-controlled randomised clinical trials of physical, psychological, and self-management treatments in a clinical pain population. Screening and data extraction were performed in duplicate, and trial features, description of control methods, and their similarity to the active intervention under investigation were extracted (protocol registration ID: CRD42020206590). The review included 198 unique control interventions, published between 2008 and December 2021. Most trials studied people with chronic pain, and more than half were manual therapy trials. The described control interventions ranged from clearly modelled based on the active treatment to largely dissimilar control interventions. Similarity between control and active interventions was more frequent for certain aspects (eg, duration and frequency of treatments) than others (eg, physical treatment procedures and patient sensory experiences). We also provide an overview of additional, potentially useful methods to enhance blinding, as well as the reporting of processes involved in developing control interventions. A comprehensive picture of prevalent blinding methods is provided, including a detailed assessment of the resemblance between active and control interventions. These findings can inform future developments of control interventions in efficacy and mechanistic trials and best-practice recommendations.

The Effect of Guided Imagery on Postoperative Pain Management in Patients Undergoing Lower Extremity Surgical Operations: A Randomized Controlled Trial

Guided imagery distracts patients from disturbing feelings and thoughts, positively affects emotional well-being, and reduces pain by producing pleasing mental images. This study aimed to determine the effects of guided imagery on postoperative pain management in patients undergoing lower extremity surgery. This randomized controlled study was conducted between April 2018 and May 2019. This study included 60 patients who underwent lower extremity surgery. After using guided imagery, the posttest mean Visual Analog Scale score of patients in the intervention group was found to be 2.56 (1.00 ± 6.00), whereas the posttest mean score of patients in the control group was 4.10 (3.00 ± 6.00), and the difference between the groups was statistically significant (p <.001). Guided imagery reduces short-term postoperative pain after lower extremity surgery.

Self-management interventions for issues identified in a geriatric assessment: A systematic review

BACKGROUND

With the development of electronic geriatric assessment (GA), recommendations for self-management can be provided to patients without the presence of health care providers. Our research question was to identify what self-management interventions can be used by patients to address issues identified in GA and to determine their effect on patient-centered outcomes such as quality of life, health, mood, cognition, and functional status.

METHODS

Searches were conducted on July 13, 2021, by a health sciences librarian in Medline, Embase, CINAHL, PsycInfo, and the Cochrane Library. A combination of database-specific subject headings and text word searches was used such as self-management, a key word for each of the geriatric assessment domains and older adults. Two independent reviewers reviewed abstracts and full texts for inclusion and abstracted data. Narrative synthesis was used to summarize findings.

RESULTS

Among 28,520 abstracts reviewed, 34 randomized controlled trials were included. The most frequently studied geriatric domains were mood (n = 13 studies), mobility/falls (n = 12), quality of life (n = 11), and functional status (n = 7). The majority of studies demonstrated positive effects on mobility/falls (9 of 12), pain (3 of 5), comorbidity (4 of 4), and medication management (4 of 4). Most studies were of low to moderate quality. All geriatric domains were targeted in at least one study.

CONCLUSIONS

Low- to moderate-quality studies show a variety of effective self-efficacy-targeted interventions exist for older adults to improve several important geriatric domains and related outcomes. However, long-term effects, validation, and scalability of these interventions remain largely unknown.

Effect of Guided Imagery on Pain and Health-Related Quality of Life in Musculoskeletal Medicine: a Comprehensive Narrative Review

PURPOSE OF REVIEW

Guided imagery (GI) is a non-pharmacological method used to reduce pain, stress, and anxiety. No comprehensive review has yet investigated the application of GI in musculoskeletal medicine, its various types, and potential mechanisms. The aim of this comprehensive narrative review was to examine the types of GI used in musculoskeletal medicine and GI effect on pain and health-related quality of life.

RECENT FINDINGS

A comprehensive narrative review of the English language scientific literature. PubMed, Google Scholar, ProQuest, and PEDro databases were searched from inception until August 2020 using keywords related to GI, musculoskeletal disorders, pain, and health-related quality of life. The search results generated 133 articles. After a critical analysis, 12 publications were included in this review. GI characteristics and protocols varied significantly between studies. Based on the reviewed studies, we advocate GI as a safe, non-invasive technique that can assist in managing pain, depression, stress, fatigue, anxiety, reducing medication use, improving general well-being, wellness, and quality of life in patients with musculoskeletal disorders. We recommend further investigations of GI mechanisms.

Deprescribing paracetamol in pain conditions: A scoping review

OBJECTIVE

To examine evidence on deprescribing paracetamol in pain conditions and inform future strategies for paracetamol deprescription.

DESIGN

Scoping review.

PARTICIPANTS

Adults with pain conditions, taking paracetamol.

RESULTS

After two independent teams of reviewers screening for titles, abstracts, and then full texts, 16 original articles were included. Deprescribing strategies were grouped into 5 categories: (1) Pharmacological, (2) Psychological, (3) Physiological, (4) Policy, and (5) Combination. We found strategies were predominately consumer-focused, conducted in community settings and involved individuals experiencing musculoskeletal pain (such as low back pain and osteoarthritis). A total of twelve studies investigated interventions targeting dose reduction and four studies examined interventions focusing on discontinuation of paracetamol. The most common strategies used to deprescribe paracetamol in pain conditions were physiological strategies, followed by psychological strategies. All included studies demonstrated some level of effectiveness to deprescribe paracetamol in a pain conditions through dose reduction or discontinuation, although the effectiveness of deprescribing strategies were highly variable, ranging from the majority of participants discontinuing their paracetamol use, to less than 10% reducing their paracetamol use upon the latest follow-up.

CONCLUSIONS

There are clear opportunities for prospective trials to be designed more purposely and primarily focused to influence reduction and cessation of paracetamol for specific pain conditions where deprescription is appropriate.

The effects of neuro-linguistic programming and guided imagery on the pain and comfort after open-heart surgery

OBJECTIVE

The present study aims to evaluate the effects of neuro-linguistic programming (NLP) and guided imagery on postoperative pain and comfort after open-heart surgery.

METHODS

In the current, prospective, randomized, single-blind clinical study, the participants received NLP with a new behavior formation technique or the guided imagery relaxation technique using an audio compact disc for a duration of 30 min.

RESULTS

The patients in the NLP group had significantly lower posttest pain levels, compared to the patients in the guided imagery and control groups. Moreover, the patients in the guided imagery group had significantly higher posttest comfort levels, compared to the patients in the NLP and control groups.

CONCLUSION

The application of both NLP and guided imagery interventions resulted in reduced postoperative pain and increased postoperative comfort levels after open-heart surgery.

The effectiveness, suitability, and sustainability of non-pharmacological methods of managing pain in community-dwelling older adults: a systematic review

Background

Pain is common in older adults. To maintain their quality of life and promote healthy ageing in the community, it is important to lower their pain levels. Pharmacological pain management has been shown to be effective in older adults. However, as drugs can have various side effects, non-pharmacological pain management is preferred for community-dwelling older adults. This systematic review evaluates the effectiveness, suitability, and sustainability of non-pharmacological pain management interventions for community-dwelling older adults.

Methods

Five databases, namely, CINHAL, Journals@Ovid, Medline, PsycInfo, and PubMed, were searched for articles. The criteria for inclusion were: full-text articles published in English from 2005 to February 2019 on randomized controlled trials, with chronic non-cancer pain as the primary outcome, in which pain was rated by intensity, using non-pharmacological interventions, and with participants over 65 years old, community-dwelling, and mentally competent. A quality appraisal using the Jadad Scale was conducted on the included articles.

Results

Ten articles were included. The mean age of the older adults was from 66.75 to 76. The interventions covered were acupressure, acupuncture, guided imagery, qigong, periosteal stimulation, and Tai Chi. The pain intensities of the participants decreased after the implementation of the intervention. The net changes in pain intensity ranged from − 3.13 to − 0.65 on a zero to ten numeric rating scale, in which zero indicates no pain and ten represents the worst pain.

Conclusions

Non-pharmacological methods of managing pain were effective in lowering pain levels in community-dwelling older adults, and can be promoted widely in the community.

The Effects of Guided Imagery on Patients Being Weaned from Mechanical Ventilation

The study purpose was to assess the effects of guided imagery on sedation levels, sedative and analgesic volume consumption, and physiological responses of patients being weaned from mechanical ventilation. Forty-two patients were selected from two community acute care hospitals. One hospital served as the comparison group and provided routine care (no intervention) while the other hospital provided the guided imagery intervention. The intervention included two sessions, each lasting 60 minutes, offered during morning weaning trials from mechanical ventilation. Measurements were recorded in groups at baseline and 30- and 60-minute intervals and included vital signs and Richmond Agitation-Sedation Scale (RASS) score. Sedative and analgesic medication volume consumption were recorded 24 hours prior to and after the intervention. The guided imagery group had significantly improved RASS scores and reduced sedative and analgesic volume consumption. During the second session, oxygen saturation levels significantly improved compared to the comparison group. Guided imagery group had 4.88 less days requiring mechanical ventilation and 1.4 reduction in hospital length of stay compared to the comparison group. Guided imagery may be complementary and alternative medicine (CAM) intervention to provide during mechanical ventilation weaning trials.

Guided Imagery for Arthritis and Other Rheumatic Diseases: A Systematic Review of Randomized Controlled Trials

Many individuals suffering from arthritis and other rheumatic diseases (AORD) supplement pharmacologic treatments with psychosocial interventions. One promising approach, guided imagery, has been reported to have positive results in randomized controlled trials (RCTs) and is a highly scalable treatment for those with AORD. The main purpose of this study was to conduct a systematic review of RCTs that have examined the effects of guided imagery on pain, function, and other outcomes such as anxiety, depression, and quality of life in adults with AORD. Ten electronic bibliographic databases were searched for reports of RCTs published between 1960 and 2013. Selection criteria included adults with AORD who participated in RCTs that used guided imagery as a partial or sole intervention strategy. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Instrument. Results were synthesized qualitatively. Seven studies representing 306 enrolled and 287 participants who completed the interventions met inclusion criteria. The average age of the participants was 62.9 years (standard deviation = 12.2). All interventions used guided imagery scripts that were delivered via audio technology. The interventions ranged from a one-time exposure to 16 weeks in duration. Risk of bias was low or unclear in all but one study. All studies reported statistically significant improvements in the observed outcomes. Guided imagery appears to be beneficial for adults with AORD. Future theory-based studies with cost-benefit analyses are warranted.

The effect of Benson's relaxation technique on the quality of sleep of Iranian hemodialysis patients: a randomized trial

OBJECTIVE

This study was performed to evaluate the effectiveness of Benson's relaxation technique in the quality of sleep of hemodialysis patients.

DESIGN

It was a randomized controlled trial with a pre-post-test design. A total of 86 hemodialysis patients referring to hemodialysis units were assigned to either the intervention (receiving Benson's relaxation technique) or the control group (routine care) through block randomization.

SETTING

The study was performed in two hemodialysis units affiliated to Shiraz University of Medical Sciences, Shiraz, Iran.

INTERVENTION

The patients in the intervention group listened to the audiotape of Benson's relaxation technique twice a day each time for twenty minutes for eight weeks.

MAIN OUTCOME MEASURES

The global score of Pittsburgh Sleep Quality Index (PSQI) as well as its components was computed in both the intervention and the control group before and at the 8th week of the intervention.

RESULTS

The results of ANCOVA indicated significant differences between the two groups regarding the scores of Pittsburgh Sleep Quality Index subscales, such as sleep disturbance, daytime dysfunction, the use of sleep medication, and subjective sleep quality and as well as its global scores at the 8th week of the intervention (p<0.05).

CONCLUSIONS

This study highlighted the importance of Benson's relaxation technique in improvement of the sleep quality of the patients on hemodialysis. Thus, educational sessions are recommended to be planned on this cost effective and easy to use relaxation technique in order to improve hemodialysis patients' sleep quality. Further studies are needed to assess the effectiveness of this technique in other groups of patients.

Intervenções de enfermagem para o cuidado de pacientes com artrite: revisão integrativa da literatura

Esta revisão integrativa buscou analisar a produção científica relacionada aos cuidados de enfermagem para pacientes com artrite. Foram incluídos 12 estudos experimentais, randomizados e controlados, publicados nas bases de dados CINAHL, MEDLINE, SciELO e LILACS, utilizando os descritores controlados "arthritis" e "nursing". Os resultados apontaram a efetividade de musicoterapia, estimulação elétrica neuromuscular, toque terapêutico e imagem guiada associada a relaxamento, para o tratamento da dor. Ser atendido por enfermeira especialista aumentou a satisfação com o atendimento, melhorou o impacto da doença e aumento a procura por serviços de saúde. Programas educativos específicos para portadores de artrite estimularam a prática de exercícios físicos e aqueles direcionados a pessoas com problemas crônicos em geral mostraram-se efetivos para controlar a dor e a incapacidade funcional. Concluímos que existe um conjunto de intervenções que podem subsidiar a prática de enfermagem baseada em evidências junto aos idosos com artrite.

Guided imagery for non-musculoskeletal pain: a systematic review of randomized clinical trials

CONTEXT

Our previous review of the literature concluded that there is encouraging evidence that guided imagery alleviates musculoskeletal pain, but the value of guided imagery in the management of non-musculoskeletal pain remains uncertain.

OBJECTIVES

The objective of this systematic review was to assess the effectiveness of guided imagery as a treatment option for non-musculoskeletal pain.

METHODS

Six databases were searched from their inception to February 2011. Randomized clinical trials were considered if they investigated guided imagery in human patients with any type of non-musculoskeletal pain in any anatomical location and assessed pain as a primary outcome measure. Trials of motor imagery and hypnosis were excluded. The selection of studies, data extraction, and validation were performed independently by two reviewers.

RESULTS

Fifteen randomized clinical trials met the inclusion criteria. Their methodological quality was generally poor. Eleven trials found that guided imagery led to a significant reduction of non-musculoskeletal pain. Four studies found no change in non-musculoskeletal pain with guided imagery in comparison with progressive relaxation, standard care, or no treatment.

CONCLUSION

The evidence that guided imagery alleviates non-musculoskeletal pain is encouraging but remains inconclusive.

The use of functional neuroimaging to evaluate psychological and other non-pharmacological treatments for clinical pain

A large number of studies have provided evidence for the efficacy of psychological and other non-pharmacological interventions in the treatment of chronic pain. While these methods are increasingly used to treat pain, remarkably few studies focused on the exploration of their neural correlates. The aim of this article was to review the findings from neuroimaging studies that evaluated the neural response to distraction-based techniques, cognitive behavioral therapy (CBT), clinical hypnosis, mental imagery, physical therapy/exercise, biofeedback, and mirror therapy. To date, the results from studies that used neuroimaging to evaluate these methods have not been conclusive and the experimental methods have been suboptimal for assessing clinical pain. Still, several different psychological and non-pharmacological treatment modalities were associated with increased pain-related activations of executive cognitive brain regions, such as the ventral- and dorsolateral prefrontal cortex. There was also evidence for decreased pain-related activations in afferent pain regions and limbic structures. If future studies will address the technical and methodological challenges of today's experiments, neuroimaging might have the potential of segregating the neural mechanisms of different treatment interventions and elucidate predictive and mediating factors for successful treatment outcomes. Evaluations of treatment-related brain changes (functional and structural) might also allow for sub-grouping of patients and help to develop individualized treatments.

Yoga for osteoarthritis: nursing and research considerations

Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Current treatment guidelines recommend nonpharmacological approaches such as yoga for firstline treatment of OA. Yoga is a promising mind-body practice that includes physical postures, breathing practices, and meditative mental focus. This article presents the current evidence, as well as a proposed conceptual model for future research. Current research on yoga for OA is scant but promising, showing some evidence of reduced pain, sleep disturbance, and disability. The conceptual model described here proposes musculoskeletal effects (strengthening, flexibility, relaxation), reduction of autonomic arousal, and therapeutic cognitive patterns (distraction, mindfulness) as potentially important mechanisms of yoga. This article also describes considerations for patients and health care providers when evaluating the potential usefulness and safety of yoga programs: yoga style, instructor qualifications, and amount of time spent in yoga practice.

How a Better Understanding of Spontaneous Mental Imagery Linked to Pain Could Enhance Imagery-Based Therapy in Chronic Pain

Therapy with mental images is prevalent in the field of chronic pain, and this has been the case for centuries. Yet few of the recent advances in the cognitive behavioural understanding of spontaneous (i.e. intrusive) mental imagery have been translated to this field. Such advances include imagery as a component of a psychopathological process, as an emotional amplifier and as a cognitive therapeutic target in its own right. Hence very little is known about the contents, prevalence and emotional impact of spontaneous mental imagery in the context of chronic pain. This article discusses the evidence in favour of spontaneous imagery being a potentially important part of patients' pain experience, and makes a case, based on neurophysiological findings, for imagery having an impact on pain perception. Furthermore, it presents how mental imagery has been used in the treatment of chronic pain. A case report illustrates further how spontaneous negative imagery linked to pain can be distressing, and how this might be addressed in therapy. Additionally, the case report demonstrates the spontaneous use of coping imagery, and raises a discussion of how this might be enhanced.

A randomized control trial: the effect of guided imagery with tape and perceived happy memory on chronic tension type headache

PURPOSE

To determine the effects of guided imagery techniques with tape and perceived happy memory on people with chronic tension-type headache (CTTH).

METHODS

Sixty people with CTTH completed the demographic questionnaire and headache diary 1 week before the treatment, that is, for 3 weeks during the treatment and 1 week immediately after that. The people were randomly assigned into one of three different treatment groups: a Guided imagery (GI) with tape group (n = 20), a GI with perceived happy memory group (n = 20) and a control group (n = 20). In addition to individualized headache therapy, subjects listened to a guided imagery audiocassette tape or imagined the happiest personal memory three times per week for 3 weeks. It should be noted that 20 control subjects received individualized therapy without guided imagery.

RESULTS

The guided imagery groups both tape and perceived happy memory had significantly more improvement than the controls in three of the outcome measures; headache intensity, headache frequency and headache duration. There were no other significant differences between the guided imagery groups (tape and perceived happy memory) at any time point.

CONCLUSIONS

Guided imagery is an effective, available and affordable nonpharmacological therapy either with tape or with perceived happy memory for the management of the CTTH.

Depression, chronic pain, and suicide by overdose: on the edge

Comorbid conditions that pose risks for suicide, especially depression, are prevalent in people living with chronic pain. The true numbers of failed attempts and successful suicides are unknown and may never be determined. Yet, risk factors for suicidal ideation are so high in this population that it must be assumed that some proportion of those who die of drug overdoses might have intended to end their lives, not just temporarily relieve their pain. The purpose of this manuscript is to highlight to clinicians the important association between chronic pain and intentional self-harm. Contemporary understanding of the epidemiology of depression and suicide and the relationship to chronic pain will be reviewed. Recommendations for the use of validated and practical screening tools as part of a comprehensive clinical assessment and for approaches to suicide prevention and interventions as crucial components of chronic pain management are outlined.

Osteoarthritis year 2010 in review: non-pharmacologic therapy

OBJECTIVE

To highlight seminal publications in the past year on the topic of non-pharmacologic management of osteoarthritis (OA).

DESIGN

A systematic search of the PUBMED and Cochrane databases from September 2009 to September 2010 was conducted to identify articles reporting on studies examining the safety or efficacy of non-pharmacologic therapies in the management of OA. Non-pharmacologic therapies were those considered in the 2008 OARSI OA guidelines. Identified articles were reviewed for quality; those of highest quality and deemed to have greatest potential impact on the management of OA were summarized.

RESULTS

The search identified 117 unique articles. Of these, four studies were chosen to highlight. A nested two-stage trial found that traditional Chinese acupuncture (TCA) was not superior to sham acupuncture, but that the providers' style affected both pain reduction and satisfaction with treatment, suggesting that the analgesic benefits of acupuncture may be partially mediated by the acupuncturists' behavior. A systematic review found little evidence of a significant effect for electrostimulation vs sham or no intervention on pain in knee OA. A single-blinded trial of Tai Chi vs attention controls found that 12 weeks of Tai Chi was associated with improvements in symptoms and disability in patients with knee OA. A randomized trial of early ACL reconstructive surgery and rehabilitation vs structured rehabilitation alone in subjects with acute anterior cruciate ligament tears found that, at 24 months following randomization, all study participants had improved, suggesting that a strategy of structured rehabilitation followed acute ACL injury may preclude the need for surgical reconstruction.

CONCLUSIONS

High quality studies of the safety and efficacy of non-pharmacologic agents in the management of OA remain challenging due to difficulties with adequate blinding and appropriate selection of attention controls. High quality studies suggest modest, if any, benefit of many non-pharmacologic therapies over attention control or placebo, but a significant impact of both over no intervention at all.