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ORIGINAL ARTICLE
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To Study the Effectiveness of Mindfulness-Based Meditation in the Functional Outcome of Osteoarthritis Knee and Perceived Stress Scores and Markers of Obesity in Postmenopausal Women


 Department of Physiology, Burdwan Medical College and Hospital (Affiliated to West Bengal University of Health Sciences), Burdwan, West Bengal, India

Date of Submission10-Feb-2020
Date of Decision06-Jul-2020
Date of Acceptance20-Jul-2020

Correspondence Address:
Arunima Chaudhuri,
Department of Physiology, Burdwan Medical College and Hospital (Affiliated to West Bengal University of Health Sciences), Burdwan, West Bengal
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_39_20

  Abstract 


Background: The global burdens of cardiovascular diseases (CVDs) and obesity are rising, producing enormous losses of life and disability-adjusted life-years in both developed and developing nations. Stress is a modifiable risk factor for the development of CVD. Postmenopausal women with osteoarthritis (OA) of knee joint may often report episodes of knee instability limiting their daily activities and this causes an added stress. Aims: To evaluate the effects of mindfulness-based meditation on functional outcome of OA knee and to study the effect of mindfulness-based meditation on perceived stress scores (PSSs) and markers of obesity in postmenopausal women. Materials and Methods: This interventional study was conducted on forty postmenopausal women in a tertiary care hospital of Eastern India after taking institutional ethical clearance and informed consent of the patients. Presumptive stressful life events scale (PSLES) scores and PSSs of the patients were assessed. Patients with PSLES scores more than 200 were included in the study. They were all on nonvegetarian diet and came from the middle socioeconomic class. Patients were randomly allocated into two groups and received either balancing exercises and mindfulness-based meditation (Group A) or balancing exercises (Group B). Patients of both groups were age matched. Body mass index (BMI) and waist/hip ratios were measured. The outcome measures were visual analog scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Results: There was no significant difference in age, PSLES and PSS scores, and WOMAC and VAS scores between the two groups before intervention. AGE Group A 62.4 ± 4.16 versus Group B 62.15 ± 3.75, P = 0.85; BMI Group A 26.6 ± 1.97 versus Group B 26.2 ± 1.002, P = 0.41; waist/hip Group A 0.833 ± 0.033 versus Group B 0.832 ± 0.03, P = 0.96; PSLES Group A 296.3 ± 34.95 versus Group B 291.8 ± 25.2, P = 0.65; PSS Group A 33.38.1 ± 1.97 versus Group B 32.8 ± 2.86, P = 0.185. PSS scores (20.75 ± 1.9 vs. 27.1 ± 1.65; P < 0.0001) and waist/hip ratio were significantly less in Group A as compared to Group B following intervention. Group A had significantly lower WOMAC (38.1 ± 4.03 vs. 50.8 ± 3.78; P < 0.0001) and VAS (4.35 ± 0.77 vs. 5.75 ± 0.68; P < 0.0001) scores as compared to Group B after practice of balancing exercises along with mindfulness-based meditation. Waist/hip ratio was significantly less in the group practicing mindfulness-based meditation (Group A) as compared to Group B. Conclusion: The results of the present study indicate that balancing exercises when practiced along with stress relaxation exercises are more effective in improving the functional ability of OA knee in postmenopausal women.

Keywords: Balancing exercise therapy, knee osteoarthritis, mindfulness-based meditation, perceived stress



How to cite this URL:
Sannigrahi N, Chaudhuri A, Adhya D. To Study the Effectiveness of Mindfulness-Based Meditation in the Functional Outcome of Osteoarthritis Knee and Perceived Stress Scores and Markers of Obesity in Postmenopausal Women. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=321278




  Introduction Top


Perception of stress is influenced by a person's experiences, genetics, and behavior. When the brain perceives stress, physiologic and behavioral responses are initiated. This leads to allostasis and adaptation. In the long run, allostatic load can accumulate; the overexposure to neural, endocrine, and immune stress mediators may have adverse effects on various systems which may lead to disease.[1]

Stress can lead to acute or chronic pathological conditions (such as metabolic syndrome and atherosclerosis) in individuals with a genetically or constitutionally vulnerable background by interacting with various axes (thyroid and growth axis) and systems (reproductive, gastrointestinal, and immune system). Glucocorticoids also antagonize the beneficial anabolic actions of growth hormone, insulin, and sex steroids on their target tissues. Chronic activation of hypothalamic–pituitary–adrenal axis may increase visceral adiposity, decrease lean body mass, suppress osteoblastic activity, and cause insulin resistance.[2],[3],[4],[5],[6]

Osteoarthritis (OA) is the most common arthritic condition leading to chronic disability in the middle aged and elderly.[7] OA is a heterogeneous and multifactorial process involving joint degeneration. Inflammation is potentially the key mechanism that appears to act through alteration of cytokines, which occurs secondary to aging of the immune system or increase in body weight.[7],[8],[9],[10] Women are more likely to develop OA as compared to men and may have more severe OA. OA in women around the time of menopause has led investigators hypothesize that hormonal factors may play a significant role. Menopause increases stress level among females. The more stress the body experiences, the more stressful thoughts the women have. A great deal of anxiety comes not from the hormonal or body changes, but just from the simple anxieties of getting older.[7],[8],[9],[10],[11]

Hence, from the above discussion, it is evident that perceived stress may increase the incidence of development of visceral adiposity, bone demineralization, and worsen outcome of OA.

In OA in addition to exercises that improve lower extremity strength, range of motion, and cardiovascular endurance, it is now being recommended that exercise therapy programs should also include techniques to improve balance and coordination and provide patients with an opportunity to practice various skills that they will likely encounter during normal daily activities.[7],[8],[9],[10],[11] Stress management programs such as meditation, yoga, hypnosis, imagery, and muscle relaxation have shown to improve in positive coping skills and has been used in the treatment of various disease as an adjuvant therapy.[12]

An evidence-based program, mindfulness-based stress reduction (MBSR), offers intensive mindfulness training to assist people with stress, anxiety, depression, and pain. It is a practical approach, which trains attention, allowing to cultivate awareness. The process was developed by Professor Jon Kabat-Zinn.[12]

A study by Wong et al.[13] was aimed to gauge the effectiveness of MBSR in reducing menopause-related symptoms by comparing with a lively control, the menopause education control (MEC). The primary outcome was measured by the modified Greene Climacteric Scale (GCS). A study by Wong et al.[13] was aimed to gauge the effectiveness of MBSR in reducing menopause-related symptoms by comparing with a lively control, the menopause education control (MEC). The primary outcome was measured by the modified Greene Climacteric Scale (GCS). All outcome measures were collected at baseline, 2 months (immediately postintervention), and 5 and 8 months (3 and 6 months' postintervention, respectively). Both MBSR and MEC groups reported a reduction in total GCS score at 8 months. Between-group analysis showed a significant symptom score reduction in the MBSR group on anxiety and depression subscales of GCS. The present study was conducted to identify the effectiveness of balancing exercises versus balancing exercises along with mindfulness-based meditation on functional outcome of OA knee in postmenopausal women in an urban population of Eastern India.


  Materials and Methods Top


This pilot study was conducted in a tertiary care hospital of Eastern India after taking Institutional Ethical Clearance (IEC BURDWAN MEDICAL COLLEGE, PURBA BARDHAMAN, MEMO NO: 60, DATED 8/1/2019 and MEMO NO: WBUHS/DEAN/2019-20/683, dated September 23, 2019) and informed consent of the patients in a time span of 1 year. Women having a history of amenorrhea for the consecutive 12 months or more were considered as menopausal. Postmenopausal women in the age group of 50–70 years with knee pain in or around the joint for most days in the last 1 month were selected.

Inclusion criteria

For inclusion of patients in the present study, the American College of Rheumatology Criteria for the Classification and Reporting of Osteoarthritis of the Knee was used.[8] Clinical and laboratory diagnostic criteria:

Knee pain plus a minimum of 5 of the subsequent 9 criteria:

  • Age >50 years
  • Stiffness <30 min
  • Crepitus
  • Bony tenderness
  • Bony enlargement
  • No palpable warmth
  • Erythrocyte sedimentation rate <40 mm/h
  • Rheumatoid Factor <1.40
  • Synovial fluid signs of OA.


Clinical and radiographic diagnostic criteria

Knee pain plus osteophytes, plus at least 1 of the following 3 subsequent criteria:

  • Age >50 years
  • Stiffness <30 min
  • Crepitus.


Patients having similar prognostic factors were selected from the orthopedic outdoor of Burdwan Medical College and opinions were taken from the Senior Consultants of Orthopedic Department of Burdwan Medical College in this regard.

Exclusion criteria

Patients with rheumatoid arthritis and polyarthritis were excluded. Patients with a history of total knee arthroplasty or major knee trauma injury; corticosteroid injection to the quadriceps or patellar tendon in the last month; suffering from neurological and psychological disorder, unresolved balance disorder, hip or ankle instability, and excessive weakness; surgery or major trauma injury; and high-risk health status such as uncontrolled hypertension, diabetes, and coronary artery disease were excluded. Patients with musculoskeletal problems such as fractures, tendonitis, or bursitis or any significant symptoms affecting the whole lower limb or back that would interfere with the exercise program were excluded.

Methods

Patients having similar prognostic factors were selected from the Orthopedic Outdoor of Burdwan Medical College and opinions were taken from the Senior Consultants of Orthopedic Department of Burdwan Medical College in this regard.

On the first appointment, histories of the patients were carefully recorded. Patients were asked to tally a list of 51 life events based on a relative score. The stress level in the patients was assessed consistent with the presumptive life event stress scale (PSLES)[14]. Finally, 40 women with scores above 200 were chosen for the study, as they had a higher risk of developing the illness.[13] They were randomly allocated into two groups using an online randomizer and received either balanced exercises and mindfulness-based meditation (Group A) or balancing exercises (Group B).

Dietary habits of both groups were comparable; all were nonvegetarian and all of them belonged to the middle socioeconomic group. The outcome measures were visual analog scale (VAS)[15] and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).[16] VAS was used to measure knee pain intensity, and WOMAC was used to assess perceived pain, stiffness, and functional ability.

The patients were requested to put a mark on the scale at the point which approximates to the relative intensity of pain experienced.

The perceived stress score (PSS) of Cohen et al.[17] was used to measure PSSs. It is a measure of the degree to which situations in one's life are appraised to be stressful.

Before starting the treatment regimen patients were assessed and all parameters were recorded for both the groups as pretreatment data.

The balance exercise programs are as follows:[7]

  • One-leg balances
  • Blind advanced one-leg balances
  • Cross body leg swings
  • Tandem walking
  • Rocker board exercise.


Steps of mindfulness-based meditation are as follows:[12]

  1. a. Take a seat. Find a spot that provides you a stable, solid seat. If you already do some kind of quite seated yoga posture, go ahead. If on a chair, it is good if the bottoms of your feet are touching the ground
  2. Straighten but don't stiffen your upper body
  3. Put your upper arms parallel to your upper body. Then, let your hands drop onto the tops of your legs. With your upper arms at your sides, your hands will land within the right spot
  4. Drop your chin a little and let your gaze fall gently downward. You may let your eyelids lower
  5. Be there for a few moments. Relax. Bring your attention to your breath
  6. Feel your breath or follow it, as it goes out and as it goes in. Inevitably, your attention will leave the breath and wander to other places. Don't worry
  7. There is no need to block or eliminate thinking
  8. When you get around to noticing your mind wandering just gently return your attention to the breath
  9. You may find your mind wandering constantly. Instead of wrestling with or engaging with those thoughts the maximum amount, practice observing without having to react. Just sit and pay attention to your breathing or counting breath
  10. In the end of a session take a moment and notice any sounds in the environment. Notice how your body feels right now. Notice your thoughts and emotions
  11. Pausing for a moment, decide how you'd like to continue on with your day.


Instruction in both active interventions included an introductory presentation and discussion, brief personal interview, personal instruction meeting, and three follow-up small group seminars. The instructional meetings lasted about 1.5 h and each and lasted over the course of 1 week.

Each patient was asked to practice mindfulness-based meditation 20 min daily. They were followed regularly through mobile and as and when possible with contact sessions. All participants were also requested not to reveal details of their program to individuals outside their treatment group. Assessments of patients were done by doctors who were blinded to the study. Patients were reevaluated after 3 months of treatment. This was a double-blinded study. The patients were not aware of the group in which they were allocated and treatment of the other group, and evaluation of VAS and WOMAC scores was done in orthopedic outdoor and physiotherapy clinic. In the department of physiology, training for mindfulness-based meditation was given and stress levels were assessed. All patients who were advised meditation and balancing exercises were asked comply to it. We had initially selected 25 participants in both groups. Two patients in Group A were lost during follow-up and three in Group B. Three patients in Group A were not practicing the meditation regimen regularly, so they had to be excluded. In Group B, two patients were not following treatment regimen regularly, so they were not considered during further evaluation. Hence, ultimately the sample size came down to forty.

The computer software “Statistical Package for the Social Sciences” (SPSS) version 16 (SPSS Inc., released 2007, SPSS for Windows, version 16.0., Chicago, IL, SPSS Inc.) was used to analyze the data. The difference between the groups was considered significant and highly significant if the analyzed probability values (P value) were P < 0.05* and P < 0.01**, respectively. t-test was used to compare both the groups.


  Results Top


There was no significant difference in age; PSLES and PSS scores, and WOMAC and VAS scores between the two groups before intervention. AGE Group A 62.4 ± 4.16 versus Group B 62.15 ± 3.75, P = 0.85; body mass index (BMI) Group A 26.6 ± 1.97 versus Group B 26.2 ± 1.002, P = 0.41; WAIST/HIP Group A 0.833 ± 0.033 versus Group B 0.832 ± 0.03, P = 0.96; PSLES Group A 296.3 ± 34.95 versus Group B 291.8 ± 25.2, P = 0.65; PSS Group A 33.38.1 ± 1.97 versus Group B 32.8 ± 2.86, P = 0.185 [Table 1] and [Figure 1]. No significant difference in BMI was observed following treatment between the two groups. PSS scores (20.75 ± 1.9 vs. 27.1 ± 1.65; P < 0.0001) and waist/hip ratio were significantly less in Group A as compared to Group B following intervention. Group A had significantly lower WOMAC (38.1 ± 4.03 vs. 50.8 ± 3.78; P < 0.0001) and VAS (4.35 ± 0.77 vs. 5.75 ± 0.68; P < 0.0001) scores as compared to Group B after practice of balancing exercises along with mindfulness-based meditation. Waist/hip ratio was significantly less in the group practicing mindfulness-based meditation (Group A) as compared to the other group. PSS was positively correlated with waist/hip ratio in both groups with r value of 0.22 in Group B and 0.061 in Group A after 3 months of observation [Table 2] and [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 1: Parameters of both groups after treatment

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Figure 2: Waist/hip ratio of both groups after treatment

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Figure 3: Perceived stress score of both groups after treatment

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Figure 4: Correlation of waist/hip ratio and perceived stress score in Group B (initial examination)

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Figure 5: Correlation of waist/hip ratio and perceived stress score in Group B (after 3 months)

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Table 1: Parameters of both groups before treatment

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Table 2: Parameters of both groups after treatment

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  Discussion Top


Progressive structural and functional changes on articular structures commence at early menopause leading to an increase in the prevalence of OA.[7] Pain, a complex and subjective conscious experience, is constructed and modulated by a constellation of sensory, cognitive, and affective factors. According to various studies, nonpharmacological-based pain manipulations attenuate the subjective experience of pain through a common final pathway, including overlapping endogenously driven and neural systems. The cognitive modulation of pain is mediated through a host of endogenous modulatory systems, including cannabinoid, serotonergic, dopaminergic, cholecystokinin, adrenergic, and other neurochemical systems; the endogenous opioid system is the most understood pain modulatory system.[18]

The present study was conducted to evaluate the effects of mindfulness-based meditation on balancing exercises to improve functional ability in postmenopausal women with OA of the knee. Forty postmenopausal women were included in the study. Patients were randomly allocated into two groups, and they received either balancing exercises and mindfulness-based meditation (Group A) or balancing exercises (Group B). There was no difference in age, PSLES and PSS scores, and WOMAC and VAS scores between the two groups on the 1st day of assessment. There was a significant improvement in WOMAC and VAS scores after 3 months of treatment in both groups. PSS scores were significantly less in Group A as compared to Group B following the treatment regimen.

Management of OA pain involves nonpharmacologic modes of therapy as well as pharmacologic agents. In the last 20 years, mindfulness-based meditation (MBSR) was studied effectively in many controlled clinical research.[19] The results suggest that it may be beneficial in stress reduction, relaxation, and improvements to quality of life.[20] MBSR might be beneficial in the treatment of fibromyalgia; however, there is no evidence of long-term benefit. Only low-quality evidence of a small short-term benefit has been observed.[21]

We had earlier conducted studies to demonstrate effects of progressive muscle relaxation (PMR) on cardiovascular profile in postmenopausal women,[11] polycystic ovary syndrome patients,[22] female health-care professionals[23] and young adult males,[24] and postmenopausal women with OA.[7] We observed positive influence of PMR on cardiovascular profile and pain management. This study was conducted to study the effects of mindfulness-based meditation on pain management in OA patients and PSS was significantly decreased in patients practicing mindfulness-based meditation and outcome of treatment in this group was significantly better as compared to the other group.

Limitations, strength, and future scope

The sample size was small in this pilot study; long-term follow-up was not done. However, the results do indicate a positive effect of stress management programs in the management of OA knee. The application of stress relaxation exercises as an adjuvant in the treatment of OA process may hold promise for the development of new, potentially disease-modifying nonpharmacologic therapies.


  Conclusion Top


The results of the present study indicate that balancing exercises when practiced along with stress relaxation exercises are more effective in improving the functional ability of OA knee in postmenopausal women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

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