How brains benefit from meditation

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Experienced meditators seem to be able switch off areas of the brain associated with daydreaming as well as psychiatric disorders such as autism and schizophrenia, according to a new brain imaging study by Yale researchers.

Meditation's ability to help people stay focused on the moment has been associated with increased happiness levels, said Judson A. Brewer, assistant professor of psychiatry and lead author of the study published the week of Nov. 21 in the Proceedings of the National Academy of Sciences. Understanding how meditation works will aid investigation into a host of diseases, he said.

"Meditation has been shown to help in variety of health problems, such as helping people quit smoking, cope with cancer, and even prevent psoriasis," Brewer said.

The Yale team conducted functional magnetic resonance imaging scans on both experienced and novice meditators as they practiced three different meditation techniques.

They found that experienced meditators had decreased activity in areas of the brain called the default mode network, which has been implicated in lapses of attention and disorders such as anxiety, attention deficit and hyperactivity disorder, and even the buildup of beta amyloid plaques in Alzheimer's disease. The decrease in activity in this network, consisting of the medial prefrontal and posterior cingulate cortex, was seen in experienced meditators regardless of the type of meditation they were doing.

The scans also showed that when the default mode network was active, brain regions associated with self-monitoring and cognitive control were co-activated in experienced meditators but not novices. This may indicate that meditators are constantly monitoring and suppressing the emergence of "me" thoughts, or mind-wandering. In pathological forms, these states are associated with diseases such as autism and schizophrenia.

The meditators did this both during meditation, and also when just resting — not being told to do anything in particular. This may indicate that meditators have developed a "new" default mode in which there is more present-centered awareness, and less "self"-centered, say the researchers.

"Meditation's ability to help people stay in the moment has been part of philosophical and contemplative practices for thousands of years," Brewer said. "Conversely, the hallmarks of many forms of mental illness is a preoccupation with one's own thoughts, a condition meditation seems to affect. This gives us some nice cues as to the neural mechanisms of how it might be working clinically."

Transcendental Meditation effective antidote to record stress levels in school students

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With record levels of student stress reported in a recent UCLA survey, can a simple stress-reducing meditation technique be a viable solution?

A new study published in the Journal of Instructional Psychology found the Transcendental Meditation (TM) technique significantly decreased psychological distress in public school students. The study, conducted with at-risk minority secondary school students, showed a 36 percent reduction in overall psychological distress. Significant decreases were also found in trait anxiety and depressive symptoms.

Rising Stress Levels Affect Emotional and Physical Health

The percentage of students in the UCLA survey reporting good or above-average high school emotional health dropped from 55.3 percent in 2009 to 51.9 percent in 2010. This marks the lowest level within the past 25 years.

Dr. Charles Elder, MD, lead author of the TM study, and investigator at Kaiser Permanente Center for Health Research, emphasized the important implications of the findings on reduced stress. "It is vital that we start addressing the high levels of emotional stress being reported by high school and college students. Decreased stress can have a positive impact on mental health, and can also reduce the risk for hypertension, obesity, and diabetes—major risk factors for heart disease," explained Dr. Elder.

Educational research has also linked student stress to negative school behavior and poor academic performance.

Promising Findings for Education

"These new findings on reduced stress, along with the recent research on academic achievement gains, hold tremendous promise for public education," said Sanford Nidich, EdD, principal investigator, and professor of education at Maharishi University of Management. "There is a growing body of evidence showing Transcendental Meditation to be an easy to implement, value-added educational program that promotes emotional health and increases academic achievement in at-risk students," said Dr. Nidich.

A total of 106 secondary school students, 87% racial and ethnic minorities, took part in the study. Results showed that over a four-month period, students practicing Transcendental Meditation as part of their schools' Quiet Time program exhibited significant reductions in psychological distress factors compared to controls.

According to James Dierke, 2008 National Association of Secondary School Principals—National Middle School Principal of the Year, "Stress is the number one enemy of public education, especially in inner-city schools. It creates tension, violence, and compromises the cognitive and psychological capacity of students to learn and grow. The TM/Quiet Time program is the most powerful, effective program I have come across in my 39 years as a public school educator for addressing this problem. It is nourishing children and providing them an immensely valuable tool for life. It is saving lives."


Study Facts

• This study evaluated change in psychological distress factors in students practicing the Transcendental Meditation program compared to non-meditating controls. A total of 106 students (68 meditating and 38 non-meditating students), took part in the study. The study included students from four public secondary schools.
• Eighty-seven percent were racial and ethnic minority students, including 26% Hispanic, 25% African American, and 19% American Indian.
• The Transcendental Meditation program was practiced in class twice a day as part of the schools' Quiet Time program for four months prior to posttesting.
• The Transcendental Meditation program was taught in the context of school-wide Quiet Time programs in which students voluntarily chose the Quiet Time program in which they wanted to participate.
• Transcendental Meditation is a simple, natural, effortless technique that allows the mind to settle down and experience a silent yet awake state of awareness, a state of "restful alertness." Practice of this stress-reduction program does not involve any change in beliefs, values, religion, or lifestyle.
• Compared to eyes-closed rest, research has found that Transcendental Meditation practice is characterized by decreased activation or arousal of the autonomic nervous system, as reflected in decreased breath rate and lower sympathetic nervous system activity. The Transcendental Meditation program has been shown to increase electroencephalographic (EEG) brain integration and coherence, especially in the frontal area of the brain, responsible for higher-order processing.
• Other published research on high school and college students has shown reduced psychological distress, improved positive coping ability, decreased blood pressure, reduced cardiovascular reactivity to stressful stimuli, reduced absenteeism, and decreased school suspensions.
• Results of the current study indicated significant reductions in overall psychological distress (p=.010) and trait anxiety (p=.035) compared to controls. Within-in group differences in depressive symptoms were found for meditating students (p=.003).

Acupuncture can prevent radiation-induced chronic dry mouth

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When given alongside radiation therapy for head and neck cancer, acupuncture has shown for the first time to reduce the debilitating side effect of xerostomia, according to new research from The University of Texas MD Anderson Cancer Center and Fudan University Shanghai Cancer Center.

The study, published in the journal Cancer, reported findings from the first randomized controlled trial of acupuncture for the prevention of xerostomia.

Xerostomia, or severe dry mouth, is characterized by reduced salivary flow, which commonly affects patients receiving radiotherapy for head and neck cancer. Most current treatments are palliative and offer limited benefit, according to Lorenzo Cohen, Ph.D., professor in MD Anderson's Departments of General Oncology and Behavioral Science and director of the Integrative Medicine Program.

The condition impairs quality of life for patients, as it creates difficulties eating, speaking and sleeping, while also increasing the risk for oral infections.

"There have been a number of small studies examining the benefits of acupuncture after xerostomia develops, but no one previously examined if it could prevent xerostomia," said Cohen, who is also the study's principal investigator. "We found incorporating acupuncture alongside radiotherapy diminished the incidence and severity of this side effect."

Cohen and his colleagues examined 86 patients with nasopharyngeal carcinoma, treated at Fudan University Shanghai Cancer Center. Forty patients were randomized to acupuncture and 46 to the standard of care. Those in the treatment arm received acupuncture therapy three times per week during the seven-week course of radiotherapy. Patients were evaluated before radiotherapy, weekly during radiotherapy, and then again one and six months later.

The results were based on data derived from two self-report questionnaires and measuring actual saliva flow. Patients completed the Xerostomia Questionnaire (XQ), an eight-item survey which assessed symptoms consistent with the condition. XQ scores under 30 corresponded to mild or no symptoms of xerostomia.

The second measure, MD Anderson Symptom Inventory Head and Neck (MDASI-HN), ranked the severity of cancer-related symptoms, other than xerostomia, and their interference with quality of life. The team also measured saliva flow rates using standardized sialometry collection techniques.


Benefits Noticed Quickly

"What was quite remarkable was that we started to see group differences as early as three weeks into radiotherapy for the development of xerostomia, cancer-related symptoms that interfere with quality of life, and saliva flow rates - an important objective measure," said Zhiqiang Meng, M.D., Ph.D., co-principle investigator of the study and deputy chair of the Department of Integrative Oncology, Fudan University Shanghai Cancer Center.

The largest group differences in XQ scores were seen by the end of radiotherapy, but the differences persisted over time. By one month after the end of radiotherapy, 54.3 percent of the acupuncture group reported XQ scores greater than 30, compared to the control group at 86.1 percent. By six months after radiotherapy, the numbers dropped to 24.1 percent in the acupuncture group and 63.6 percent of the control group still reporting symptoms of xerostomia. Saliva flow rates were also greater in the acupuncture group, starting at three weeks into radiotherapy and persisting through the one and six month follow-up.

Acupuncture also helped cancer-related symptoms, other than xerostomia, as measured by the MDASI-HN questionnaire, with differences that emerged in week three and continued through six months.

"The medical implications are quite profound in terms of quality of life, because while chronic dry mouth may sound benign, it has a significant impact on sleeping, eating and speaking," Cohen said. "Without saliva, there can be an increase in microbial growth, possible bone infection and irreversible nutritional deficits."

Additional studies are needed to determine the mechanisms for the benefits of acupuncture, and while the study didn't examine this issue, Cohen said it may have an impact on local blood flux, specifically at the parotid gland.

Further research is planned, including a large trial conducted at MD Anderson in collaboration with Fudan University Shanghai Cancer Center. Both centers will enroll 150 patients undergoing radiotherapy for head and neck cancer: 50 will receive acupuncture, 50 sham acupuncture and 50 will be enrolled in a control group. Researchers will also examine saliva constituents and a number of other measures to better determine the mechanisms of acupuncture.

Yoga more effective for patients with chronic low back pain at reducing symptoms and improving function

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Yoga classes were found to be more effective than a self-care book for patients with chronic low back pain at reducing symptoms and improving function, but they were not more effective than stretching classes, according to a study published Online First by the Archives of Internal Medicine.

"Despite the availability of numerous treatments for chronic back pain, none have proven highly effective, and few have been evaluated for cost-effectiveness," the authors provide as background information. "Self-management strategies, like exercise, are particularly appealing because they are relatively safe, inexpensive, and accessible and may have beneficial effects on health beyond those for back pain. One form of exercise with at least 'fair' evidence for effectiveness for back pain is yoga, which might be an especially promising form of exercise because it includes a mental component that could enhance the benefits of its physical components."

Karen J. Sherman, Ph.D., M.P.H., from Group Health Research Institute, Seattle, and colleagues designed a study to determine whether yoga is more effective than conventional stretching exercises or a self-care book for primary care patients with chronic low back pain. A total of 228 adults with chronic low back pain were randomized to 12 weekly yoga classes (92 patients) or conventional stretching exercise classes (91 patients), or a self-care book that provided information on causes of back pain and advice on exercising, lifestyle modifications and managing flare-ups (45 patients). The main outcomes measured were back-related functional status and how much the back pain was bothering the patients. Telephone interviews were conducted at baseline, and at six, 12, and 26 weeks after randomization.

"Back-related dysfunction declined over time in all groups," the authors report. Compared with the self-care group, the yoga group reported superior function at 12 and 26 weeks (average difference, -2.5 and -1.8, respectively) and the stretching group reported superior function at six, 12 and 26 weeks (-1.7, -2.2, -1.5, respectively). "There were no statistically or clinically significant differences between the yoga and stretching groups" at any time point, the authors note.

"We found that physical activity involving stretching, regardless of whether it is achieved using yoga or more conventional exercises, has moderate benefits in individuals with moderately impairing low back pain. Finding similar effects for both approaches suggests that yoga's benefits were largely attributable to the physical benefits of stretching and strengthening the muscles and not to its mental components." The benefits of these approaches may last several months, the authors conclude.


Commentary: Comparative Effectiveness Studies in Chronic Low Back Pain

In an accompanying commentary, Timothy S. Carey, M.D., M.P.H., from Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, writes, "The study by Sherman et al in this issue is an excellent example of a pragmatic comparative effectiveness trial."

"This research now represents best evidence for stretching therapies. Support by payers for these therapies will be very helpful through partial financial support for the classes. Such support will encourage patients to utilize the classes, representing a value-based reimbursement policy."

"We physicians should refer our patients for exercise, practitioners should work to standardize treatments, and payers should encourage these treatments through minimization of copayments for therapies that have both effectiveness and modest cost. Comparative effectiveness research, when well conducted, can assist us in making these clinical and policy recommendations."

Direct access to physical therapists associated with lower costs and fewer visits

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A new study suggesting that "the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases" could have significant implications for the US health care system, says the American Physical Therapy Association (APTA).

The study, published ahead of print September 23 in the journal Health Services Research (HSR), reviewed 62,707 episodes of physical therapy using non-Medicare claims data from a Midwest insurer over a 5-year period. Patients who visited a physical therapist directly for outpatient care (27%) had fewer visits and lower overall costs on average than those who were referred by a physician, while maintaining continuity of care within the overall medical system and showing no difference in health care use in the 60 days after the physical therapy episode.

The study is noteworthy because services delivered by physical therapists account for "a significant portion" of outpatient care costs in the United States, according to the study, and some health insurance plans require a physician referral for reimbursement of these services. In addition, although 46 states and the District of Columbia now allow some form of direct access to physical therapists, some of them nonetheless impose restrictions if patients have not been referred by a physician.

"Physical therapists have long known that direct access to our services is safe and effective," said APTA President R. Scott Ward, PT, PhD. "The elimination of referral requirements and other restrictions has been a priority of APTA for decades. This study provides further evidence that direct access to physical therapists could go a long way toward helping to make health care more affordable and accessible for all. We encourage researchers and insurers to continue to further investigate this important issue that could have a profound impact on patient care."

"When patients choose direct access to a physical therapist, it does not mean the end of collaboration with their physician, nor does it diminish continuity of care," added Thomas DiAngelis, PT, DPT, president of APTA's Private Practice Section. "We believe the results of this study will support our efforts to work with legislators and physician groups to establish policies that reduce unnecessary regulations, improve access, and build models of delivery that best serve the patient and the health care system. Although this study focused on direct access, it is not about the provider. It is about the patient. It means better opportunities to provide the proper care to those who need it, when they need it."

Led by Jane Pendergast, PhD, professor of biostatistics and director of the Center for Public Health Studies at the University of Iowa, the study retrospectively analyzed 5 years (2003-2007) of private health insurance claims data from a Midwest insurer on beneficiaries aged 18-64 in Iowa and South Dakota. A total of nearly 63,000 outpatient physical therapy episodes of care were analyzed – more than 45,000 were classified as physician-referred and more than 17,000 were classified as "self-referred" to physical therapists. Physical therapy episodes began with the initial physical therapist evaluation and ended on the last date of services before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of physical therapy. Researchers found that self-referred patients had fewer physical therapy visits (86% of physician-referred) and lower allowable amounts ($0.87 for every $1.00 of physician-referred) during the episode of care, after adjusting for age, gender, diagnosis, illness severity, and calendar year. In addition, overall related health care use – or care related to the problem for which physical therapy was received, but not physical therapy treatment – was lower in the self-referred group after adjustment. Examples of this type of care might include physician services or diagnostic testing. Potential differences in functional status and outcomes of care were not addressed.

"Health care use did not increase in the self-referred group, nor was continuity of care hindered," the researchers write. "The self-referred patients were still in contact with physicians during and after physical therapy. Concerns about patient safety, missed diagnoses, and continuity of care for individuals who self-refer may be overstated."

According to Rick Gawenda, PT, president of APTA's Section on Health Policy and Administration, the study should cause insurers and policymakers to rethink the physician gatekeeper concept when it comes to physical therapist services. "Evidence shows that, in the case of physical therapy, the physician gatekeeper model is doing exactly the opposite of what it was originally designed to do; it does not reduce ineffective and duplicate care nor reduce health care costs," says Gawenda. "It's time to end the physician referral requirement in every state, and it's time for all payers to embrace direct access to physical therapists."

Earlier research has supported direct access to physical therapists, but the new HSR study is the most comprehensive to date. A 1994 study analyzed 4 years of Blue Cross Blue Shield of Maryland claims data and found that total paid claims for physician referral episodes to physical therapists were 2.2 times higher than the paid claims for direct access episodes. In addition, physician referral episodes were 65% longer in duration than direct access episodes and generated 67% more physical therapy claims and 60% more office visits. The HSR study looked at a far more extensive number of episodes than the previous study, and also controlled for illness severity and other factors that could have affected the patients' outcomes.

"In summary," the researchers write, "our findings do not support the assertion that self-referral leads to overuse of care or discontinuity in care, based on a very large population of individuals in a common private health insurance plan with no requirement for PT [physical therapy] referral or prohibition on patient self-referral. We consistently found lower use in the self-referral group, after adjusting for key demographic variables, diagnosis group, and case mix. We also found that individuals in both groups were similarly engaged with the medical care system during their course of care and afterwards."

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Ginger Root Supplement Reduced Colon Inflammation Markers

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Ginger supplements reduced markers of colon inflammation in a select group of patients, suggesting that this supplement may have potential as a colon cancer prevention agent, according to a study published in Cancer Prevention Research, a journal of the American Association for Cancer Research.

Suzanna M. Zick, N.D., M.P.H., a research assistant professor at the University of Michigan Medical School, and colleagues enrolled 30 patients and randomly assigned them to two grams of ginger root supplements per day or placebo for 28 days.
After 28 days, the researchers measured standard levels of colon inflammation and found statistically significant reductions in most of these markers, and trends toward significant reductions in others.

Inflammation has been implicated in prior studies as a precursor to colon cancer, but another trial would be needed to see how ginger root affects that risk, Zick said.
“We need to apply the same rigor to the sorts of questions about the effect of ginger root that we apply to other clinical trial research,” she said. “Interest in this is only going to increase as people look for ways to prevent cancer that are nontoxic, and improve their quality of life in a cost-effective way.”

Zick is a naturopathic doctor (N.D.), which is a four-year degree that supplements a traditional medical education with instruction on the proper use of natural therapies, diet, nutrition and other alternative treatments. Her program is one of eight in the country, compared with about 135 traditional medical schools.

Complementary and Alternative Medicine Treatments for Mood Disorders

Mood disorders are among the most prevalent mental health issues today. While medication is available, more and more people are turning to complementary and alternative medicine (CAM), including herbal remedies, acupuncture, and meditation to help manage their mood disorders.

Andrew Newberg, MD, director of Research,Daniel Monti, MD, medical and executive director and Aleeze Moss, PhD, instructor of the Mindfulness-Based Art Therapy program at the Jefferson-Myrna Brind Center of Integrative Medicine at Thomas Jefferson University Hospital review the most commonly used CAM practices in the management of patients with mood disorders and the available data on CAM use for mood disorders in the recent issue of Expert Reviews in Neurotherapeutics.

Mood and anxiety disorders include a broad range of diagnoses such as major depression; dysthymia, a type of mild depression, and others.

A 2007 National Health Interview Survey (NHIS) showed that almost 40 percent of adults use CAM, with Americans with depression more likely to use CAM remedies than conventional antidepressants or psychotherapy.

Newberg, Monti and Moss evaluated CAM modalities across four categories: natural products; mind-body medicine and manipulative and body-based practices; and other CAM practices. A snapshot of their findings is outlined here:

Natural Products

Botanical medicines, vitamins, minerals and natural products found to positively impact patients with mood disorders, include: Hypericum (St. John’s Wort); S-adenosyl-methionine- an amino acid essential in production and delivery of dopamine, serotonin and norepenephrine throughout the brain; Omega-3 fatty acids- essential fatty acids (EFAs) play a role in maintaining brain structure and function. Research shows that reduced levels of EFAs may be associated with depression. The most common source of EFAs is fish oil.

Mind-body practices

Meditation, yoga, qi-gong, tai-chi and acupuncture are among the most commonly used. Yoga is effective in improving anxiety and depression, suggests a growing body of research; Meditation-based practices such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have supporting data suggesting therapeutic benefit, including decreases in depression, anxiety and distress for a variety of health conditions, including mood disorders; Acupuncture- inconclusive evidence shows acupuncture can be a beneficial treatment modality for mood disorders.

Other CAM products

There are several CAM products that are used for mood disorders, but many have little supporting data. A few that do include: TRP and 5-HTP, amino acid precursors of serotonin, and the botanical Rhodiola rosea.
The popularity of CAM interventions within the general Western population continues to grow as does the body of rigorous research into the effects and mechanisms of CAM interventions for mood disorders.

“As the field grows, we anticipate that the data will be able to provide a more detailed evaluation of CAM interventions with more practical applications regarding potential benefit effects and helping to avoid adverse effects,” conclude Drs. Newberg and Monti and Moss.
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