Full Title: Clinical hypnosis versus cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations

A randomized controlled trial was conducted to compare the efficacy of clinical hypnosis versus cognitive behavioral (CB) coping skills training in alleviating the pain and distress of 30 pediatric cancer patients (age 5 to 15 years) undergoing bone marrow aspirations. Patients were randomized to one of three groups: hypnosis, a package of CB coping skills, and no intervention. Patients who received either hypnosis or CB reported less pain and pain-related anxiety than did control patients and less pain and anxiety than at their own baseline. Hypnosis and CB were similarly effective in the relief of pain. Results also indicated that children reported more anxiety and exhibited more behavioral distress in the CB group than in the hypnosis group. It is concluded that hypnosis and CB coping skills are effective in preparing pediatric oncology patients for bone marrow aspiration.

Int J Clin Exp Hypn. 1999 Apr;47(2):104-16. Liossi C, Hatira P. University of Sunderland, United Kingdom.

Hypnosis is a modified state of consciousness linking the conscious and the unconscious of a person. In the context of chronic pain, hypnosis enables to help controlling the intensity of the pain, managing the pain and the emotions accompanying it and to help the patient finding his own resources allowing him getting involved in his treatment.

Rev Med Suisse. 2009 Jun 17;5(208):1380-2, 1384-5. Grünenwald M. Centre multidisciplinaire de la douleur, Service de pharmacologie et toxicologie cliniques, HUG, Genève. grunenwaldmichele@hotmail.com

Full Title: Women's views regarding hypnosis for the control of surgical pain in the context of a randomized clinical trial

OBJECTIVE: The aim of this study was to assess women's satisfaction with a hypnotic intervention for anxiety and pain management during a pregnancy-terminating procedure. METHODS: Women (N = 350) scheduled for first-trimester surgical abortion were randomly assigned to standard care or to a short, standardized hypno-analgesia intervention before and during the procedure. We assessed their individual use of the various hypnotic strategies proposed during the intervention and their views (likes/dislikes) about the hypnotic intervention, the pregnancy termination experience, and their participation in this randomized study. RESULTS: Mental imagery of a secure place was the strategy used by most women (71%) in the hypnosis group, but a significant proportion of them also used dissociation (42%) and focal analgesia (39%). Advantages of hypnosis over standard care were found in the patients' report that they could resume their normal activities right after being discharged from the hospital (72% in hypnosis vs. 56% in control group) and in their appreciation of the accompaniment (hypnotherapist vs. nurse) provided during the procedure (97% in hypnosis vs. 56% in control group). Among those who received hypnosis, 97% affirmed that they would recommend hypnosis to a friend for a similar procedure. More than 98% in both groups indicated they would again volunteer to participate in a study evaluating hypnosis for pain management. CONCLUSIONS: Women in the hypnosis group generally reported higher levels of satisfaction with various aspects of the procedure. This is consistent with the growing literature in favor of hypnotic interventions to improve pain management and care.

J Womens Health (Larchmt). 2009 Sep;18(9):1441-7. Marc I, Rainville P, Masse B, Dufresne A, Verreault R, Vaillancourt L, Dodin S. Department of Pediatrics, Centre Hospitalier Universitaire de l'Universite Laval, Université Laval, Quebec, Canada. Isabelle.Marc@crsfa.ulaval.ca

Full Title: Qualitative systemic review of randomized controlled trials on complementary and alternative medicine treatments in fibromyalgia

The objectives of the study were identification, quality evaluation and summary of RCTs on complementary and alternative medicine as defined by the National Institute of Health with the exception of dietary and nutritional supplements. A computerized search of databases from 1990 (year of publication of the ACR criteria for fibromyalgia) to July 2007 was performed. The RCTs were assessed by a methodological quality score. A total of 23 RCTs issued from 1992 to 2007 on acupuncture, balneotherapy, thermotherapy, magnetic therapy, homeopathy, manual manipulation, mind-body medicine, diet therapy and music therapy were identified. The RCTs had an average group size of 25 with the number of groups ranging from two to four. The quality score assessment of the RCTs yielded a mean score of 51 out of 100. The average methodological quality of the identified studies was fairly low. Best evidence was found for balneotherapy/hydrotherapy in multiple studies. Positive results were also noted for homeopathy and mild infrared hyperthermia in 1 RCT in each field. Mindfulness meditation showed mostly positive results in two trials and acupuncture mixed results in multiple trials with a tendency toward positive results. Tendencies for improvement were furthermore noted in single trials of the Mesendieck system, connective tissue massage and to some degree for osteopathy and magnet therapy. No positive evidence could be identified for Qi Gong, biofeedback, and body awareness therapy.

Rheumatol Int. 2009 Aug 12. Baranowsky J, Klose P, Musial F, Haeuser W, Dobos G, Langhorst J. Department of Internal Medicine, Complementary and Integrative Medicine, Kliniken Essen-Mitte, University Duisburg-Essen, Essen, Germany.

FULL TITLE: The effectiveness of hypnosis for reducing procedure-related pain in children and adolescents: a comprehensive methodological review

A comprehensive, methodologically informed review of studies of the effectiveness of hypnosis for reducing procedure-related pain in children and adolescents is provided. To be included in the review, studies were required to use a between-subjects or mixed model design in which hypnosis was compared with a control condition or an alternative intervention in reducing the procedure-related pain of patients younger than age 19. An exhaustive search identified 13 studies satisfying these criteria. Hypnosis was consistently found to be more effective than control conditions in alleviating discomfort associated with bone marrow aspirations, lumbar punctures, voiding cystourethograms, the Nuss procedure, and post-surgical pain. Furthermore, hypnosis was as at least as effective as distraction. Three hypnotic interventions met criteria as a possibly efficacious empirically supported therapy for reducing post-surgical or lumbar puncture pain. Several other hypnotic interventions would have achieved the status of a possibly efficacious therapy had studies used a treatment manual.

J Behav Med. 2009 Aug;32(4):328-39. Epub 2009 Mar 3. Accardi MC, Milling LS. Department of Psychology, University of Hartford, 200 Bloomfield Avenue, West Hartford, CT 06117, USA.

by Jane Nash, BEd, MEd, CHt, NLP Master

I met Anne at a community Weight Management program I was delivering. She learned and practiced Neuro Linguistic Programming techniques following a mixture of Paul McKenna, John Plester and my own techniques rolled into a four week program. During this time it became apparent that she really needed relief from the intense physical pain she experienced on a daily basis. Following a short discussion, we agreed to work together to relieve the symptoms in her body caused by emotional isAnnes which she believed were holding onto the body and adding to her pain levels.

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Suggestion, a powerful factor in everyday social interaction, is most effective during hypnosis. Subjective evaluations and brain-imaging findings converge to propose that hypnotic suggestion strongly modulates sensory processing. To reveal the brain regions that mediate such a modulation, we analyzed data from a functional-magnetic-resonance-imaging study on hypnotic-suggestion-induced pain on 14 suggestible subjects. Activation strengths in the right dorsolateral prefrontal cortex (DLPFC) during initiation of suggestion for pain correlated positively with the subjective intensity of the subsequent suggestion-induced pain, as well as with the strengths of the maximum pain-related activation in the in the secondary somatosensory (SII) cortex. Furthermore, activation of the insula and the anterior cingulate cortex predicted the pain-related SII activation. The right DLPFC, as an area important for executive functions, likely contributes to functional modulation in the modality-specific target areas of given suggestions. Hum Brain Mapp 2009. (c) 2009 Wiley-Liss, Inc.

Hum Brain Mapp. 2009 Jan 30. Raij TT, Numminen J, Närvänen S, Hiltunen J, Hari R. Brain Research Unit, Low Temperature Laboratory and Advanced Magnetic Imaging Centre, Helsinki University of Technology, FIN-02015 TKK, Finland.

Twenty-two patients with multiple sclerosis (MS) and chronic pain we recruited into a quasi-experimental trial comparing the effects of self-hypnosis training (HYP) with progressive muscle relaxation (PMR) on pain intensity and pain interference; 8 received HYP and the remaining 14 participants were randomly assigned to receive either HYP or PMR. HYP-condition participants reported significantly greater pre- to postsession as well as pre- to posttreatment decreases in pain and pain interference than PMR-condition participants, and gains were maintained at 3-month follow-up. Most of the participants in both conditions reported that they continued to use the skills they learned in treatment and experienced pain relief when they did so. General hypnotizability was not significantly related to treatment outcome, but treatment-outcome expectancy assessed before and after the first session was. The results support the efficacy of self-hypnosis training for the management of chronic pain in persons with MS.

Int J Clin Exp Hypn. 2009 Apr;57(2):198-221. Jensen MP, Barber J, Romano JM, Molton IR, Raichle KA, Osborne TL, Engel JM, Stoelb BL, Kraft GH, Patterson DR. University of Washington School of Medicine, Seattle, Washington 98195-6490, USA. mjensen@u.washington.edu

The neural mechanisms underlying the antinociceptive effects of hypnosis still remain unclear. Using a parametric single-trial thulium-YAG laser fMRI paradigm, we assessed changes in brain activation and connectivity related to the hypnotic state as compared to normal wakefulness in 13 healthy volunteers. Behaviorally, a difference in subjective ratings was found between normal wakefulness and hypnotic state for both non-painful and painful intensity-matched stimuli applied to the left hand. In normal wakefulness, non-painful range stimuli activated brainstem, contralateral primary somatosensory (S1) and bilateral insular cortices. Painful stimuli activated additional areas encompassing thalamus, bilateral striatum, anterior cingulate (ACC), premotor and dorsolateral prefrontal cortices. In hypnosis, intensity-matched stimuli in both the non-painful and painful range failed to elicit any cerebral activation. The interaction analysis identified that contralateral thalamus, bilateral striatum and ACC activated more in normal wakefulness compared to hypnosis during painful versus non-painful stimulation. Finally, we demonstrated hypnosis-related increases in functional connectivity between S1 and distant anterior insular and prefrontal cortices, possibly reflecting top-down modulation.

Neuroimage. 2009 May 19. Vanhaudenhuyse A, Boly M, Balteau E, Schnakers C, Moonen G, Luxen A, Lamy M, Degueldre C, Brichant JF, Maquet P, Laureys S, Faymonville ME. Coma Science Group, Cyclotron Research Center, University of Liège, Belgium.

Twenty-two patients with multiple sclerosis (MS) and chronic pain we recruited into a quasi-experimental trial comparing the effects of self-hypnosis training (HYP) with progressive muscle relaxation (PMR) on pain intensity and pain interference; 8 received HYP and the remaining 14 participants were randomly assigned to receive either HYP or PMR. HYP-condition participants reported significantly greater pre- to postsession as well as pre- to posttreatment decreases in pain and pain interference than PMR-condition participants, and gains were maintained at 3-month follow-up. Most of the participants in both conditions reported that they continued to use the skills they learned in treatment and experienced pain relief when they did so. General hypnotizability was not significantly related to treatment outcome, but treatment-outcome expectancy assessed before and after the first session was. The results support the efficacy of self-hypnosis training for the management of chronic pain in persons with MS.

Int J Clin Exp Hypn. 2009 Apr;57(2):198-221. Jensen MP, Barber J, Romano JM, Molton IR, Raichle KA, Osborne TL, Engel JM, Stoelb BL, Kraft GH, Patterson DR. University of Washington School of Medicine, Seattle, Washington 98195-6490, USA. mjensen@u.washington.edu

This study describes the effect of hypnosis on pain relief during labor and childbirth. Using a qualitative approach, 6 pregnant women were trained to use self-hypnosis for labor. Outcomes were analyzed using Colaizzi's procedure. Women described their feelings about hypnosis during labor as: a sense of relief and consolation, self-confidence, satisfaction, lack of suffering labor pain, changing the feeling of pain into one of pressure, a decrease in fear of natural childbirth, lack of tiredness, and lack of anxiety. They expressed increased concentration on the uterus and cervical muscle, awareness of all the stages of labor, and having "positive thoughts." Births were perceived as being very satisfactory compared to their previous experiences.

Int J Clin Exp Hypn. 2009 Apr;57(2):174-83. Abbasi M, Ghazi F, Barlow-Harrison A, Sheikhvatan M, Mohammadyari F. Middlesex University, London, United Kingdom. M.abbasi@mdx.ac.uk

Venepuncture for blood sampling can be a distressing experience for a considerable number of children. A prospective controlled trial was conducted to compare the efficacy of a local anaesthetic (EMLA) with a combination of EMLA with self-hypnosis in the relief of venepuncture-induced pain and anxiety in 45 paediatric cancer outpatients (age 6-16years). A secondary aim of the trial was to test whether the intervention will have a beneficial effect on parents' anxiety levels during their child's procedure. Patients were randomized to one of three groups: local anaesthetic, local anaesthetic plus hypnosis, and local anaesthetic plus attention. Results confirmed that patients in the local anaesthetic plus hypnosis group reported less anticipatory anxiety, and less procedure-related pain and anxiety, and were rated as demonstrating less behavioural distress during the procedure than patients in the other two groups. Parents whose children were randomized to the local anaesthetic plus hypnosis condition experienced less anxiety during their child's procedure than parents whose children had been randomized to the other two conditions. The therapeutic benefit of the brief hypnotic intervention was maintained in the follow-up. The present findings are particularly important in that this study was a randomized, controlled trial conducted in a naturalistic medical setting. In this context, convergence of subjective and objective outcomes was reached with large effect sizes that were consistently supportive of the beneficial effects of self-hypnosis, an intervention that can be easily taught to children, is noninvasive and poses minimal risk to young patients and their parents.

Pain. 2009 Apr;142(3):255-63. Epub 2009 Feb 23. Liossi C, White P, Hatira P. School of Psychology, University of Southampton, Highfield, Southampton S017 1BJ, UK. cliossi@soton.ac.uk

A comprehensive, methodologically informed review of studies of the effectiveness of hypnosis for reducing procedure-related pain in children and adolescents is provided. To be included in the review, studies were required to use a between-subjects or mixed model design in which hypnosis was compared with a control condition or an alternative intervention in reducing the procedure-related pain of patients younger than age 19. An exhaustive search identified 13 studies satisfying these criteria. Hypnosis was consistently found to be more effective than control conditions in alleviating discomfort associated with bone marrow aspirations, lumbar punctures, voiding cystourethograms, the Nuss procedure, and post-surgical pain. Furthermore, hypnosis was as at least as effective as distraction. Three hypnotic interventions met criteria as a possibly efficacious empirically supported therapy for reducing post-surgical or lumbar puncture pain. Several other hypnotic interventions would have achieved the status of a possibly efficacious therapy had studies used a treatment manual.

J Behav Med. 2009 Mar 3. Accardi MC, Milling LS. Department of Psychology, University of Hartford, 200 Bloomfield Avenue, West Hartford, CT, 06117, USA.

OBJECTIVE: Functional chronic recurrent abdominal pain (FCRAP) is long lasting, intermittent, or constant pain affecting 15-30% of children ages 4-18 and presents a diagnostic and treatment challenge to the physician. The predictive value of diagnostic tests is questionable, and studies of the treatment of chronic abdominal pain show inconclusive evidence regarding diet regimens as well as medical and surgical treatments. However, there is evidence that cognitive-behavioral therapy may be useful in improving pain and disability outcome. Increasing the understanding of the neural-pain pathways and research in cognitive modulation of pain led to the application of behavioral strategies in children with FCRAP with variable success. However, the use of hypnotherapy in children with recurrent abdominal pain is not common. During the last 3 years, we have implemented hypnosis as the preferred treatment for patients with FCRAP. In the current study, we aimed to summarize our experience with hypnosis for the treatment of FCRAP in children. PATIENTS AND METHODS: Twenty patients who met the criteria for FCRAP were candidates for hypnosis. Hypnosis or imagery was offered to the families, of whom 3 refused. Seventeen patients underwent just one single session of hypnosis. RESULTS: A possible nonorganic etiology for the abdominal pain was revealed in all cases. In 14 adolescents, all clinical symptoms resolved. Hypnosis was not effective in 3 cases, in whom secondary gain was probably responsible for their symptoms. No side effects have been noted during and after the study. Follow-up was available for a period of 4-24 months. CONCLUSIONS: Although effective in the management of acute pain and distress in pediatric cancer patients, the use of hypnotherapy in children with FCRAP is not a common practice. The current study highly supports the use of hypnosis as a part of the biobehavioral approach for this dilemma.

J Laparoendosc Adv Surg Tech A. 2009 Feb;19(1):93-6. Galili O, Shaoul R, Mogilner J. Department of General Surgery, Bnei-Zion Medical Center, Haifa, Israel.

We compared the methodology and the recommendations of evidence-based guidelines for the management of fibromyalgia syndrome (FMS) to give an orientation within the continuously growing number of reviews on the therapy of FMS. Systematic searches up to April 2008 of the US-American National Guideline Clearing House, the Scottish Intercollegiate Guidelines Network, the Association of the Scientific Medical Societies in Germany (AWMF) and Medline were conducted. Three evidence-based guidelines for the management of FMS published by professional organizations were identified: The American Pain Society (APS) (2005), the European League Against Rheumatism (EULAR) (2007), and the AWMF (2008). The steering committees and panels of APS and AWMF were comprised of multiple disciplines engaged in the management of FMS and included patients, whereas the task force of EULAR only consisted of physicians, predominantly rheumatologists. APS and AWMF ascribed the highest level of evidence to systematic reviews and meta-analyses, whereas EULAR credited the highest level of evidence to randomised controlled studies. Both APS and AWMF assigned the highest level of recommendation to aerobic exercise, cognitive-behavioral therapy, amitriptyline, and multicomponent treatment. In contrast, EULAR assigned the highest level of recommendation to a set of to pharmacological treatment. Although there was some consistency in the recommendations regarding pharmacological treatments among the three guidelines, the APS and AWMF guidelines assigned higher ratings to CBT and multicomponent treatments. The inconsistencies across guidelines are likely attributable to the criteria used for study inclusion, weighting systems, and composition of the panels.

Eur J Pain. 2009 Mar 3. Häuser W, Thieme K, Turk DC. Department of Internal Medicine I, Klinikum Saarbrücken, Winterberg 1, D-66119 Saarbrücken, Germany.

A U.S. Army soldier stationed in Iraq developed myriad pain problems after sustaining a high-level spinal cord injury (SCI) from a gunshot wound. These problems were negatively impacting his ability to participate fully in his physical rehabilitation and care. Ten sessions of self-hypnosis training were administered to the patient over a 5-week period to help him address these problems. Both the patient and his occupational therapist reported a substantial reduction in pain over the course of treatment, which allowed the patient to actively engage in his therapies. Six months post treatment, the patient reported continued use of the hypnosis strategies taught, which effectively reduced his experience of pain. This case study demonstrates the efficacy of hypnotic analgesia treatment for U.S. military veterans who are experiencing pain problems due to traumatic or combat-related SCIs.

Am J Clin Hypn. 2009 Jan;51(3):273-80. Stoelb BL, Jensen MP, Tackett MJ. University of Washington School of Medicine, Department of Rehabilitation Medicine, Seattle, WA 98195, USA. bstoelb@u.washington.edu

Experimental (Price & Barber, 1987) and neuroimaging studies (Rainville, Carrier, Hofbauer, Bushnell, & Duncan, 1999), suggest that it is the affective dimension of pain as processed in the anterior cingulate cortex (ACC) that is most associated with suffering and autonomic arousal. Conversely, pain related emotions (Rainville, Bao, & Chretien, 2005) and expectations (Koyama, McHaffie, Laurenti, & Coghill, 2005) modulate pain perception and associated pain affect. This paper presents both the scientific background and the general clinical steps involved in a practical hypnotic approach that uses emotion specific wording and the elicitation of prior positive experience to intervene at both the affective and sensory dimensions of pain. Such an approach enables patients to therapeutically use hypnosis to reduce their subjective distress even if they are not able to greatly reduce the sensation of pain. The utilization of positive state dependent learning (Rossi, 1986), following the advice of Milton Erickson to "discover their patterns of happiness" (Parsons-Fein, 2005) is emphasized.

Am J Clin Hypn. 2009 Jan;51(3):235-54. Feldman JB. Wake Forest University School of Medicine, USA. jfeldman@wfubmc.edu

Experimental (Price & Barber, 1987) and neuroimaging studies (Rainville, Carrier, Hofbauer, Bushnell, & Duncan, 1999), suggest that it is the affective dimension of pain as processed in the anterior cingulate cortex (ACC) that is most associated with suffering and autonomic arousal. Conversely, pain related emotions (Rainville, Bao, & Chretien, 2005) and expectations (Koyama, McHaffie, Laurenti, & Coghill, 2005) modulate pain perception and associated pain affect. This paper presents both the scientific background and the general clinical steps involved in a practical hypnotic approach that uses emotion specific wording and the elicitation of prior positive experience to intervene at both the affective and sensory dimensions of pain. Such an approach enables patients to therapeutically use hypnosis to reduce their subjective distress even if they are not able to greatly reduce the sensation of pain. The utilization of positive state dependent learning (Rossi, 1986), following the advice of Milton Erickson to "discover their patterns of happiness" (Parsons-Fein, 2005) is emphasized.

Am J Clin Hypn. 2009 Jan;51(3):235-54. Feldman JB. Wake Forest University School of Medicine, USA. jfeldman@wfubmc.edu

Three articles of special interest to the hypnosis community recently appeared in the general scientific and medical literatures. The first paper is a thoughtful review of the clinical applications of hypnosis in pediatric settings. The second article reports the findings of a randomized, controlled trial of hypnosis for burn-wound care, carried out at the University of Washington Medical School. The third article describes an innovative EEG laboratory case study tracking the cortex functional connectivity of a highly hypnotizable subject across various baseline and experimental conditions. These three articles are sturdy examples of how hypnosis illuminates (and is illuminated by) medical and psychological science.

Int J Clin Exp Hypn. 2008 Oct;56(4):463-9. Nash MR, Levy JJ, Tasso A, Perez N. University of Tennessee, Knoxville, Tennessee 37996-0900, USA. mnash@utk.edu

The tonic immobility state (TIS) in rabbit has great potential as an animal model of hypnosis in humans, due to the strong similarities between TIS and hypnosis. It is additionally the only mammalian model available for studying mechanisms of hypnosis. However, its ability to modulate pain perception has yet to be clearly determined. The present experiment examined the effect of nociceptive conditioning in normal, TIS and lidocaine-treated rabbits. This involved three separate phases. In phase one all animals were trained on a continuous performance test (CPT). In the second phase animals were given Pavlovian conditioning to an auditory CS paired with a nociceptive US. In the third phase the animals are given a sensory recognition test. The control group were conditioned during a normal state, the TIS group were conditioned during TIS, the pain control animals were conditioned after lidocaine injection in the skin area stimulated by the nociceptive US. All animals in the normal group showed the greatest amount of pain conditioning, with an average disruption time (dt) of 175s. Animals in the lidocaine group showed little signs of conditioning with an average dt of 16s. Animals conditioned during TIS had an average dt of 42s. These results show that TIS can modulate pain perception similar to animals that did not experience a pain CS. They additionally argue that tonic immobility can produce attenuation of pain perception similar to hypnosis in humans.

Behav Brain Res. 2009 Jan 30;197(1):198-204. Castiglioni JA, Russell MI, Setlow B, Young KA, Welsh JC, Steele-Russell I. Sensory Neuroscience Laboratory, TAMUS HSC and S&W Hospital, Texas A & M University, College Station, TX 77843, USA.

BACKGROUND: Hypnosis treatment in general practice is a rather new concept. This pilot study was performed to evaluate the effect of a standardized hypnosis treatment used in general practice for patients with chronic widespread pain (CWP). METHODS: The study was designed as a randomized control group-controlled study. Sixteen patients were randomized into a treatment group or a control group, each constituting eight patients. Seven patients in the treatment group completed the schedule. After the control period, five of the patients in the control group also received treatment, making a total of 12 patients having completed the treatment sessions. The intervention group went through a standardized hypnosis treatment with ten consecutive therapeutic sessions once a week, each lasting for about 30 minutes, focusing on ego-strengthening, relaxation, releasing muscular tension and increasing self-efficacy. A questionnaire was developed in order to calibrate the symptoms before and after the 10 weeks period, and the results were interpolated into a scale from 0 to 100, increasing numbers representing increasing suffering. Data were analyzed by means of T-tests. RESULTS: The treatment group improved from their symptoms, (change from 62.5 to 55.4), while the control group deteriorated, (change from 37.2 to 45.1), (p = 0,045). The 12 patients who completed the treatment showed a mean improvement from 51.5 to 41.6. (p = 0,046). One year later the corresponding result was 41.3, indicating a persisting improvement. CONCLUSION: The study indicates that hypnosis treatment may have a positive effect on pain and quality of life for patients with chronic muscular pain. Considering the limited number of patients, more studies should be conducted to confirm the results. TRIAL REGISTRATION: The study was registered in ClinicalTrials.gov and released 27.08.07 Reg nr NCT00521807 Approval Number: 05032001.

BMC Musculoskelet Disord. 2008 Sep 18;9:124. Grøndahl JR, Rosvold EO. Institute of General Practice and Community Medicine, Faculty of Medicine, University of Oslo, Norway. janrob@c2i.net

The tonic immobility state (TIS) in rabbit has great potential as an animal model of hypnosis in humans, due to the strong similarities between TIS and hypnosis. It is additionally the only mammalian model available for studying mechanisms of hypnosis. However, its ability to modulate pain perception has yet to be clearly determined. The present experiment examined the effect of nociceptive conditioning in normal, TIS and lidocaine-treated rabbits. This involved three separate phases. In phase one all animals were trained on a continuous performance test (CPT). In the second phase animals were given Pavlovian conditioning to an auditory CS paired with a nociceptive US. In the third phase the animals are given a sensory recognition test. The control group were conditioned during a normal state, the TIS group were conditioned during TIS, the pain control animals were conditioned after lidocaine injection in the skin area stimulated by the nociceptive US. All animals in the normal group showed the greatest amount of pain conditioning, with an average disruption time (dt) of 175s. Animals in the lidocaine group showed little signs of conditioning with an average dt of 16s. Animals conditioned during TIS had an average dt of 42s. These results show that TIS can modulate pain perception similar to animals that did not experience a pain CS. They additionally argue that tonic immobility can produce attenuation of pain perception similar to hypnosis in humans.

Behav Brain Res. 2008 Aug 27. Castiglioni JA, Russell MI, Setlow B, Young KA, Welsh JC, Li LH, Steele-Russell I. Sensory Neuroscience Laboratory, TAMUS HSC and S&W Hospital, Texas A & M University, College Station, TX 77843, USA; Department of Neuroscience & Experimental Therapeutics, Texas A & M University, College Station, TX 77843, USA.

Pain may cause physical and emotional distress in children experiencing medical procedures. Complementary and alternative medical (CAM) therapies have become increasingly important in treating children's painful conditions, yet it is still unclear whether CAM has a place in acute pediatric pain analgesia. This review aims to present an overview of the available published evidence. Most research has examined the efficacy of hypnosis, which has emerged as useful in alleviating acute pain associated with a number of medical procedures. Music therapy also has gained some attention and for the most part shows promise in the pediatric acute pain setting. Acupuncture, laughter therapy, and massage also may prove beneficial. Despite the promise of many of these modalities, we conclude that further empirical research into safety and efficacy using well-designed studies and large samples is required before guidelines can be established. In addition, further work is needed in standardizing interventions, creating treatment manuals, and determining treatment efficacy as a function of the child's development, his or her individual characteristics, and the type of procedure the child is undergoing.

Altern Ther Health Med. 2008 Sep-Oct;14(5):52-6. Evans S, Tsao JC, Zeltzer LK. Pediatric Pain Program, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, USA.

This case report evaluates virtual reality hypnosis (VRH) in treating chronic neuropathic pain in a patient with a 5-year history of failed treatments. The patient participated in a 6-month trial of VRH, and her pain ratings of intensity and unpleasantness dropped on average 36% and 33%, respectively, over the course of 33 sessions. In addition, she reported both no pain and a reduction of pain for an average of 3.86 and 12.21 hours, respectively, after treatment sessions throughout the course of the VRH treatment. These reductions and the duration of treatment effects following VRH treatment were superior to those following a trial of standard hypnosis (non-VR) treatment. However, the pain reductions with VRH did not persist over long periods of time. The findings support the potential of VRH treatment for helping individuals with refractory chronic pain conditions.

Int J Clin Exp Hypn. 2008 Oct;56(4):451-62. Oneal BJ, Patterson DR, Soltani M, Teeley A, Jensen MP. University of Washington School of Medicine, Seattle, Washington, USA. davepatt@u.washington.edu

Improvement in functional neuroimaging allows researchers to disentangle the brain mechanisms involved in the pain modulation encountered during hypnosis. It has been shown that the anterior cingulate and prefrontal cortices are important in the modulation of incoming sensory and noxious input. Moreover, clinical studies in certain types of surgery (eg thyroidectomy, mastectomy and plastic surgery) have demonstrated that hypnosis may avoid general anesthesia.

Rev Med Liege. 2008 May-Jun;63(5-6):424-8. Vanhaudenhuyse A, Boveroux P, Boly M, Schnakers C, Bruno MA, Kirsch M, Demertzi A, Lamy M, Maquet P, Laureys S, Faymonville ME. Coma Science Group, Centre de Recherches du Cyclotron, Université de Liège, Liège, Belgique.

It is a tenet of cognitive behavioral treatment of persistent pain problems that ex-patients should adhere to treatment methods over the longer term, in order to maintain and to extend treatment gains. However, no research has quantified the causal influence of adherence on short-term outcome in this field. The aims of this study are to assess determinants of adherence to treatment recommendations in several domains, and to examine the extent to which cognitive and behavioral adherence predicts better outcome of cognitive behavioral treatment for persistent pain. Longitudinal data from a sample of 2345 persistent pain patients who attended a multicomponent treatment programme were subjected to structural equation modeling. Adherence emerged as a mediating factor linking post-treatment and follow-up treatment outcome, but contributed only 3% unique variance to follow-up outcomes. Combined end-of-treatment outcomes and adherence factors accounted for 72% of the variance in outcome at one-month follow-up. Notwithstanding shortcomings in the measurement of adherence, these findings question the emphasis normally given to adherence in the maintenance of behavioral and cognitive change, and clinical implications are discussed.

Curran C, Williams AC, Potts HW. Research Department of Clinical, Education and Health Psychology, University College London, Gower Street, London WC1E 6BT, United Kingdom. Eur J Pain. 2008 Jul 22.

BACKGROUND: A guideline for the treatment and diagnostic procedures in fibromyalgia syndrome (FMS) was developed in cooperation with 10 German medical and psychological associations and 2 patient self-help groups. METHODS: A systematic literature search including all controlled studies of evaluated multicomponent therapy was performed in the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-12/2006), PsychInfo (1966-12/2006) and Scopus (1980-12/ 2006). Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. Grading of the strengths of recommendations was done according to the German program for disease management guidelines. Standardized procedures to reach a consensus on recommendations were used. RESULTS: Cognitive and operant behavioral therapy is strongly recommended (grade A). Guided imagery/hypnotherapy and written emotional disclosure are recommended (grade B). CONCLUSIONS: Psychotherapeutic programs tailored to FMS subgroups should be developed and tested.

Schmerz. 2008 Jun;22(3):295-302. Thieme K, Häuser W, Batra A, Bernardy K, Felde E, Gesmann M, Illhardt A, Settan M, Wörz R, Köllner V. Institut für Neuropsychologie und Klinische Psychologie, Zentralinstitut für Seelische Gesundheit Mannheim, Universität Heidelberg , J5, 68159 Mannheim. thieme@zi-mannheim.de

This exploratory, descriptive study, done retrospectively from perinatal medical records, compared childbirth outcomes in one obstetrician's caseload between 50 women who elected antepartal hypnosis preparation (usually a 5-class series) and 51 who did not. The groups were demographically similar. To achieve similar numbers to the hypnosis group, the control group was randomly selected from the women in the caseload who opted not to take hypnosis preparation, based on characteristics of parity and delivery mode. Prenatal hypnosis preparation resulted in significantly less use of sedatives, analgesia, and regional anesthesia during labor and in higher 1-minute neonatal Apgar scores. Other physiologic and outcome measures did not reveal statistical significance, although some trends were of clinical interest. Well-controlled studies are warranted for clinicians to offer hypnosis more frequently as a pain relief option for childbirth. Additional information provided includes pragmatic, clinical, and cost information about incorporating hypnosis into a physician's practice.

Am J Clin Hypn. 2007 Oct;50(2):109-19. VandeVusse L, Irland J, Healthcare WF, Berner MA, Fuller S, Adams D. Marquette University College of Nursing, Milwaukee, WI 53201-1881, USA. leona.vandevusse@mu.edu

Exercise-induced muscle damage (EIMD) can be caused by novel or unaccustomed exercise and results in a temporary decrease in muscle force production, a rise in passive tension, increased muscle soreness and swelling, and an increase in intramuscular proteins in blood. Consequently, EIMD can have a profound effect on the ability to perform subsequent bouts of exercise and therefore adhere to an exercise training programme. A variety of interventions have been used prophylactically and/or therapeutically in an attempt to reduce the negative effects associated with EIMD. This article focuses on some of the most commonly used strategies, including nutritional and pharmacological strategies, electrical and manual therapies and exercise. Long-term supplementation with antioxidants or beta-hydroxy-beta-methylbutyrate appears to provide a prophylactic effect in reducing EIMD, as does the ingestion of protein before and following exercise. Although the administration of high-dose NSAIDs may reduce EIMD and muscle soreness, it also attenuates the adaptive processes and should therefore not be prescribed for long-term treatment of EIMD. Whilst there is some evidence that stretching and massage may reduce muscle soreness, there is little evidence indicating any performance benefits. Electrical therapies and cryotherapy offer limited effect in the treatment of EIMD; however, inconsistencies in the dose and frequency of these and other interventions may account for the lack of consensus regarding their efficacy. Both as a cause and a consequence of this, there are very few evidence-based guidelines for the application of many of these interventions. Conversely, there is unequivocal evidence that prior bouts of eccentric exercise provide a protective effect against subsequent bouts of potentially damaging exercise. Further research is warranted to elucidate the most appropriate dose and frequency of interventions to attenuate EIMD and if these interventions attenuate the adaptation process. This will both clarify the efficacy of such strategies and provide guidelines for evidence-based practice.

Howatson G, van Someren KA. School of Human Sciences, St Mary's University College, Twickenham, UK. howatsong@smuc.ac.uk Sports Med. 2008;38(6):483-503.

BACKGROUND: With increasing survival estimates for cystic fibrosis (CF) long-term management has become an important focus. Psychological interventions are largely concerned with adherence to treatment, emotional and social adjustments and quality of life. We are unaware of any relevant systematic reviews. OBJECTIVES: Assess whether psychological interventions for CF provide significant psychosocial and physical benefits in addition to standard care. SEARCH STRATEGY: Trials were identified from two Cochrane trial registers (CF and Genetic Disorders Group; Depression, Anxiety and Neurosis Group), Ovid MEDLINE and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search: September 2007. SELECTION CRITERIA: Randomised controlled trials of a broad range of psychological interventions in children and adults with CF and their immediate family. DATA COLLECTION AND ANALYSIS: Two authors independently selected relevant trials and assessed their methodological quality. MAIN RESULTS: The review includes 13 studies (five new at this update) representing data from 529 participants. Studies mainly assessed behavioural and educational interventions:1. gene pre-test education counselling for relatives of those with CF;2. biofeedback, massage and music therapy to assist physiotherapy;3. behavioural and educational interventions to improve dietary intake and airway clearance;4. self-administration of medication and education to promote independence, knowledge and quality of life; and5. systemic interventions promoting psychosocial functioning.A substantial proportion of outcomes were educational or behavioural relating to issues of adherence, change in physical status or other specific treatment concerns during the chronic phase of the disease.Some evidence was found for relative's acceptance of a genetic test for carrier status when using home-based rather than clinic-based information leaflets and testing. There is some evidence that behavioural interventions improve emotional outcomes in people with CF and their carers, and that psychoeducational interventions improve knowledge in the short term. There was no consistent effect on lung function, although one small study showed that biofeedback-assisted breathing re-training helped improve some lung function measurements. Some studies point to educational and behavioural interventions aiding nutrition and growth in people with CF. Currently there is insufficient evidence for interventions aimed at other aspects of the disease process. AUTHORS' CONCLUSIONS: Currently no clear evidence exists on the best psychological interventions to help people with CF and their carers manage the disease. Trials of interventions to improve adherence to treatment are needed. Multicentre approaches, with consequent funding implications, will increase the sample size of trials and enhance the power and precision of their findings.

Glasscoe CA, Quittner AL. Academic Child Mental Health Unit, Royal Liverpool Children's Hospital, Eaton Road, Liverpool, UK, L12 2AP. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD003148.

Palliative care is care that is given to patients and their significant others who are experiencing life-threatening or life-altering illnesses by providing emotional, spiritual, and physical support. Patients can continue to receive aggressive medical treatment while receiving palliative care and recovery is possible. Pain control is a top priority in palliative care. Non-pharmacological interventions have also been shown to be effective in palliative care as well. Palliative care is truly a holistic, collaborative practice engaging many disciplines in the care of the patient and their love ones.

Geoghan DA. J Pract Nurs. 2008 Spring;58(1):6-9; quiz 10-1.

Objective:To study the effect of maternal massage therapy on hospital stay in very-low-birth-weight infants who were already submitted to skin-to-skin care.Study Design:A randomized study was performed including infants of birth weight >/=750 and Mendes EW, Procianoy RS. Department of Maternal-Infant Nursing, Nursing School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil [2] 3Newborn Section, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil. J Perinatol. 2008 Jul 17.

BACKGROUND: Chronic pain is a prevalent and costly problem that eludes adequate treatment. Persistent pain affects all domains of people's lives and in the absence of cure, success will greatly depend on adaptation to symptoms and self-management. METHOD: We reviewed the psychological models that have been used to conceptualize chronic pain-psychodynamic, behavioural (respondent and operant), and cognitive-behavioural. Treatments based on these models, including insight, external reinforcement, motivational interviewing, relaxation, meditation, biofeedback, guided imagery, and hypnosis are described. RESULTS: The cognitive-behavioural perspective has the greatest amount of research supports the effectiveness of this approach with chronic pain patients. Importantly, we differentiate the cognitive-behavioural perspective from cognitive and behavioural techniques and suggest that the perspective on the role of patients' beliefs, attitudes, and expectations in the maintenance and exacerbation of symptoms are more important than the specific techniques. The techniques are all geared to fostering self-control and self-management that will encourage a patient to replace their feelings of passivity, dependence, and hopelessness with activity, independence, and resourcefulness. CONCLUSIONS: Psychosocial and behavioural factors play a significant role in the experience, maintenance, and exacerbation of pain. Self-management is an important complement to biomedical approaches. Cognitive-behavioural therapy alone or within the context of an interdisciplinary pain rehabilitation program has the greatest empirical evidence for success. As none of the most commonly prescribed treatment regimens are sufficient to eliminate pain, a more realistic approach will likely combine pharmacological, physical, and psychological components tailored to each patient's needs.

Turk DC, Swanson KS, Tunks ER. University of Washington School of Medicine, Seattle, WA 98195-6540, USA. turkdc@u.washington.edu Can J Psychiatry. 2008 Apr;53(4):213-23.

This study examined potential psychosocial stressors of 30 children with headaches (mean age, 15 years), and the role of insight generation in the outcome of hypnosis therapy. The mean duration of headache occurrence was 3 years. All of the patients were instructed in how to use hypnosis-induced relaxation and headache-related imagery to improve their symptoms. Thirty-seven percent reported their headaches were associated with fixed stressors, defined as caused by events over which patients had no control, while 63% reported variable stressors, defined as modifiable by the patients' actions. Four patients were lost to follow-up. Overall, 96% (25/26) reported a decrease in headache frequency and/or intensity following use of hypnosis. However, prior to insight generation patients reporting fixed stressors were significantly less likely to improve than those reporting variable stressors (p = 0.018). Thus, insight generation may be more important for achievement of improvement in children whose headaches are associated with fixed stressors.

Anbar RD, Zoughbi GG. Department of Pediatrics, University Hospital, State University of New York Upstate Medical University Syracuse, NY 13110, USA. anbarr@upstate.edu Am J Clin Hypn. 2008 Apr;50(4):335-41.

STUDY DESIGN: Prospective, multicenter, cohort study. OBJECTIVE: To examine which clinical and sociodemographic baseline variables can predict a favorable outcome in subjects with neck pain treated by chiropractors. SUMMARY OF BACKGROUND DATA: Relatively little is known on predictors of neck pain, particularly for those subjects undergoing chiropractic care. No previous study has examined predictors of outcome for subjects with neck pain by modeling the trajectories of subjects in a longitudinal design. METHODS: All new, consecutive patients, between 18 and 65 years of age with neck pain of any duration, who had not undergone chiropractic or manual therapy in the prior 3 months, were recruited. Questionnaires were administered at the first 3 visits, and at 3 and 12 months. In all, 29 putative prognostic baseline variables were evaluated. Multivariate multilevel longitudinal regression analyses were conducted using neck pain, neck disability, and perceived recovery as outcomes. RESULTS: In total, 529 patients fulfilled the inclusion criteria. The response rate at 12-months was 92%. In the multivariate analyses, 14 (48%) of the prognostic variables examined were retained in at least one of the models. Shorter duration of neck pain at the first visit was the only variable retained in all 3 final regression models. The following were predictive of a favorable outcome for any 2 of the 3 outcome measures examined: intermittent neck pain, those not on sick-leave or receiving workers compensation at baseline, a higher level of education, less tiredness, higher expectations that the treatment would be beneficial, lack of morning pain, and worse perceived general health. CONCLUSION: On the basis of the patient's history, the clinician can identify a number of determinants, which are predictive of a favorable outcome. Shorter duration of neck pain at the first visit was the only variable consistently found to be predictive of a favorable outcome for all 3 outcome measures examined.

Rubinstein SM, Knol DL, Leboeuf-Yde C, de Koekkoek TE, Pfeifle CE, van Tulder MW. Institute for Research in Extramural Medicine (EMGO-Institute), VU University Medical Center, Amsterdam, The Netherlands. SM.Rubinstein@vumc.nl Spine. 2008 Jun 1;33(13):1451-8.

This controlled and patient blinded study tested the effect of hypnosis on persistent idiopathic orofacial pain (PIOP) in terms of clinical and psychosocial findings. Forty-one PIOP were randomized to active hypnotic intervention or simple relaxation as control for five individual 1-h sessions. Primary outcome was average pain intensity scored three times daily in a pain diary using visual analogue scale (VAS). Secondary outcome measures were pain quality assessed by McGill pain questionnaire (MPQ), psychological symptoms assessed by symptom check list (SCL), quality of life assessed by SF36, sleep quality, and consumption of analgesic. Data were compared between groups before and after treatment using ANOVA models and paired t-tests. The change in VAS pain scores from baseline to the last treatment (t4) was (33.1+/-7.4%) in the hypnosis group and (3.2+/-5.4%) in the control group (P<0.03). In the hypnosis group, highly hypnotic susceptible patients had greater decreases in VAS pain scores (55.0+/-12.3%) when compared to less susceptible patients (17.9+/-6.7%) (P<0.02). After the last treatment there were also statistically significant differences between groups in perceived pain area (MPQ) and the use of weak analgesics (P<0.03). There were no statistically significant changes in SCL or SF36 scores from baseline to t4. In conclusion, hypnosis seems to offer clinically relevant pain relief in PIOP, particularly in highly susceptible patients. However, stress coping skills and unresolved psychological problems need to be included in a comprehensive management plan in order also to address psychological symptoms and quality of life.

Abrahamsen R, Baad-Hansen L, Svensson P. Department of Clinical Oral Physiology, School of Dentistry, University of Aarhus, Vennelyst Boulevard 9, DK-8000 Aarhus, Denmark. rabrahamsen@odont.au.dk Pain. 2008 May;136(1-2):44-52.

OBJECTIVE: To determine the efficacy of an Internet-based Arthritis Self-Management Program (ASMP) as a resource for arthritis patients unable or unwilling to attend small-group ASMPs, which have proven effective in changing health-related behaviors and improving health status measures. METHODS: Randomized intervention participants were compared with usual care controls at 6 months and 1 year using repeated-measures analyses of variance. Patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia and Internet and e-mail access (n = 855) were randomized to an intervention (n = 433) or usual care control (n = 422) group. Measures included 6 health status variables (pain, fatigue, activity limitation, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 5 utilization variables (physician visits, emergency room visits, chiropractic visits, physical therapist visits, and nights in hospital), and self-efficacy. RESULTS: At 1 year, the intervention group significantly improved in 4 of 6 health status measures and self-efficacy. No significant differences in health behaviors or health care utilization were found. CONCLUSION: The Internet-based ASMP proved effective in improving health status measures at 1 year and is a viable alternative to the small-group ASMP.

Lorig KR, Ritter PL, Laurent DD, Plant K. Stanford University School of Medicine, Stanford, California, USA. Arthritis Rheum. 2008 Jul 15;59(7):1009-17.

Pain is a complex phenomenon, influenced by many individual and external factors, and may be experienced differently with age. The detrimental health and social effects of chronic pain are well known. Age-related disorders, such as dementia, may interfere with the communication of pain. Health care provider bias and cultural expectations also may be barriers to the recognition and management of pain in the elderly. A multidisciplinary and multimodal approach in older adults is essential to effective assessment and management. Behavioral approaches to pain should be considered and incorporated into treatment where appropriate.

Norelli LJ, Harju SK. Department of Psychiatry, Albany Medical College, 43 New Scotland Avenue, Albany, NY 12208, USA. norelll@mail.amc.edu Clin Geriatr Med. 2008 May;24(2):335-44, vii.

OBJECTIVES: To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low-back pain (CLBP) when managed in a hospital by either a regional pain clinic or a chiropractor. DESIGN: The study was a pragmatic, randomized, controlled trial. SETTING: The trial was performed at a National Health Service (NHS) hospital outpatient clinic (pain clinic) in the United Kingdom. SUBJECTS AND INTERVENTIONS: Patients with CLBP (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an NHS hospital setting. OUTCOME MEASURES: The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student's t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated. RESULTS: Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023). Conclusions: This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with CLBP.

J Altern Complement Med. 2008 Jun;14(5) Wilkey A, Gregory M, Byfield D, McCarthy PW. Private Practice, Oldham, United Kingdom.

Non-specific low back pain (NSLBP) is commonly conceptualised and managed as being inflammatory and/or mechanical in nature. This study was designed to identify common symptoms or signs that may allow discrimination between inflammatory low back pain (ILBP) and mechanical low back pain (MLBP). Experienced health professionals from five professions were surveyed using a questionnaire listing 27 signs/symptoms. Of 129 surveyed, 105 responded (81%). Morning pain on waking demonstrated high levels of agreement as an indicator of ILBP. Pain when lifting demonstrated high levels of agreement as an indicator of MLBP. Constant pain, pain that wakes, and stiffness after resting were generally considered as moderate indicators of ILBP, while intermittent pain during the day, pain that develops later in the day, pain on standing for a while, with lifting, bending forward a little, on trunk flexion or extension, doing a sit up, when driving long distances, getting out of a chair, and pain on repetitive bending, running, coughing or sneezing were all generally considered as moderate indicators of MLBP. This study identified two groups of factors that were generally considered as indicators of ILBP or MLBP. However, none of these factors were thought to strongly discriminate between ILBP and MLBP.

Man Ther. 2008 Jun 12. Walker BF, Williamson OD. School of Chiropractic and Sports Science, Faculty of Health Sciences, Murdoch University, 6150 Murdoch, Western Australia, Australia.