Randomised clinical trial: yoga vs a low-FODMAP diet in patients with irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome is the most frequent gastrointestinal disorder. It is assumed that lifestyle interventions might be a rational treatment approach. AIM: To examine the effect of a yoga-based intervention vs a low-FODMAP diet on patients with irritable bowel syndrome. METHODS: Fifty-nine patients with irritable bowel syndrome undertook a single-blind, randomised controlled trial involving yoga or a low-FODMAP diet for 12 weeks. Patients in the yoga group received two sessions weekly, while patients in the low-FODMAP group received a total of three sessions of nutritional counselling. The primary outcome was a change in gastrointestinal symptoms (IBS-SSS). Secondary outcomes explored changes in quality of life (IBS-QOL), health (SF-36), perceived stress (CPSS, PSQ), body awareness (BAQ), body responsiveness (BRS) and safety of the interventions. Outcomes were examined in weeks 12 and 24 by assessors "blinded" to patients' group allocation. RESULTS: No statistically significant difference was found between the intervention groups, with regard to IBS-SSS score, at either 12 (Δ = 31.80; 95%CI = -11.90, 75.50; P = .151) or 24 weeks (Δ = 33.41; 95%CI = -4.21, 71.04; P = .081). Within-group comparisons showed statistically significant effects for yoga and low-FODMAP diet at both 12 and 24 weeks (all P < .001). Comparable within-group effects occurred for the other outcomes. One patient in each intervention group experienced serious adverse events (P = 1.00) and another, also in each group, experienced nonserious adverse events (P = 1.00). CONCLUSIONS: Patients with irritable bowel syndrome might benefit from yoga and a low-FODMAP diet, as both groups showed a reduction in gastrointestinal symptoms. More research on the underlying mechanisms of both interventions is warranted, as well as exploration of potential benefits from their combined use.

[Complementary and alternative procedures for fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. / Komplementäre und alternative Verfahren beim Fibromyalgiesyndrom : Aktualisierte Leitlinie 2017 und Übersicht von systematischen Übersichtsarbeiten.

BACKGROUND: The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017. METHODS: The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A search of the literature for systematic reviews of randomized controlled trials of complementary and alternative therapies from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was formed by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines. RESULTS AND CONCLUSION: Meditative movement therapies (e.g. qi gong, tai chi and yoga) are strongly recommended. Acupuncture and weight reduction in cases of obesity can be considered.

Randomised clinical trial: yoga vs written self-care advice for ulcerative colitis.

BACKGROUND: Perceived stress seems to be a risk factor for exacerbation of ulcerative colitis. Yoga has been shown to reduce perceived stress. AIMS: To assess the efficacy and safety of yoga for improving quality of life in patients with ulcerative colitis. METHODS: A total of 77 patients (75% women; 45.5 ± 11.9 years) with ulcerative colitis in clinical remission but impaired quality of life were randomly assigned to yoga (12 supervised weekly sessions of 90 min; n = 39) or written self-care advice (n = 38). Primary outcome was disease-specific quality of life (Inflammatory Bowel Disease Questionnaire). Secondary outcomes included disease activity (Rachmilewitz clinical activity index) and safety. Outcomes were assessed at weeks 12 and 24 by blinded outcome assessors. RESULTS: The yoga group had significantly higher disease-specific quality of life compared to the self-care group after 12 weeks (Δ = 14.6; 95% confidence interval=2.6-26.7; P = 0.018) and after 24 weeks (Δ = 16.4; 95% confidence interval=2.5-30.3; P = 0.022). Twenty-one and 12 patients in the yoga group and in the self-care group, respectively, reached a clinical relevant increase in quality of life at week 12 (P = 0.048); and 27 and 17 patients at week 24 (P = 0.030). Disease activity was lower in the yoga group compared to the self-care group after 24 weeks (Δ = -1.2; 95% confidence interval=-0.1-[-2.3]; P = 0.029). Three and one patient in the yoga group and in the self-care group, respectively, experienced serious adverse events (P = 0.317); and seven and eight patients experienced nonserious adverse events (P = 0.731). CONCLUSIONS: Yoga can be considered as a safe and effective ancillary intervention for patients with ulcerative colitis and impaired quality of life. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02043600.

Altered Cerebellar Activity in Visceral Pain-Related Fear Conditioning in Irritable Bowel Syndrome.

There is evidence to support a role of the cerebellum in emotional learning processes, which are demonstrably altered in patients with chronic pain. We tested if cerebellar activation is altered during visceral pain-related fear conditioning and extinction in irritable bowel syndrome (IBS). Cerebellar blood oxygenation level-dependent (BOLD) data from N = 17 IBS patients and N = 21 healthy controls, collected as part of a previous fMRI study, was reanalyzed utilizing an advanced normalizing method of the cerebellum. The differential fear conditioning paradigm consisted of acquisition, extinction, and reinstatement phases. During acquisition, two visual conditioned stimuli (CS) were presented either paired (CS+) or unpaired (CS-) with painful rectal distension as unconditioned stimulus (US). In the extinction phase, the CS+ and CS- were presented without US. For reinstatement, unpaired US presentations were followed by unpaired CS+ and CS- presentations. Group differences in cerebellar activation were analyzed for the contrasts CS+ > CS- and CS- > CS+. During acquisition, IBS patients revealed significantly enhanced cerebellar BOLD responses to pain-predictive (CS+) and safety (CS-) cues compared to controls (p < 0.05, family-wise error corrected). Increased activation was found in three main clusters, including the vermis (maximum in vermal lobule VI), intermediate cerebellum (maximum in lobule VIII), and the posterolateral cerebellar hemisphere (maximum in lobule VI). Areas overlapped for the contrasts CS+ > CS- and CS- > CS+. Group differences were most prominent in the contrast CS- > CS+. During extinction and reinstatement, no significant group differences were found. During visceral pain-related fear conditioning, IBS patients showed increased activations in circumscribed areas of the medial, intermediate, and lateral cerebellum. These areas are involved in autonomic, somatosensory, and cognitive functions and likely contribute to the different aspects of pain-related fear. The cerebellum contributes to altered pain-related fear learning in IBS.

Neural circuitry of abdominal pain-related fear learning and reinstatement in irritable bowel syndrome.

BACKGROUND: Altered pain anticipation likely contributes to disturbed central pain processing in chronic pain conditions like irritable bowel syndrome (IBS), but the learning processes shaping the expectation of pain remain poorly understood. We assessed the neural circuitry mediating the formation, extinction, and reactivation of abdominal pain-related memories in IBS patients compared to healthy controls (HC) in a differential fear conditioning paradigm. METHODS: During fear acquisition, predictive visual cues (CS(+)) were paired with rectal distensions (US), while control cues (CS(-)) were presented unpaired. During extinction, only CSs were presented. Subsequently, memory reactivation was assessed with a reinstatement procedure involving unexpected USs. Using functional magnetic resonance imaging, group differences in neural activation to CS(+) vs CS(-) were analyzed, along with skin conductance responses (SCR), CS valence, CS-US contingency, state anxiety, salivary cortisol, and alpha-amylase activity. The contribution of anxiety symptoms was addressed in covariance analyses. KEY RESULTS: Fear acquisition was altered in IBS, as indicated by more accurate contingency awareness, greater CS-related valence change, and enhanced CS(+)-induced differential activation of prefrontal cortex and amygdala. IBS patients further revealed enhanced differential cingulate activation during extinction and greater differential hippocampal activation during reinstatement. Anxiety affected neural responses during memory formation and reinstatement. CONCLUSIONS & INFERENCES: Abdominal pain-related fear learning and memory processes are altered in IBS, mediated by amygdala, cingulate cortex, prefrontal areas, and hippocampus. Enhanced reinstatement may contribute to hypervigilance and central pain amplification, especially in anxious patients. Preventing a 'relapse' of learned fear utilizing extinction-based interventions may be a promising treatment goal in IBS.

Systematic review of complementary and alternative medicine treatments in inflammatory bowel diseases.

OBJECTIVE: We performed a systematic review for Complementary and Alternative Medicine [CAM] as defined by the National Institute of Health in Inflammatory Bowel Disease [IBD], ie Crohn's disease [CD] and ulcerative colitis [UC], with the exception of dietary and nutritional supplements, and manipulative therapies. METHODS: A computerized search of databases [Cochrane Library, Pubmed/Medline, PsychINFO, and Scopus] through March 2014 was performed. We screened the reference sections of original studies and systematic reviews in English language for CAM in IBD, CD and UC. Randomized controlled trials [RCT] and controlled trials [CT] were referred and assessed using the Cochrane risk of bias tool. RESULTS: A total of: 26 RCT and 3 CT for herbal medicine, eg aloe-vera gel, andrographis paniculata, artemisia absinthium, barley foodstuff, boswellia serrata, cannabis, curcumin, evening primrose oil, Myrrhinil intest®, plantago ovata, silymarin, sophora, tormentil, wheatgrass-juice and wormwood; 1 RCT for trichuris suis ovata; 7 RCT for mind/body interventions such as lifestyle modification, hypnotherapy, relaxation training and mindfulness; and 2 RCT in acupuncture; were found. Risk of bias was quite heterogeneous. Best evidence was found for herbal therapy, ie plantago ovata and curcumin in UC maintenance therapy, wormwood in CD, mind/body therapy and self-intervention in UC, and acupuncture in UC and CD. CONCLUSIONS: Complementary and alternative therapies might be effective for the treatment of inflammatory bowel diseases; however, given the low number of trials and the heterogeneous methodological quality of trials, further in-depth research is necessary.

A systematic review and meta-analysis of exercise interventions for colorectal cancer patients.

The aim of this systematic review and meta-analysis was to investigate the effectiveness of exercise for colorectal cancer patients. PubMed/Medline, Scopus and the Cochrane Library were searched through December 2012 without language restrictions. Randomised controlled trials (RCTs) comparing exercise interventions to control conditions were analysed when they assessed health-related quality of life, fatigue, physical fitness, survival and/or tumour-associated biomarkers in colorectal cancer patients. Risk of bias was assessed using the risk of bias tool recommended by the Cochrane Back Review Group. Literature search identified 342 non-duplicate records of which five RCTs with a total of 238 patients were included; three RCTs had low risk of bias. No evidence was found for short-term effects on quality of life [standardised mean difference (SMD) = 0.18; 95% confidence interval (CI) -0.39, 0.76; P = 0.53] or fatigue (SMD = 0.18; 95% CI -0.22, 0.59; P = 0.38). There was strong evidence for short-term improvements of physical fitness after aerobic exercise compared with controls (SMD = 0.59; 95% CI 0.25, 0.93; P < 0.01). One RCT each assessed immune parameters and oxidative DNA damage. No study reported survival rates or safety data. Given this insufficient evidence and the lack of safety data, no recommendation can be made regarding exercise interventions as a routine intervention for colorectal cancer patients.

[Urticaria. Sometimes IgE-mediated?]. / Urtikaria. Manchmal doch IgE-vermittelt?

There are specific diagnostic recommendations for approaching chronic spontaneous urticaria, physical urticaria and special forms of urticaria. They include the detection of subclinical viral and bacterial infections, particularly with Helicobacter pylori. Frequently an autoimmune urticaria is diagnosed by using the autologous serum test. Less specific findings, such as leukocytosis and elevated CRP can sometimes be helpful in suggesting subclinical infections as the cause of acute urticaria; usually no further procedures are recommended. However, in cases with a long history of intermittent attacks, particularly with severe and generalized symptoms, it is recommended to look for IgE-mediated reactions (e.g. alpha-Gal, Omega-5-Gliadin). In our hands at the Department of Dermatology and Allergy at the Hannover Medical School a standardized set of diagnostic procedures was successfully established, and is now individually completed with selected single allergens and allergen components.

Randomised clinical trial: a herbal preparation of myrrh, chamomile and coffee charcoal compared with mesalazine in maintaining remission in ulcerative colitis--a double-blind, double-dummy study.

BACKGROUND: The herbal treatment with myrrh, dry extract of chamomile flowers and coffee charcoal has anti-inflammatory and antidiarrhoeal potential and might benefit patients with UC. Aminosalicylates are used as standard treatment for maintaining remission in ulcerative colitis (UC). AIM: To compare the efficacy of the two treatments in maintaining remission in patients with ulcerative colitis. METHODS: We performed a randomised, double-blind, double-dummy study over a 12-month period in patients with UC. Primary endpoint was non-inferiority of the herbal preparation as defined by mean Clinical Colitis Activity Index (CAI-Rachmilewitz). Secondary endpoints were relapse rates, safety profile, relapse-free times, endoscopic activity and faecal biomarkers. RESULTS: A total of 96 patients (51 female) with inactive UC were included. Mean CAI demonstrated no significant difference between the two treatment groups in the intention-to-treat (P = 0.121) or per-protocol (P = 0.251) analysis. Relapse rates in total were 22/49 patients (45%) in the mesalazine treatment group and 25/47 patients (53%) in the herbal treatment group (P = 0.540). Safety profile and tolerability were good and no significant differences were shown in relapse-free time, endoscopy and faecal biomarkers. CONCLUSIONS: The herbal preparation of myrrh, chamomile extract and coffee charcoal is well tolerated and shows a good safety profile. We found first evidence for a potential efficacy non-inferior to the gold standard therapy mesalazine, which merits further study of its clinical usefulness in maintenance therapy of patients with ulcerative colitis. EudraCT-Number 2007-007928-18.

A systematic review and meta-analysis of Tai Chi for osteoarthritis of the knee.

OBJECTIVES: This paper aimed to systematically review and meta-analyze the effectiveness of Tai Chi for osteoarthritis of the knee. METHODS: MEDLINE, the Cochrane Library, EMBASE, Scopus, PsycInfo and CAMBASE were screened through April 2013. Randomized controlled trials (RCTs) comparing Tai Chi to control conditions were included. Two authors independently assessed risk of bias using the risk of bias tool recommended by the Cochrane Back Review Group. Outcome measures included pain, physical functional, joint stiffness, quality of life, and safety. For each outcome, standardized mean differences and 95% confidence intervals were calculated. RESULTS: 5 RCTs with a total of 252 patients were included. Four studies had a low risk of bias. Analysis showed moderate overall evidence for short-term effectiveness for pain, physical function, and stiffness. Strong evidence was found for short-term improvement of the physical component of quality of life. No long-term effects were observed. Tai Chi therapy was not associated with serious adverse events. CONCLUSION: This systematic review found moderate evidence for short-term improvement of pain, physical function and stiffness in patients with osteoarthritis of the knee practicing Tai Chi. Assuming that Tai Chi is at least short-term effective and safe it might be preliminarily recommended as an adjuvant treatment for patients with osteoarthritis of the knee. More high quality RCTs are urgently needed to confirm these results.

[Mental disorders in patients with fibromyalgia syndrome: screening in centres of different medical specialties]. / Psychische Störungen beim Fibromyalgiesyndrom: Screening in Einrichtungen verschiedener Fachrichtungen.

BACKGROUND: Systematic reviews have reported a wide range of prevalence rates for depressive, anxiety and posttraumatic stress disorders (PTSD) in patients with fibromyalgia syndrome (FMS) which have been partially explained by setting differences. No data are currently available on the prevalence of potential mental disorders depending on the medical specialty in Germany. MATERIAL AND METHODS: All consecutive FMS patients of 8 study centres (3 rheumatology/orthopaedic surgery, 3 psychosomatic/pain medicine, 2 physical/integrative medicine) were assessed from February 1 to July 31, 2012 with standardised questionnaires. Patients with FMS diagnosed by a study physician were included. Non-German speaking and mentally retarded patients were excluded. The German version of the Patient Health Questionnaire 4 was used to screen for potential depressive and anxiety disorders. Severe life events were assessed by the trauma list of the Munich Composite International Diagnostic Interview and symptom criteria of PTSD of the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) using the Posttraumatic Diagnostic Scale. RESULTS: Of 538 patients, 396 patients (93.9 % women, mean age 52.3 years, mean duration since chronic widespread pain 12.8 years, mean duration since FMS diagnosis 4.5 years) were analysed. In all, 65.7 % of patients met the criteria of a potential depressive disorder, 67.9 % of a potential anxiety disorder and 45.5 % of a potential PTSD. Potential depressive disorders were more frequent in the psychosomatic/pain medicine setting than in the rheumatology setting. CONCLUSION: Potential mental disorders were frequent in FMS patients regardless of the medical specialty. All FMS patients of all types of clinical settings should be screened for mental disorders.

[Are members of fibromyalgia syndrome self-help groups "different"? Demographic and clinical characteristics of members and non-members of fibromyalgia syndrome self-help groups]. / Sind Mitglieder von Fibromyalgiesyndrom-Selbsthilfegruppen "anders"? Demografische und klinische Charakteristika von Mitgliedern und Nicht-Mitgliedern von Fibromyalgiesyndrom-Selbsthilfegruppen.

BACKGROUND: No data were available on demographic and clinical characteristics of members of fibromyalgia syndrome (FMS) self-help groups in Germany. MATERIAL AND METHODS: The study was carried out from November 2010 to April 2011. A set of questionnaires was distributed by the German League Against Rheumatism and the German Fibromyalgia Association to members and to all consecutive FMS patients at nine clinical centres of different levels of care. The set included a self-developed questionnaire on demographic and medical data and on previously and currently used therapies, the patient health questionnaire (PHQ 4) and the fibromyalgia survey questionnaire. RESULTS: Members of FMS self-help groups (N = 1,014) were older and reported a longer duration of chronic widespread pain, less anxiety and depression and a more frequent current use of aerobic exercise, relaxation training and complementary alternative medication than participants not affiliated with FMS self-help groups (N = 630). CONCLUSIONS: Membership in FMS self-help groups was associated with less psychological distress and a more frequent use of active self-management strategies.