Shrinking Number of Primary Care Doctors Reaches Tipping Point

By Elisabeth Rosenthal, KFF Health News

I’ve been receiving an escalating stream of panicked emails from people telling me their longtime physician was retiring, was no longer taking their insurance, or had gone concierge and would no longer see them unless they ponied up a hefty annual fee.

They have said they couldn’t find another primary care doctor who could take them on or who offered a new-patient appointment sooner than months away.

Their individual stories reflect a larger reality: American physicians have been abandoning traditional primary care practice — internal and family medicine — in large numbers. Those who remain are working fewer hours. And fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.

The percentage of U.S. doctors in adult primary care has been declining for years and is now about 25% — a tipping point beyond which many Americans won’t be able to find a family doctor at all.

Already, more than 100 million Americans don’t have usual access to primary care, a number that has nearly doubled since 2014. One reason our coronavirus vaccination rates were low compared with those in countries such as China, France, and Japan could be because so many of us no longer regularly see a familiar doctor we trust.

Another telling statistic: In 1980, 62% of doctor’s visits for adults 65 and older were for primary care and 38% were for specialists, according to Michael L. Barnett, a health systems researcher and primary care doctor in the Harvard Medical School system.

By 2013, that ratio had exactly flipped and has likely “only gotten worse,” Barnett said, noting sadly: “We have a specialty-driven system. Primary care is seen as a thankless, undesirable backwater.” That’s “tragic,” in his words — studies show that a strong foundation of primary care yields better health outcomes overall, greater equity in health care access, and lower per capita health costs.

Practices Sold

One explanation for the disappearing primary care doctor is financial. The payment structure in the U.S. health system has long rewarded surgeries and procedures while shortchanging the diagnostic, prescriptive, and preventive work that is the province of primary care. Furthermore, the traditionally independent doctors in this field have little power to negotiate sustainable payments with the mammoth insurers in the U.S. market.

Faced with this situation, many independent primary care doctors have sold their practices to health systems or commercial management chains (some private equity-owned) so that, today, three-quarters of doctors are now employees of those outfits.

One of them was Bob Morrow, who practiced for decades in the Bronx. For a typical visit, he was most recently paid about $80 if the patient had Medicare, with its fixed-fee schedule. Commercial insurers paid significantly less. He just wasn’t making enough to pay the bills, which included salaries of three employees, including a nurse practitioner.

“I tried not to pay too much attention to money for four or five years — to keep my eye on my patients and not the bottom line,” he said by phone from his former office, as workers carted away old charts for shredding.

Morrow finally gave up and sold his practice last year to a company that took over scheduling, billing, and negotiations with insurers. It agreed to pay him a salary and to provide support staff as well as supplies and equipment.

The outcome: Calls to his office were routed to a call center overseas, and patients with questions or complaining of symptoms were often directed to a nearby urgent care center owned by the company — which is typically more expensive than an office visit. His office staff was replaced by a skeleton crew that didn’t include a nurse or skilled worker to take blood pressure or handle requests for prescription refills. He was booked with patients every eight to 10 minutes.

He discovered that the company was calling some patients and recommending expensive tests — such as vascular studies or an abdominal ultrasound — that he did not believe they needed.

He retired in January. “I couldn’t stand it,” he said. “It wasn’t how I was taught to practice.”

‘Squeezed From All Sides’

Of course, not every practice sale ends with such unhappy results, and some work out well. But the dispirited feeling that drives doctors away from primary care has to do with far more than money. It’s a lack of respect for nonspecialists. It’s the rising pressure to see and bill more patients: Employed doctors often coordinate the care of as many as 2,000 people, many of whom have multiple problems.

And it’s the lack of assistance. Profitable centers such as orthopedic and gastroenterology clinics usually have a phalanx of support staff. Primary care clinics run close to the bone.

“You are squeezed from all sides,” said Barnett.

Many ventures are rushing in to fill the primary care gap. There had been hope that nurse practitioners and physician assistants might help fill some holes, but data shows that they, too, increasingly favor specialty practice. Meanwhile, urgent care clinics are popping up like mushrooms. So are primary care chains such as One Medical, now owned by Amazon. Dollar General, Walmart, Target, CVS Health, and Walgreens have opened “retail clinics” in their stores.

Rapid-fire visits with a rotating cast of doctors, nurses, or physician assistants might be fine for a sprained ankle or strep throat. But they will not replace a physician who tells you to get preventive tests and keeps tabs on your blood pressure and cholesterol — the doctor who knows your health history and has the time to figure out whether the pain in your shoulder is from your basketball game, an aneurysm, or a clogged artery in your heart.

Some relatively simple solutions are available, if we care enough about supporting this foundational part of a good medical system. Hospitals and commercial groups could invest some of the money they earn by replacing hips and knees to support primary care staffing; giving these doctors more face time with their patients would be good for their customers’ health and loyalty if not (always) the bottom line.

Reimbursement for primary care visits could be increased to reflect their value — perhaps by enacting a national primary care fee schedule, so these doctors won’t have to butt heads with insurers. And policymakers could consider forgiving the medical school debt of doctors who choose primary care as a profession.

They deserve support that allows them to do what they were trained to do: diagnosing, treating, and getting to know their patients.

The United States already ranks last among wealthy countries in certain health outcomes. The average life span in America is decreasing, even as it increases in many other countries. If we fail to address the primary care shortage, our country’s health will be even worse for it.

KFF Health News is a national newsroom that produces in-depth journalism about health issues. 

Doctors and Patients Shame Insurers to Reverse Treatment Denials

By Lauren Sausser, KFF Health News

Sally Nix was furious when her health insurance company refused to pay for the infusions she needs to ease her chronic pain and fatigue.

Nix has struggled with a combination of autoimmune diseases since 2011. Brain and spinal surgeries didn’t ease her symptoms. Nothing worked, she said, until she started intravenous immunoglobulin infusions late last year. Commonly called IVIG, the treatment bolsters her compromised immune system with healthy antibodies from other people’s blood plasma.

“IVIG turned out to be my great hope,” she said.

That’s why, when Nix’s health insurer started denying payment for the treatment, she turned to Facebook and Instagram to vent her outrage.

“I was raising Cain about it,” said Nix, 53, of Statesville, North Carolina, who said she was forced to pause treatment because she couldn’t afford to pay more than $13,000 out of pocket every four weeks.

“There are times when you simply must call out wrongdoings,” she wrote on Instagram. “This is one of those times.”

Prior authorization is a common cost-cutting tool used by health insurers that requires patients and doctors to secure approval before moving forward with many tests, procedures, and prescription medications.

SALLY NIX

Insurers say the process helps them control costs by preventing medically unnecessary care. But patients say the often time-consuming and frustrating rules create hurdles that delay or deny access to the treatments they need. In some cases, delays and denials equal death, doctors say.

That’s why desperate patients like Nix — and even some physicians — say they have turned to publicly shaming insurance companies on social media to get tests, drugs, and treatments approved.

“Unfortunately, this has become a routine practice for us to resort to if we don’t get any headway,” said Shehzad Saeed, a pediatric gastroenterologist at Dayton’s Children’s Hospital in Ohio. In March, he tweeted a photo of an oozing skin rash, blaming Anthem for denying the biologic treatment his patient needed to ease her Crohn’s disease symptoms.

In July, Eunice Stallman, a psychiatrist based in Idaho, joined X, formerly known as Twitter, for the first time to share how her 9-month-old daughter, Zoey, had been denied prior authorization for a $225 pill she needs to take twice a day to shrink a large brain tumor. “This should not be how it’s done,” Stallman said.

Prior Authorization Reform

The federal government has proposed ways to reform prior authorization that would require insurance companies to provide more transparency about denials and to speed up their response times. If finalized, those federal changes would be implemented in 2026.

But even then, the rules would apply only to some categories of health insurance, including Medicare, Medicare Advantage, and Medicaid plans, but not employer-sponsored health plans. That means roughly half of all Americans wouldn’t benefit from the changes.

The 2010 Patient Protection and Affordable Care Act prohibits health insurance plans from denying or canceling coverage to patients due to their preexisting conditions.

AHIP, an industry trade group formerly called America’s Health Insurance Plans, did not respond to a request for comment.

“They just delay and delay and delay until you die. And you’re absolutely helpless as a patient.”

— Linda Peeno, Healthcare Consultant

But some patient advocates and health policy experts question whether insurers are using prior authorization as “a possible loophole” to this prohibition, as a way of denying care to patients with the highest health care costs, explained Kaye Pestaina, a KFF vice president and the co-director of its Program on Patient and Consumer Protections.

“They take in premiums and don’t pay claims. That’s how they make money,” said Linda Peeno, a health care consultant and retired Kentucky physician who was employed as a medical reviewer by Humana in the 1980s and later became a whistleblower. “They just delay and delay and delay until you die. And you’re absolutely helpless as a patient.”

But there’s reason to hope things may get marginally better. Some major insurers are voluntarily revamping their prior authorization rules to ease preapproval mandates for doctors and patients. And many states are passing laws to rein in the use of prior authorization.

“Nobody is saying we should get rid of it entirely,” said Todd Askew, senior vice president for advocacy at the American Medical Association, in advance of the group’s annual meeting in June. “But it needs to be right-sized, it needs to be simplified, it needs to be less friction between the patient and accessing their benefits.”

Online Venting

Customers are increasingly using social media to air their complaints across all industries, and companies are paying attention. Nearly two-thirds of complainants reported receiving some sort of response to their online post, according to the 2023 “National Consumer Rage Survey,” conducted by Customer Care Measurement & Consulting in collaboration with Arizona State University.

Some research suggests companies are better off engaging with unhappy customers offline, rather than responding to public social media posts. But many patients and doctors believe venting online is an effective strategy, though it remains unclear how often this tactic works in reversing prior authorization denials.

“It’s not even a joke. The fact that that’s how we’re trying to get these medications is just sad,” said Brad Constant, an inflammatory bowel disease specialist who has published research on prior authorization. His work found that prior authorizations are associated with an increased likelihood that children with inflammatory bowel disease will be hospitalized.

Saeed said the day after he posted the picture of the skin rash, the case was marked for a peer-to-peer review, meaning the prior authorization denial would get a closer look by someone at the insurance company with a medical background. Eventually, the biologic medicine Saeed’s patient needed was approved.

Stallman, who is insured through her employer, said she and her husband were prepared to pay out of pocket if Blue Cross of Idaho didn’t reverse the denial for the drug Zoey needed.

Bret Rumbeck, a spokesperson for the insurer, said Zoey’s medication was approved on July 14 after the company consulted an outside specialist and obtained more information from Zoey’s doctor.

Stallman posted details about the ordeal online only after the insurer approved the drug, in part, she said, to prevent them from denying the treatment again when it comes up for a 90-day insurance review in October. “The power of the social media has been huge,” she said.

Nix had been insured by Blue Cross Blue Shield of Illinois through her husband’s employer for almost two decades. Dave Van de Walle, a spokesperson for the company, did not specifically address Nix’s case. But in a prepared statement, the company said it provides administrative services for many large employers who design and fund their own health insurance plans.

Nix said an “escalation specialist” from the insurance company reached out after she posted her complaints on social media, but the specialist couldn’t help.

Then, in July, after KFF Health News contacted Blue Cross Blue Shield of Illinois, Nix logged in to the insurer’s online portal and found that $36,000 of her outstanding claims had been marked “paid.” No one from the company had contacted her to explain why or what had changed. She also said she was informed by her hospital that the insurer will no longer require her to obtain prior authorization before her infusions, which she restarted in late July.

“I’m thrilled,” she said. But “it just should never have happened this way.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.  

Medicare May Cover Training for Family Caregivers

By Judith Graham, KFF Health News

Even with extensive caregiving experience, Patti LaFleur was unprepared for the crisis that hit in April 2021, when her mother, Linda LaTurner, fell out of a chair and broke her hip.

LaTurner, 71, had been diagnosed with early-onset dementia seven years before. For two years, she’d been living with LaFleur, who managed insulin injections for her mother’s Type 1 diabetes, helped her shower and dress, dealt with her incontinence, and made sure she was eating well.

In the hospital after her mother’s hip replacement, LaFleur was told her mother would never walk again. When LaTurner came home, two emergency medical technicians brought her on a stretcher into the living room, put her on the bed LaFleur had set up, and wished LaFleur well.

That was the extent of help LaFleur received upon her mother’s discharge.

She didn’t know how to change her mother’s diapers or dress her since at that point LaTurner could barely move. She didn’t know how to turn her mother, who was spending all day in bed, to avoid bedsores.

Even after an occupational therapist visited several days later, LaFleur continued to face caretaking tasks she wasn’t sure how to handle.

“It’s already extremely challenging to be a caregiver for someone living with dementia. The lack of training in how to care for my mother just made an impossible job even more impossible,” said LaFleur, who lives in Auburn, Washington, a Seattle suburb. Her mother passed away in March 2022.

LINDA AND PATTI LAFLEUR

A new proposal from the Centers for Medicare & Medicaid Services addresses this often-lamented failure to support family, friends, and neighbors who care for frail, ill, and disabled older adults. For the first time, it would authorize Medicare payments to health care professionals to train informal caregivers who manage medications, assist loved ones with activities such as toileting and dressing, and oversee the use of medical equipment.

The proposal, which covers both individual and group training, is a long-overdue recognition of the role informal caregivers — also known as family caregivers — play in protecting the health and well-being of older adults. About 42 million Americans provided unpaid care to people 50 and older in 2020, according to a much-cited report.

“We know from our research that nearly 6 in 10 family caregivers assist with medical and nursing tasks such as injections, tube feedings, and changing catheters,” said Jason Resendez, president and CEO of the National Alliance for Caregiving. But fewer than 30% of caregivers have conversations with health professionals about how to help loved ones, he said.

Even fewer caregivers for older adults — only 7% — report receiving training related to tasks they perform, according to a June 2019 report in JAMA Internal Medicine.

Nancy LeaMond, chief advocacy and engagement officer for AARP, experienced this gap firsthand when she spent six years at home caring for her husband, who had amyotrophic lateral sclerosis, a neurological condition also known as Lou Gehrig’s disease. Although she hired health aides, they weren’t certified to operate the feeding tube her husband needed at the end of his life and couldn’t show LeaMond how to use it. Instead, she and her sons turned to the internet and trained themselves by watching videos.

“Until very recently, there’s been very little attention to the role of family caregivers and the need to support caregivers so they can be an effective part of the health delivery system,” she told me.

Training Coverage Could Begin Next Year

Several details of CMS’ proposal have yet to be finalized. Notably, CMS has asked for public comments on who should be considered a family caregiver for the purposes of training and how often training should be delivered.

If you’d like to let CMS know what you think about its caregiving training proposal, you can comment on the CMS site until 5 p.m. ET on Sept. 11. The expectation is that Medicare will start paying for caregiver training next year, and caregivers should start asking for it then.

Advocates said they favor a broad definition of caregiver. Since often several people perform these tasks, training should be available to more than one person, Resendez suggested. And since people are sometimes reimbursed by family members for their assistance, being unpaid shouldn’t be a requirement, suggested Anne Tumlinson, founder and chief executive officer of ATI Advisory, a consulting firm in aging and disability policy.

As for the frequency of training, a one-size-fits-all approach isn’t appropriate given the varied needs of older adults and the varied skills of people who assist them, said Sharmila Sandhu, vice president of regulatory affairs at the American Occupational Therapy Association.

Some caregivers may need a single session when a loved one is discharged from a hospital or a rehabilitation facility. Others may need ongoing training as conditions such as heart failure or dementia progress and new complications occur, said Kim Karr, who manages payment policy for AOTA.

When possible, training should be delivered in a person’s home rather than at a health care institution, suggested Donna Benton, director of the University of Southern California’s Family Caregiver Support Center and the Los Angeles Caregiver Resource Center. All too often, recommendations that caregivers get from health professionals aren’t easy to implement at home and need to be adjusted, she noted.

Nancy Gross, 72, of Mendham, New Jersey, experienced this when her husband, Jim Kotcho, 77, received a stem cell transplant for leukemia in May 2015.

Once Kotcho came home, Gross was responsible for flushing the port that had been implanted in his chest, administering medications through that site, and making sure all the equipment she was using was sterile.

Although a visiting nurse came out and offered education, it wasn’t adequate for the challenges Gross confronted.

“I’m not prone to crying, but when you think your loved one’s life is in your hands and you don’t know what to do, that’s unbelievably stressful,” she told me.

NANCY AND JIM KOTCHO

For her part, Cheryl Brown, 79, of San Bernardino, California — a caregiver for her husband, Hardy Brown Sr., 80, since he was diagnosed with ALS in 2002 — is skeptical about paying professionals for training. At the time of his diagnosis, doctors gave Hardy five years, at most, to live. But he didn’t accept that prognosis and ended up defying expectations.

HARDY AND CHERYL BROWN

Today, Hardy’s mind is fully intact, and he can move his hands and his arms but not the rest of his body. Looking after him is a full-time job for Cheryl, who is also chair of the executive committee of California’s Commission on Aging and a former member of the California State Assembly.

She said hiring paid help isn’t an option, given the expense. And that’s what irritates Cheryl about Medicare’s training proposal.

“What I need is someone who can come into my home and help me,” she told me. “I don’t see how someone like me, who’s been doing this a very long time, would benefit from this. We caregivers do all the work, and the professionals get the money? That makes no sense to me.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Can Peppermint Oil Help With Postoperative Pain?

By Pat Anson, PNN Editor

In recent years, hospitals around the world have resorted to unconventional and novel methods to reduce the use of opioids by patients recovering from surgery. 

Some use “harp therapy” to help patients relax and forget about their postoperative pain while listening to live music played on a harp.  Others use virtual reality games to help distract patients.  And some German hospitals even played a recording of “positive suggestions” to surgery patients while they were under general anesthesia.

Aromatherapy may soon be added to the growing list of alternative treatments for postoperative pain. A small study in Iran suggests that aromatherapy with peppermint oil can reduce pain and improve sleep in patients recovering from surgery.    

Aromatherapy with concentrated extracts from plants – known as essential oils -- has been used for thousands of years to help reduce stress and treat infections. Peppermint essential oil is particularly useful because it has a pleasant smell, binds easily to nasal mucous, and enters the bloodstream quickly, where it promotes the release of endorphins that ease pain and improve mood.

Iranian researchers wanted to know if peppermint oil could also help patients recovering from open heart surgery, a major invasive procedure that requires breaking through the breastbone (sternum), as well as mechanical ventilation to help breathing. Patients waking up in intensive care following heart surgery often have high levels of pain, stress and difficulty sleeping.

“Among complementary medicine treatments, particular attention should be given to essential oils, which are both pleasant and inexpensive and can be quite useful,” wrote lead author Dr. Ismail Azizi-Fini, MD, Kashan University of Medical Sciences. “There is some clinical scientific evidence in favour of using aromatherapy with essential oils in various phases of preoperative and postoperative treatment.”

For the study, 59 adults undergoing cardiac surgery were randomly divided into two groups. One group received a diluted solution of essential peppermint oil for 30 minutes before their breathing tube was removed, and six times afterward through a nebulizer, a small machine that turns liquids into a mist than can be easily inhaled. The control group breathed a placebo mist of distilled water.  

After 2 days of treatment, the average on a zero-to10 pain score was 3.22 in the aromatherapy group and 4.56 in the control group, a statistically significant difference. Average sleep scores were also better in the aromatherapy group, which used fewer opioid analgesics (morphine and fentanyl) than the control group.  

“The results show that inhalation of peppermint essential oil can reduce the pain intensity of patients after open heart surgery and consequently reduce the use of pain relievers by patients,” researchers reported in the journal BMJ Supportive & Palliative Care.

“Also, the use of this herbal product can improve the sleep quality of patients in the first nights after surgery and bring them more comfort. Considering the effect of peppermint essential oil inhalation on pain and sleep quality of patients after open-heart surgery, it can be concluded that this herbal product can be safely used as a complementary treatment in relieving pain and making patients comfortable after heart surgery.” 

It’s rare for a patient to become addicted or develop a dependence on opioids after surgery. One study finding that less than one percent of seniors were still taking opioids a year after major elective surgery.

A 2021 survey found that nearly 8 out of 10 U.S. adults believe opioids are sometimes necessary to manage postoperative pain. Most people are more worried about treating surgical pain than they are about becoming addicted.

Pain Patients Get ‘Substantial Relief’ from Scrambler Therapy

By Pat Anson, PNN Editor

A little-known therapy for Complex Regional Pain Syndrome (CRPS) and other painful neuropathic conditions is finally getting some attention from a prominent medical journal.

“Scrambler therapy is the most exciting development I have seen in years — it’s effective, it’s noninvasive, it reduces opioid use substantially and it can be permanent,´ says Thomas Smith, MD, a professor of oncology at the Johns Hopkins University School of Medicine and co-author of a review recently published in The New England Journal of Medicine.

Scrambler therapy – also known as Calmare pain therapy -- sends mild electric signals through the skin via electrodes placed near areas where chronic nerve pain is felt. Similar to transcutaneous electrical nerve stimulation (TENS), the idea is to “scramble” pain signals being sent to the brain and reduce central sensitization.

Some patients get immediate relief after a 30-minute scrambler session, but most will have to undergo a series of treatments on successive days to have a prolonged analgesic effect. Smith says many patients “get really substantial relief.”

“The duration of relief usually increases with each day of treatment, and in contrast to TENS, analgesic effects have been reported to last for weeks, months, or even years after a treatment course,” wrote Smith, who reviewed 381 clinical trials of TENS and scrambler therapy with his co-author.

“The major limitation with respect to our understanding of electroanalgesia is the small number of well-designed, large, randomized, sham-controlled clinical trials of TENS and scrambler therapy.”

In one small study, patients getting scrambler therapy had a 91% reduction in pain and reduced their use of opioids and other pain relievers by 75 percent.

“If you can block the ascending pain impulses and enhance the inhibitory system, you can potentially reset the brain so it doesn’t feel chronic pain nearly as badly,” Smith says. “It’s like pressing Control-Alt-Delete about a billion times.”

Scrambler therapy seems to be most effective in patients with CRPS or those who develop neuropathic pain after chemotherapy. It’s also been used to treat fibromyalgia, shingles, diabetic neuropathy and post-operative pain.

Amanda Greening was bedridden by CRPS at the young age of 20, but was able to walk again after several sessions of scrambler therapy. Amanda’s father wrote a column for PNN on her recovery. So did a local TV station:

Although scrambler therapy was approved by the FDA in 2009 for patients with chronic or neuropathic pain, the procedure is still not widely available or covered by insurance. Only one company makes the scrambler device, which costs about $65,000, and practitioners have to undergo several days of training to use it. Treatments cost about $300 per session.

Like other pain treatments, scrambler therapy doesn’t work for everyone. About 10 to 20% of  patients have no analgesic response -- a risk many would be willing to take, if it means freeing themselves from a lifetime of pain.

How to Overcome Repetitive Negative Thinking

By Anna Andrianova, Laval University

Do you ever find yourself caught in a cycle of negative thoughts? Maybe you ruminate on past mistakes, worry excessively about the future, or imagine worst-case scenarios?

Do you sometimes have a great day, everything goes well, and then your brain says, “Hey, remember that time you embarrassed yourself in front of everyone? Let’s relive that moment for the next 20 minutes.” And suddenly, your good day turns into a cringe-fest.

If so, know that you’re not alone. Many people struggle with repetitive negative thinking, and this can have a serious impact on mental health and well-being.

As the coordinator of expertise in caregiving at the Centre for Research and Expertise in Social Gerontology and an associate member of the Centre for Study and Research on India, South Asia and its Diaspora, I would like to shed light on the negative impact of repetitive negative thinking on the mental and physical health of caregivers.

Repetitive negative thinking (RNT) is a cognitive process characterized by persistent and intrusive contemplation on past events, commonly known as rumination, and apprehensions about future possibilities, often referred to as worries.

RNT is a recurring, unwelcome, and difficult to dislodge pattern of thinking that has been implicated in the onset and perpetuation of diverse mental disorders, including depression, anxiety, and post-traumatic stress disorder. Furthermore, RNT has been found to be associated with physical health and has been linked to an increased likelihood of future health issues. RNT may negatively impact one’s quality of sleep, decrease efficiency, and hinder decision-making abilities.

Recent studies have revealed that the severity of RNT is connected with changes in brain morphology, leading to a decline in general cognitive abilities and increasing the risk of developing Alzheimer’s disease. Even at low levels, RNT can have detrimental effects on the cardiovascular, autonomic nervous, and endocrine systems.

The Power of Mindfulness

So, what would be the most effective strategy for managing repetitive negative thinking? Research has demonstrated a negative correlation between RNT and mindfulness, implying that a low level of mindfulness can increase one’s susceptibility to RNT.

Mindfulness can be seen as a mental faculty or skill that can be developed through regular practice. It entails cultivating a non-judgmental and non-reactive awareness of the present moment. The objective is to be fully engaged in what’s happening right now, rather than dwelling on the past or worrying about the future.

There are two main styles of mindfulness practice: focused attention meditation and open monitoring meditation. Focused attention meditation involves choosing a specific object, such as the breath, and bringing your full attention to it. Whenever the mind wanders, it is simply brought back to the object of focus.

In contrast, open monitoring meditation involves being aware of everything occurring in the present moment. Instead of trying to focus on a specific object, one simply observes whatever arises in the experience, including thoughts, emotions, and physical sensations.

But what’s happening in the brain during these practices? Recent studies have revealed that only during focused attention meditation, there is a deactivation of the “default mode network” — a network of brain areas that are typically active when we’re not focused on any particular task. This network is implicated in “resting-state” thinking, which involves repetitive negative thinking. By deactivating the “default mode network,” focused attention meditation can help reduce this harmful type of thinking.

An Intervention for Caregivers

As part of our project, we will develop and examine an intervention targeted at reducing RNT in family caregivers.

According to a recent report, over eight million Canadians aged 15 and older, or 25 per cent of the population, provide care to a family member or friend with a long-term health condition, disability, or aging-related needs.

While caregiving can be rewarding, it can also be challenging and stressful, particularly for those who provide extensive or complex care. Chronic stress is a common experience for family caregivers, and it can take a toll on their health and well-being. A survey of caregivers found that the top areas of need for caregivers were emotional health (58 per cent) and physical health (32 per cent). RNT is strongly associated with caregiver burden and predicts negative impacts on the physical and mental health of caregivers.

We will recruit 100 caregivers with high levels of RNT. The intervention will be presented to participants in the form of interactive videos that guide them through the practice of focused attention meditation. We will measure changes in RNT, stress, anxiety, depression, and quality of life before and after the intervention, as well as at a six-month follow-up.

If the intervention is effective, it could serve as the basis for the development of an innovative tool for monitoring and reducing RNT. This tool could be deployed as a mobile app or on virtual reality platforms, providing caregivers with access to an intervention that they can use at their convenience. This could significantly expand the reach of the intervention, making it more accessible and convenient for caregivers who may not have the time or resources to participate in traditional face-to-face interventions.

Overall, the potential of the focused attention meditation intervention to improve the mental and physical health of caregivers, as well as the development of new innovative tools, represents a promising avenue in the field of caregiver support services. Further research and implementation of such interventions could significantly improve the quality of life for caregivers and the people they care for.

After all, to echo the words of philosopher Marcus Aurelius, “the happiness of your life depends upon the quality of your thoughts.”

Anna Andrianova holds degrees in psychology and social work, and is currently a doctoral candidate in social work at Laval University in Quebec. As part of her doctoral thesis, she explores the impact of the practice of mindfulness on the reduction of repetitive negative thoughts on well-being and health.

This article originally appear in The Conversation and is republished with permission.

A Little Extra Weight Is Okay for Older Adults

By Judith Graham, Kaiser Health News

Millions of people enter later life carrying an extra 10 to 15 pounds, weight they’ve gained after having children, developing joint problems, becoming less active, or making meals the center of their social lives.

Should they lose this modest extra weight to optimize their health? This question has come to the fore with a new category of diabetes and weight loss drugs giving people hope they can shed excess pounds.

For years, experts have debated what to advise older adults in this situation. On one hand, weight gain is associated with the accumulation of fat. And that can have serious adverse health consequences, contributing to heart disease, diabetes, arthritis, and a host of other medical conditions.

On the other hand, numerous studies suggest that carrying some extra weight can sometimes be protective in later life. For people who fall, fat can serve as padding, guarding against fractures. And for people who become seriously ill with conditions such as cancer or advanced kidney disease, that padding can be a source of energy, helping them tolerate demanding therapies.

Of course, it depends on how heavy someone is to begin with. People who are already obese (with a body mass index of 30 or over) and who put on extra pounds are at greater risk than those who weigh less. And rapid weight gain in later life is always a cause for concern.

Making sense of scientific evidence and expert opinion surrounding weight issues in older adults isn’t easy. Here’s what I learned from reviewing dozens of studies and talking with nearly two dozen obesity physicians and researchers.

Bodies Change with Age 

As we grow older, our body composition changes. We lose muscle mass — a process that starts in our 30s and accelerates in our 60s and beyond — and gain fat. This is true even when our weight remains constant.

Also, less fat accumulates under the skin while more is distributed within the middle of the body. This abdominal fat is associated with inflammation and insulin resistance and a higher risk of cardiovascular disease, diabetes and stroke, among other medical conditions.

“The distribution of fat plays a major role in determining how deleterious added weight in the form of fat is,” said Mitchell Lazar, director of the Institute for Diabetes, Obesity and Metabolism at the University of Pennsylvania’s Perelman School of Medicine. “It’s visceral [abdominal] fat [around the waist], rather than peripheral fat [in the hips and buttocks] that we’re really concerned about.”

Activity Diminishes

Also, with advancing age, people tend to become less active. When older adults maintain the same eating habits (energy intake) while cutting back on activity (energy expenditure), they’re going to gain weight.

According to the Centers for Disease Control and Prevention, 27% of 65- to 74-year-olds are physically inactive outside of work; that rises to 35% for people 75 or older.

For older adults, the health agency recommends at least 150 minutes a week of moderately intense activity, such as brisk walking, as well as muscle-strengthening activities such as lifting weights at least twice weekly. Only 27% to 44% of older adults meet these guidelines, according to various surveys.

Experts are more concerned about a lack of activity in older adults who are overweight or mildly obese (a body mass index in the low 30s) than about weight loss.

With minimal or no activity, muscle mass deteriorates and strength decreases, which “raises the risk of developing a disability or a functional impairment” that can interfere with independence, said John Batsis, an obesity researcher and associate professor of medicine at the University of North Carolina School of Medicine in Chapel Hill.

Weight loss contributes to inadequate muscle mass, insofar as muscle is lost along with fat. For every pound shed, 25% comes from muscle and 75% from fat, on average.

Since older adults have less muscle to begin with, “if they want to lose weight, they need to be willing at the same time to increase physical activity.” said Anne Newman, director of the Center for Aging and Population Health at the University of Pittsburgh School of Public Health.

Ideal BMI Higher for Older Adults

Epidemiologic research suggests that the ideal body mass index (BMI) might be higher for older adults than younger adults. BMI is a measure of a person’s weight, in kilograms or pounds, divided by the square of their height, in meters or feet.

One large, well-regarded study found that older adults at either end of the BMI spectrum — those with low BMIs (under 22) and those with high BMIs (over 33) — were at greater risk of dying earlier than those with BMIs in the middle range (22 to 32.9).

Older adults with the lowest risk of earlier deaths had BMIs of 27 to 27.9. According to World Health Organization standards, this falls in the “overweight” range (25 to 29.9) and above the “healthy weight” BMI range (18.5 to 24.9). Also, many older adults that the study found to be at highest mortality risk — those with BMIs under 22 — would be classified as having “healthy weight” by the WHO.

The study’s conclusion: “The WHO healthy weight range may not be suitable for older adults.” Instead, being overweight may be beneficial for older adults, while being notably thin can be problematic, contributing to the potential for frailty.

Indeed, an optimal BMI for older adults may be in the range of 24 to 29, Carl Lavie, a well-known obesity researcher, suggested in a separate study reviewing the evidence surrounding obesity in older adults.

Lavie is the medical director of cardiac rehabilitation and prevention at Ochsner Health, a large health care system based in New Orleans, and author of “The Obesity Paradox,” a book that explores weight issues in older adults. Lavie and other experts say maintaining fitness and muscle mass is more important than losing weight for many older adults.

“Is losing a few extra pounds going to dramatically improve their health? I don’t think the evidence shows that,” Lavie said.

Unintentional weight loss is associated with several serious illnesses and is a danger signal that should always be attended to. “See your doctor if you’re losing weight without trying to,” said Newman of the University of Pittsburgh. She’s the co-author of a new paper finding that “unanticipated weight loss even among adults with obesity is associated with increased mortality” risk.

Maintain Healthy Diet

Ensuring diet quality is essential. “Older adults are at risk for vitamin deficiencies and other nutritional deficits, and if you’re not consuming enough protein, that’s a problem,” said Batsis of the University of North Carolina.

“I tell all my older patients to take a multivitamin,” said Dinesh Edem, director of the Medical Weight Management program at the University of Arkansas for Medical Sciences.

Losing weight is more important for older adults who have a lot of fat around their middle (an apple shape) than it is for people who are heavier lower down (a pear shape). “For patients with a high waist circumference, we’re more aggressive in reducing calories or increasing exercise,” said Dennis Kerrigan, director of weight management at Henry Ford Health in Michigan.

Maintaining weight stability is a good goal for healthy older adults who are carrying extra weight but who don’t have moderate or severe obesity (BMIs of 35 or higher). By definition, “healthy” means people don’t have serious metabolic issues (overly high cholesterol, blood sugar, blood pressure, and triglycerides), obesity-related disabilities (problems with mobility are common), or serious obesity-related illnesses such as diabetes or heart disease.

“No great gains and no great losses — that’s what I recommend,” said Katie Dodd, a geriatric dietitian who writes a blog about nutrition.

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Hydrogel Shows Promise as Treatment for Arthritic Joints

By Pat Anson, PNN Editor

An experimental hydrogel that helps regenerate bone and cartilage tissue is showing promise as a treatment for arthritic joints, according to new research by Chinese and Canadian scientists. The gel is biodegradable and mimics the articular cartilage found in knee and hip joints.

In tests on laboratory animals, researchers say the gel showed signs of repairing articular cartilage 12 weeks after being implanted in rabbits, with no gel remaining and no rejection by the animals’ immune systems, according to findings published in the journal Nature.

Further animal testing is needed, but if the hydrogel proves useful in human trials, it could be used someday as an alternative to knee and hip replacement surgery. About one in four adults in the United States have some form of arthritis, which causes thinning of cartilage and progressive joint damage. Many resort to risky joint repair and replacement procedures.

“Cartilage is tricky,” says senior author Dr. Hongbin Li, a professor in the University of British Columbia’s department of chemistry. “Articular cartilage repair represents an important medical challenge because naturally speaking, it doesn’t repair itself.”

A delicate balance is needed to make biodegradable cartilage implants tough and stiff enough to support muscle-bearing tissues. They can’t be too stiff, or they’ll break when bent too far. Conversely, if they are too soft, they may not be useful in a joint.

In animal studies, researchers say a stiffer version of the gel had better results than a softer version, because it formed a scaffold that was more compatible with bone and cartilage tissue. That provided a physical cue to the body for tissue regeneration.

Dr. Linglan Fu holding the hydrogel

“This just shows how complex this area of research is, and the need to take into account the many different physical and biochemical cues and factors when designing these scaffolds,” says co-author Dr. Qing Jiang, a professor and surgeon at Nanjing University.

The research team used a new approach to stiffen biomaterials in the gel without sacrificing toughness, by physically entangling the chains of a protein.

“These entangled chains can move, which allows energy, for instance, the impact from jumping, to be dissipated, just like shock absorbers in bikes. In addition, we combined this with an existing method of folding and unfolding proteins, which also allows for energy dissipation,” says first author Dr. Linglan Fu, who conducted the research as a doctoral student at UBC’s department of chemistry.

The resulting gel is tough, able to resist slicing with a scalpel, and is more stiff than other protein-based hydrogels. Its ability to resist compression was among the highest achieved by any such gel, according to researchers, who say it compared favorably with actual articular cartilage. The gel was also able to rapidly recover its original shape after compression, as real cartilage does.

Researchers at Duke University are also working on an experimental hydrogel to replace damaged knee cartilage. The gel is made with thin sheets of cellulose fibers infused with a water absorbing polymer, creating a Jello-like material that is surprisingly strong. The cellulose fibers act like the collagen in natural cartilage, giving the gel strength when pulled or stretched.  

Massage Therapists Ease Pain of Hospice Patients — But Are Hard to Find

By Kate Ruder, KFF Health News

Ilyse Streim views massage for people in hospice care as “whispering to the body through touch.”

“It’s much lighter work. It’s nurturing. It’s slow,” said Streim, a licensed massage therapist.

Massage therapy for someone near the end of life looks and feels different from a spa treatment. Some people stay clothed or lie in bed. Others sit up in their wheelchairs. Streim avoids touching bedsores and fresh surgery wounds and describes her work as “meditating and moving at the same time.”

She recalled massaging the shoulders, hands, and feet of one client as he sat in his favorite recliner and watched baseball on TV in the final weeks of his life.

“When you’re dying and somebody touches you without expectation of anything in return, you just get to be,” said Streim.

Massage therapists like Streim, who specializes in working with people who are dying or have an advanced form of cancer or other illness, are rare. Fewer than 1% of therapists specialize in hospice or palliative care massage, according to research by the American Massage Therapy Association, although many more may periodically offer massage for hospice patients.

Streim has a private practice in Lafayette, Colorado and her clients pay her out-of-pocket, as Medicare and private insurance typically don’t cover massage therapy. She also volunteers as a hospice massage therapist four hours a month.

It’s common for hospice organizations to use volunteer therapists for treatments, though some massage therapists, with physicians backing them, are pushing for paid positions as part of medical teams working alongside nurses and social workers.

In the hospice unit at Palo Alto VA Medical Center, in Palo Alto, California, for example, massage therapists have been integral members of the multidisciplinary team for decades, said VJ Periyakoil, a professor of medicine at Stanford University and the founding director of its palliative care education and training program.

The covid-19 pandemic made the recruitment of specialists for this intimate work, both paid and volunteer, more difficult, as the pool of massage therapists shrank amid school closures and exits from the profession. There are up to 10% fewer massage therapists today than before the pandemic, according to Les Sweeney, president of Associated Bodywork & Massage Professionals.

“It’s still hard for us to hire and recruit therapists,” said Kerry Jordan, operations director at Healwell, a nonprofit that trains and employs massage therapists to work in hospitals in the Washington, D.C., area.

‘We Need to Get More Therapists’

For three weeks in April 2020, licensed massage therapist Cindy Spence, who works at Faith Presbyterian Hospice in Dallas, could not massage patients due to the state’s lockdown orders. Then, the state granted an allowance for massage therapists like her, working in medical settings under supervision, to resume giving massages. But it took several months for many therapists to return to work, and some didn’t return at all, Spence said.

“The pandemic was not kind to massage therapists,” Spence said. “And so we have lost a lot of people like me who are of an age and experience level that would really be called to and suitable” for oncology, hospice, and palliative massage.

“We need to get more therapists trained,” she said. She described receiving several calls each month from people who have found her name online. It has become harder since covid to find a therapist to refer them to, Spence said.

At TRU Community Care, which operates in several locations in Colorado, Volunteer Services Supervisor Wendy Webster said massages are a top request from patients and their families, but they’re limited in how many sessions they can offer, with only two volunteer massage therapists. (A third volunteer did not return after the pandemic.)

Finding new massage therapist volunteers is challenging, said Webster, in part because they can earn money in other settings and “they’re coming to us for free.” Thirty years ago, TRU Community Care’s nonprofit status was the norm, but now the majority of hospices are for-profit, with growing investment from private equity.

Despite that shift, hospices still rely heavily on volunteers. Medicare pays for at least six months of hospice for a patient on the condition that providers use volunteers for at least 5% of the patient-care hours worked by paid staff and contractors. Sometimes, those volunteer hours are filled by massage therapists.

“All hospices, not-for-profit or for profit alike, should aim to include medically-trained massage therapists as part of best holistic care,” Hunter Groninger, a professor of medicine at Georgetown University who directs palliative care at MedStar Washington Hospital Center in Washington, D.C., wrote in an email. Employing these specialists is beneficial and does not diminish the important service of volunteers, particularly in end-of-life care, he added.

Benefits of Massage

More studies on the impact of specialized massage could enact changes in the field, said Cal Cates, founder and executive director of Healwell, which, since 2009, has trained 500 therapists in hospital-based and oncology massage, as well as in how to work collaboratively with doctors and nurses.

In a recent clinical trial of 387 patients in palliative care at MedStar, including some nearing the end of their lives, Groninger, Cates, Jordan, and other co-authors found that massage therapy improved quality of life.

Despite new research on the benefits of massage, Cates said, many hospices bring on volunteers who don’t have advanced training, because hospices may not know that specialized training — such as the kind Healwell offers — exists.

Streim, who paid for her own classes in oncology and lymphatic massage, said that investment in education qualified her for a six-year career as an oncology massage therapist at Good Samaritan Medical Center’s Center for Integrative Medicine in Lafayette and later her private practice. She teaches classes in adapting massage for the elderly and those with illnesses at Boulder Massage Therapy Institute. In her 39 years as a therapist, Streim has done it all: volunteer, staff, entrepreneur, teacher.

Like Streim, Spence has continually redefined her role. She began in private practice before becoming an employee of a large hospice agency in which she traveled across nine counties in Texas, giving thousands of massages to people dying in their homes, assisted living communities, and skilled nursing homes. Today, at Faith Presbyterian Hospice, she is one of three licensed massage therapists on staff and fully integrated as an employee of the organization, which has more than 100 patients.

“Those of us who do this work have made big investments in our profession and I’m glad to see that we can be paid for it,” she said.

Spence collects data on how patients rate their pain on a scale of 1 to 10 before and after a massage. Most fall asleep during the massage, which she takes as an indication their pain has lessened or they became more relaxed. Of those who stay awake, almost all say their pain subsided significantly or went away completely.

That kind of positive engagement with providers is more urgent than ever since the pandemic, Groninger said. Spence agreed: “The pandemic taught us all, in a very painful way, what it’s like to be deprived of human touch and human connections.”

Sometimes the nursing staff at Faith Presbyterian will roll a bed out onto the patio so a patient can hear the sounds of nature and the fountain gurgling during Spence’s massage. There is more teasing and laughter than she would have imagined. For patients unable to speak, Spence watches their reactions carefully: a deep exhalation or the face and body softening. Sometimes it’s tears running down their cheeks.

“It’s profound, helping someone find safe breaths along this very difficult dying journey,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Ketamine Nasal Spray May Be Effective Migraine Treatment

By Pat Anson, PNN Editor

In recent years, ketamine has become a trendy drug for treating depression, anxiety, post-traumatic stress and some types of chronic pain. Usually administered by infusion or injection, ketamine is a non-opioid analgesic that acts on the brain by putting patients into a temporary dream-like state.

A new study at Thomas Jefferson University suggests that ketamine may also be an effective treatment for chronic migraine. Several previous trials have shown that intravenous ketamine is effective for chronic headache, but it required close monitoring by a pain specialist to adjust the dose and monitor any side effects.

In the new study, researchers gave 169 migraine patients a ketamine nasal spray that they could use at home without supervision. Over two-thirds of the participants suffered from daily headaches and nearly 85% had tried over 3 types of migraine prevention drugs, with limited success.

The study findings, published in the journal Regional Anesthesia & Pain Medicine, showed that nearly half the participants said the nasal spray was “very effective” and about 40% found it “somewhat effective.” Over a third said their quality of life was “much better.” 

Nearly 3 in 4 patients reported at least one side effect from ketamine, the most common being fatigue and double/blurred vision, followed by cognitive effects such as confusion, dissociation, vivid dreams and hallucinations. Most of the side effects were only temporary.

“In this descriptive study, intranasal ketamine served as an acute treatment for refractory chronic migraine by reducing headache intensity and improving quality of life with relatively tolerable adverse events. Most patients found intranasal ketamine effective and continued to use it despite these adverse events,” wrote lead author Michael Marmura, MD, Outpatient Director at the Jefferson Headache Center.

Marmura and his colleagues are cautious about who should use ketamine because of its potential for abuse. Ketamine has a short half-life of less than two hours, meaning patients may be tempted to use it repeatedly to keep chronic headaches at bay. Patients in this study used the nasal spray an average of just 6 times a month, but a small number (13.9%) used the spray daily.

“Clinicians should only consider the use of a potentially addictive medication such as ketamine for significantly disabled patients with migraine,” they warned. “(This) should be addressed carefully and individually, as some may respond only to repeated ketamine, while some may overuse it.”

In 2019, the FDA approved the use of Spravato, a nasal spray that contains a ketamine-like substance, for severe depression. Because of the risk of abuse, Spravato can only be administered in a doctor’s office, where patients can be observed for two hours after taking a dose. The use of such a spray to treat migraine would be considered an off-label use.

In addition to its medical uses, ketamine has long been known as a party drug – “Special K” -- because it can cause hallucinations and intense, dream-like states.

It didn’t take long for drug dealers to note the increase in ketamine’s popularity. Recent research published in JAMA shows that seizures of illicit ketamine in the U.S. have risen from 55 seizures in 2017 to 247 in 2022, a 350% increase. Because much of its was seized in powder form, researchers are concerned black market ketamine could easily be adulterated with illicit fentanyl.

FDA Expands Use of Spinal Cord Stimulators to More Types of Back Pain

By Pat Anson, PNN Editor

The U.S. Food and Drug Administration continues to expand the use of spinal cord stimulators, despite a growing body of research that questions the safety and effectiveness of the devices.

This month the FDA approved the use of Abbott’s spinal cord stimulators for the treatment of chronic back pain in people who are unable to get corrective surgery – known as non-surgical back pain -- because they are too medically frail or have numerous degenerative disc problems. Those patients are usually treated with pain medication, physical therapy or spinal injections.

FDA approval was granted after a clinical study showed that SCS devices equipped with Abbott's BurstDR technology provided significant pain relief, better physical function, and improved quality of life in 200 patients with non-surgical back pain. The devices are surgically placed near the spine and emit mild electrical impulses to disrupt pain signals before they reach the brain. 

Participants in the study had chronic and disabling back pain for an average of nearly 13 years before getting the devices.

"We have struggled with how to treat people who weren't considered a good surgical candidate because we didn't have clear, data-driven treatment options for non-surgical back pain," Timothy Deer, MD, CEO of the Spine and Nerve Centers of the Virginias, said in an Abbott press release. "This new indication for Abbott's SCS devices, together with BurstDR stimulation, allows physicians the ability to identify and treat a new group of people, providing them with relief from chronic back pain."

BurstDR stimulation uses mild electrical pulses — or bursts — without creating an uncomfortable tingling sensation in the spine known as paresthesia.  All of Abbott's SCS devices use BurstDR technology.

Nine out of ten patients who received BurstDR therapy experienced significantly better function or pain relief, with pain levels reduced an average of nearly 70 percent. The improvements were sustained 12 months after the devices were implanted.

"This FDA expanded indication approval for our SCS devices is a significant step forward in Abbott's goal to provide treatment access to those who suffer daily with chronic back pain but are not eligible for corrective surgery," said Pedro Malha, vice president of neuromodulation for Abbott.

SCS devices were long considered a treatment of last resort for people with severe back, neck and leg pain, but in recent years the FDA has expanded use of the devices for conditions such as painful diabetic neuropathy. The devices are often promoted as safer alternatives than opioid pain medication.

Recent research, however, has raised questions about the safety, efficacy and long-term benefits of the devices. A recent Cochrane review concluded the stimulators work no better than a placebo for treating chronic low back pain, and provide little or no improvement in quality of life.  In a review of 13 clinical trials, researchers found little clinical data on the long-term effectiveness of SCSs, and noted that most of the studies lasted less than a month, were poorly blinded, or funded by device makers.

A 2018 study by investigative journalists found that SCSs have some of the worst safety records of medical devices tracked by the FDA.

A 2020 FDA review of adverse events involving stimulators found that nearly a third were reports of unsatisfactory pain relief. Other common adverse events are nerve damage, infections, and device malfunctions that may lead to further surgeries.

A 2022 study found that patients who get the devices did not reduce their use of opioids, and continued getting medical procedures such as injections, epidurals and radiofrequency ablation.

FDA Authorizes Smartphone App for Fibromyalgia

By Pat Anson, PNN Editor 

The U.S. Food and Drug Administration has authorized the marketing of the first smartphone-based digital therapy for fibromyalgia. The Stanza mobile app doesn’t relieve the physical pain of fibromyalgia, but is designed to help patients manage the anxiety, depression and other psychological symptoms that often come with fibromyalgia.

Fibromyalgia is a poorly understood condition characterized by widespread body pain, headaches, fatigue, insomnia and mood disorders. The FDA has approved only three medications for fibromyalgia -- duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica) – but many patients consider the drugs ineffective or have too many side effects.

“This represents a major milestone both for our company and the fibromyalgia patients we serve, and is a big step towards meaningfully addressing patient access barriers by making evidence-based, non-drug treatments available to more people,” said Mike Rosenbluth, CEO of Swing Therapeutics, the maker of Stanza.

“On top of dealing with the debilitating symptoms, fibromyalgia patients have been historically underserved and even stigmatized. Current FDA-approved medications, while offering moderate efficacy, are often accompanied by side effects.”  

The Stanza app provides training in acceptance and commitment therapy (ACT), a form of cognitive behavioral therapy (CBT), to help patients develop flexibility and resilience in coping with fibromyalgia. ACT teaches mindfulness strategies and behavioral changes to help people accept and manage their pain.

In a clinical trial, Stanza significantly reduced depression and anxiety in fibromyalgia patients, while improving their quality of life. About 80% of patients responded to Stanza therapy and the benefits were sustained for up to 12 months.

Stanza is designed to be used five to seven days per week, for about 15 to 20 minutes a day, over a 12-week period. After 12 weeks, the app can be used as needed.

Stanza is only available by prescription. It was first made available last year under the FDA’s Digital Health Enforcement Policy for Digital Health Devices. Swing Care, an online clinic that provides personalized treatment of fibromyalgia, includes Stanza as an option for patients in Texas. Swing Therapeutics anticipates that Stanza will also be available through Swing Care in other states later this year.

Staying Socially Connected Can Help With Chronic Pain

By Jill Suttie, Greater Good Science Center

Many people live with chronic pain. Whether it’s from injury or illness, chronic pain can affect a person’s mood, relationships, work productivity, and more, making it difficult to enjoy daily life.

Unfortunately, getting pain relief can be a complex process. One reason is that it involves both physiological and social-psychological factors — meaning, pain doesn’t just come from having a fever or breaking your arm, but other things happening in your brain, body, and environment. For example, your experience of pain can be lessened by things like distraction, listening to music, or practicing mindfulness meditation.

As researcher Laura Case of the University of California, San Diego, explains, “There’s no one-to-one relationship between activation of sensory nerves and your experience of pain or touch… Though there’s debate about which brain areas correspond to our final pain experience, all of the main players are interconnected with cognitive and emotional brain areas.”

Now a new study that she coauthored with Jennifer Baumgartner suggests another potential influence on pain: feeling socially connected.

A Sense of Belonging Helps

This new study reanalyzed measures collected in an earlier study, in which a group of chronic pain sufferers had been randomly assigned to an intervention shown to reduce pain (sleeping with a heavily weighted blanket) or to a control condition (sleeping with a slightly weighted blanket, which is considered non-therapeutic). After sleeping with their assigned blanket for a week, changes in people’s pain levels were assessed, and the two groups were compared to each other.

In the earlier study, the pain sufferers had also reported on their anxiety and depression symptoms, levels of loneliness, and sense of social connectedness—not how many social connections they had currently, but how generally close they were to other people and how strongly they experienced a sense of belonging. But these had not all been analyzed to see how they related to pain and pain relief from the blankets. That’s where the new study came in.

The new findings showed that people who were more socially connected experienced less pain than those who were less socially connected. After taking into account differences in expectations for pain relief and people’s initial pain levels, those who were socially disconnected felt more pain relief from the weighted blanket than from the lighter blanket, while more socially connected people received equal pain relief from both blankets.

For Baumgartner, these findings suggest that having a sense of belonging provides some level of protection against pain, regardless of any blanket intervention.

“Social support is really important for things that could potentially be threatening, such as stress or pain,” she says. “Having an internalized feeling of being connected with people has an effect on our physical sensations.”

Why would a sense of belonging help with pain? Neither Case nor Baumgartner is sure why.

However, in their study, people who were more socially connected had less anxiety, which could be a factor. Socially connected people probably feel safer and less anxious, says Baumgartner, because they know they can lean on others for support when they’re hurting. Less anxiety means less vigilance around unpleasant bodily sensations, which could decrease their experience of pain.

“Anxiety is strongly coupled with pain, exacerbating people’s surveillance of pain within their body,” she says. “So, having less anxiety is protective—no matter what intervention you receive.”

Case, who studies tactile sensations, says that positive social touch — like receiving a friendly hug or massage — has been shown to reduce pain sensation, and people who are more socially connected likely experience more of those types of touch. Someone who doesn’t have that in their lives much may crave soothing tactile pressure, which is why the weighted blankets can help somewhat.

“If you have difficulty feeling close to others, maybe there are some sensory ways to get around that and help your pain,” she says. “Deep pressure is calming, because it’s associated with the safety of being close to someone else, of being held and protected.”

The Power of a Big Hug

Surprisingly, feelings of depression didn’t seem to affect the relationship between social connection and pain, even though depression has been tied to pain in other research. While this study’s finding might prove to be an outlier, it could also suggest that the hyper vigilance accompanying anxiety is more impactful on pain than feeling down.

Either way, it appears that social connection matters when it comes to pain. However, that can’t be manipulated in an experiment. Baumgartner explains that this trait tends to develop early in childhood and may be tied to general attachment styles (secure, anxious, or avoidant). Since these are not easily changed, it’s good to have a useful, non-pharmacological treatment for pain relief in those without good social connectivity, like the weighted blanket.

“The weighted blanket doesn’t involve any sort of social situation at all, but it still seems to have the ability to help people, to some extent,” says Baumgartner. “Though there haven’t been enough rigorous studies done yet, I’m pretty optimistic that a weighted blanket could serve as an alternative or an adjunct to pain treatment—or maybe even a strategy to prevent people from getting chronic pain in the first place.”

Case says that it could substitute in some ways for what’s missing for people when they tend to be avoidant of others.

“Just anecdotally, people [in the study] found a weighted blanket tended to make them feel like they’re getting a big hug, and it’s relaxing and calming,” she says. “A weighted blanket isn’t a cure for chronic pain, and it’s not going to help everyone. But some people in our study did find it valuable.”

Case and Baumgartner’s study adds to a growing body of research showing how important social connectedness and social touch are for our health and well-being — something that’s been getting more attention in recent years. In fact, in a recent advisory report, the U.S. Surgeon General, Vivek Murthy, argued that our country is facing a “loneliness epidemic” that is affecting our health and longevity and that we need to create more opportunities for people to connect and build a sense of belonging in their lives.

Now, we know that social connection may also help those who suffer from chronic pain.

“Psychosocial factors are not peripheral to someone’s sense of chronic pain; they are central,” Baumgartner says. “Connecting with people and seeking out positive, healthy connections within your social environment is critical.”

This article originally appeared on Greater Good, the online magazine of the Greater Good Science Center at UC Berkeley.

Colostrum: A Regenerative Hormone for Arachnoiditis

By Dr. Forest Tennant, PNN Columnist

Persons with adhesive arachnoiditis (AA) and other severe painful conditions such as Ehlers-Danlos syndrome (EDS) have multiple tissues that become damaged, painful and dysfunctional.

Healing those damaged tissues and reversing the pain and neurologic impairments will require regenerative hormones. This is in contrast to other types of hormones that control inflammation (cortisone), metabolism (thyroid) or sexual functions (estradiol).

The human body makes some natural regenerative hormones, and they are now available for clinical use. Our first realization of their value in treating AA was with human chorionic gonadotropin (HCG). Other regenerative hormones that can be used to treat AA include colostrum, pregnenolone, dehydroepiandrosterone (DHEA), nandrolone, and human growth hormone (HGH). We have used all of these and believe that persons with AA should use at least one of them. But our first choice is colostrum.

Colostrum is in mother’s milk produced during the first few days after birth. It contains high levels of tissue growth factors, anti-inflammatories, pain relievers, and anti-infectious agents. Its natural purpose is to allow the newborn baby to initiate growth, protect against infection, and provide pain relief from the trauma of birth.

Colostrum supplements are sold by a number of companies and are usually made from the milk of cows that have recently given birth. Colostrum is recommended for use at least 3 to 5 days a week by persons with AA or EDS, who may wish to double the labeled recommended dosage. Colostrum is non-prescription, relatively inexpensive, and has few side effects. It can be taken with opioids and other drugs.

Regenerative hormones work best when they are used simultaneously with a high protein diet, collagen or amino acid supplements, vitamin C, B12, and polypeptides.

If a person with AA is not doing well or deteriorating, we recommend adding a second regenerative hormone such as nandrolone. A significant reversal of AA symptoms may require one or more regenerative hormones.

Several times a week we get inquiries from people who have just been diagnosed with AA and are pleading for information on what to do. 

The Tennant Foundation recently published an inexpensive short handbook for persons with newly diagnosed AA that gives a step-by-step plan that can hopefully slow progression of this disease.

If you have had AA for a while and aren't doing well, you may still benefit from some of our most up-to-date knowledge and recommendations in the “Handbook for Newly Diagnosed Cases of Adhesive Arachnoiditis.”

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. This column is adapted from bulletins recently issued by the Tennant Foundations’s Arachnoiditis Research and Education Project. Readers interested in subscribing to the bulletins should click here.

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.  

Should I Laugh or Should I Cry?

By Mia Maysack, PNN Columnist

Right now, I’m having one of those moments when the pain level is so high, it's almost unbelievable. It made me remember when a fellow chronically ill friend shared a story about her time in a grocery store.  She said that it felt as though a knife was cutting her open, all while she was just attempting to buy a few things.

Her response to this experience was laughter!

Perhaps you've heard the saying, "Should I laugh or should I cry?" Personally, I feel as though there's something to that. As I write this, I'm turning to the written word as my savior and deliverer from the wretched flare I'm in the midst of. I can barely see, let alone keep thoughts straight in my mind. But I'm choosing to smile, at least on the inside, because I'm thinking of my friend.

She said she laughed because it was comical in that moment -- her essentially feeling like the walking dead but having to function normally in a public place. No one else in the store could possibly know the inner crisis she was having. 

I can attest to this sort of thing making me feel a little crazy. Perhaps what helps to push us toward the bright side is the madness that's produced along the way. 

It’s been said that laughter is the best medicine. I've yet to have an ailment cured by laughing, but it's important to remember that despite our health or hardships, we possess a playful side. We are more than just a condition or diagnosis, there are other aspects of our identities. We're not what has occurred to us; what we are becoming is a result of our choice.

I'm choosing to laugh about the fact I've been attempting to get in touch with a provider, but cannot seem to get a call back. A previous appointment with the provider was so draining it left me feeling worse than I did upon arrival. It's all a reminder of how much it took to reach out to the provider in the first place, and the countless other let downs when the healthcare system falls short, which is most of the time. Healthcare is a joke and patients are often the punchline.

A common response to a person who is struggling is to advise them to seek help. That is a valid suggestion, but if “help” is the remedy, then it must be available and within reach.

We need to see what we need within ourselves, not to solely exist, but to excel in our experiences -- as opposed being dependent on systems that don’t serve our interests.

An example:  Recently when the exact opposite thing I felt like doing was grinning, I beamed in an effort to trick my brain into stimulating an increase in endorphins. This technique is readily available to me at any point, plus it’s free and doesn’t cause any adverse side effects! 

Laughter is another great way to assist in boosting mood, as is exercise to any extent that’s doable. The idea is to consciously work to counteract the pain signals that are firing as best we can, while living with unmanageable pain of one sort or another. 

Presently, I am choosing to be mentally mindful and to rejoice in breathing. This is how I prevail. I also find solace in knowing that what I’ve already endured will give me the strength I’ll need to face whatever is coming. Until then, I’ll strive to greet every moment that tests me with a smile. 

Mia Maysack lives with chronic migraine, cluster headache and fibromyalgia. She is the founder of Keepin’ Our Heads Up, a Facebook advocacy and support group, and Peace & Love, a wellness and life coaching practice for the chronically ill.