The Role of Mindfulness Therapy in the Treatment of Chronic Pain.

PURPOSE OF REVIEW: Mindfulness therapy is a widely used treatment for many diseases and has been shown to improve pain-related functions. There is growing support for the use of psychotherapy in the treatment of chronic pain. While studies have shown a positive effect of mindfulness therapy, it is important to consider psychosocial factors as there are still a small number of studies that question its effectiveness. RECENT FINDINGS: Based on current studies, mindfulness therapy involves cognitive factors related to chronic pain, both in terms of cognitive production and its impact on cognitive control. Psychological and neurobasic studies were reviewed to provide a deeper understanding of these components, which include thought inhibition, attention deficit, pain catastrophizing, and self-efficacy. Mindfulness therapy has the potential to normalize psychology and nerves, and increase internal and external connectivity to work networks related to stress perception, cognition, and emotion. However, further research is needed to fully understand its effects. By exploring the relationship between mindfulness therapy and chronic pain. This review provides a new avenue for future research in psychotherapy for patients with chronic pain.

The impact of mindfulness therapy combined with mentalization-based family therapy on suicidal ideation in adolescents with depressive disorder: randomized intervention study.

BACKGROUND: Adolescents with depression who engage in non-suicidal self harming behaviors are more likely to adopt negative coping strategies when faced with negative events. Therefore, these patients should be introduced to positive coping strategies. Evidences have showed that mindfulness-based interventions can positively impact the psychology of patients with mental disorders. This study was to explore the impact of a combination of mindfulness therapy and mentalization-based family therapy (MBFT) on suicidal ideation in adolescents with depressive disorder. METHODS: Eighty adolescent patients with depression and suicidal ideation admitted to our hospital from September 2021 to February 2022 were selected as subjects. They were divided into a control group and a study group using the random number table method, with each group comprising 40 subjects. The control group received MBFT, whereas the study group received both mindfulness therapy and MBFT. The psychological status and suicidal ideations of the two groups were compared before and after the intervention. RESULTS: The psychological health scores of both groups of patients were lower after the intervention, with the scores of the study group being lower than those of the control group (P < 0.05). The scores on the suicidal ideation scales for both groups were lower after intervention, and the study group scored lower than the control group (P < 0.05). The absolute values of the differences in psychological health scale scores and suicidal ideation scale scores before and after the intervention were higher in the study group than in the control group (P < 0.05). CONCLUSION: The combination of mindfulness therapy and MBFT can improve the psychological condition of adolescents with depression, reduce their suicidal ideations, and help them develop a healthy and positive outlook toward life, making this method worthy of clinical recommendation.

Perceived Benefits and Barriers of mHealth Mindfulness Use for Caregivers of Older Adults with Cognitive Impairment: A Qualitative Exploration.

OBJECTIVES: Mobile (mHealth) mindfulness-based interventions have the potential to be feasible, acceptable, effective, and scalable interventions for caregivers of people living with cognitive impairment. This qualitative study of caregivers of older adults with cognitive impairment explored caregivers' experiences using a mindfulness therapy mobile application. METHODS: Fifteen caregivers were interviewed using a semi-structured interview guide. Analysis was guided by the phenomenological approach and inductive-deductive analysis. RESULTS: Six themes were generated from the data: convenience, barriers, perceived helpfulness, useful features, suggested app improvements, and skill transfer. Caregivers reported that the app was easy to use with many perceived benefits. Caregivers also noted some barriers to using the app. CONCLUSIONS: This study revealed that self-directed mHealth delivered mindfulness therapy may be a promising intervention for the caregivers involved in the study. Having the ability to use the app anywhere and at any time was a prominent reason for continued regular use for the participants. This was especially important to some caregivers during the COVID-19 pandemic. The barriers discussed by the caregivers are important considerations for future app-based interventions for caregivers. CLINICAL IMPLICATIONS: Clinicians can consider recommending mHealth mindfulness therapy to caregivers as a tool to provide caregivers with additional support.

Effects of brain-Computer interface combined with mindfulness therapy on rehabilitation of hemiplegic patients with stroke: a randomized controlled trial.

Aim: To explore the effects of brain-computer interface training combined with mindfulness therapy on Hemiplegic Patients with Stroke. Background: The prevention and treatment of stroke still faces great challenges. Maximizing the improvement of patients' ability to perform activities of daily living, limb motor function, and reducing anxiety, depression, and other social and psychological problems to improve patients' overall quality of life is the focus and difficulty of clinical rehabilitation work. Methods: Patients were recruited from December 2021 to November 2022, and assigned to either the intervention or control group following a simple randomization procedure (computer-generated random numbers). Both groups received conventional rehabilitation treatment, while patients in the intervention group additionally received brain-computer interface training and mindfulness therapy. The continuous treatment duration was 5 days per week for 8 weeks. Limb motor function, activities of daily living, mindfulness attention awareness level, sleep quality, and quality of life of the patients were measured (in T0, T1, and T2). Generalized estimated equation (GEE) were used to evaluate the effects. The trial was registered with the Chinese Clinical Trial Registry (ChiCTR2300070382). Results: A total of 128 participants were randomized and 64 each were assigned to the intervention and control groups (of these, eight patients were lost to follow-up). At 6 months, compared with the control group, intervention group showed statistically significant improvements in limb motor function, mindful attention awareness, activities of daily living, sleep quality, and quality of life. Conclusion: Brain-computer interface combined with mindfulness therapy training can improve limb motor function, activities of daily living, mindful attention awareness, sleep quality, and quality of life in hemiplegic patients with stroke. Impact: This study provides valuable insights into post-stroke care. It may help improve the effect of rehabilitation nursing to improve the comprehensive ability and quality of life of patients after stroke. Clinical review registration: https://www.chictr.org.cn/, identifier ChiCTR2300070382.

Exploring the potential of mindfulness-based therapy in the prevention and treatment of neurodegenerative diseases based on molecular mechanism studies.

Neurodegenerative diseases (ND) have received increasing attention due to their irreversibility, but there is still no means to completely cure ND in clinical practice. Mindfulness therapy (MT), including Qigong, Tai Chi, meditation, and yoga, etc., has become an effective complementary treatment modality in solving clinical and subclinical problems due to its advantages of low side effects, less pain, and easy acceptance by patients. MT is primarily used to treat mental and emotional disorders. In recent years, evidence has shown that MT has a certain therapeutic effect on ND with a potential molecular basis. In this review, we summarize the pathogenesis and risk factors of Alzheimer's disease (AD), Parkinson's disease (PD), and amyotrophic lateral sclerosis (ALS), relating to telomerase activity, epigenetics, stress, and the pro-inflammatory transcription factor nuclear factor kappa B (NF-κB) mediated inflammatory response, and analyze the molecular mechanism basis of MT to prevent and treat ND, to provide possible explanations for the potential of MT treatments for ND.

Mindfulness Intervention for Improving Psychological Wellbeing Among Students During COVID-19 Pandemic: A Scoping Review.

The COVID-19 pandemic can cause mental health problems such as stress, social anxiety, depression, and decrease social life on students. Mental health problems need to be taken seriously to develop the stage of development and improve the psychological well-being of students on learning in the school. The aim of this study was to explore mindfulness interventions to improve psychological well-being among students. This study used the Scoping Review method. Literature from CINAHL, PubMed, and Scopus databases. The keywords used in English are psychological wellbeing, students, and mindfulness. The inclusion criteria were full text, study design randomized control trial or quasi-experimental, English language, population and sample were students, and the publication period is the last 10 years (2013-2022). From 2194 articles based on initial research, we found 10 articles were analyzed related to mindfulness interventions consisting of several methods, namely internet-based mindfulness, mindfulness-based intervention, and mindfulness-based stress reduction. Most of samples the study from the United States with the range samples were 20-166 students. Mindfulness interventions can be carried out improve the psychological well-being of students. Mindfulness therapy is done by fully concentrating the mind in meditation so that it can improve psychological health. Providing mindfulness therapy involves health workers such as nurses and psychologists to provide comprehensive therapy covering both physical and psychological aspects.

Evaluation of Guided Respiration Mindfulness Therapy (GRMT) for Reducing Stress in Nurses.

Guided respiration mindfulness therapy (GRMT) is a clinical model of breathwork that has shown promise as a treatment for depression, anxiety, and stress. This study examined the effectiveness of GRMT as a holistically oriented intervention for reducing psychological distress in nurses. Sixty-two nurses were assigned to either five sessions of GRMT or 5 sessions of a mindfulness-based intervention (MBI) comparison condition which were conducted over 5 weeks. A no-treatment control was also included. Session-by-session change in depression, anxiety, and stress, along with change in mindfulness and self-compassion were assessed. Multilevel analysis showed GRMT resulted in statistically significant reductions in overall psychological distress, anxiety, and stress levels, as well as significant increases in mindfulness and self-compassion with large to very large effect sizes. On all measures, GRMT performed better than the comparison MBI intervention which showed no significant effect on stress levels. Results suggest that GRMT can provide nurses with an effective group intervention for reducing stress, and increasing mindfulness and self-compassion which are foundational elements of self-care for the holistic nurse.

Research progress of mindfulness therapy in the treatment of common mental diseases / 中国神经精神疾病杂志

Mindfulness-based psychotherapy was developed from mindfulness-based psychotherapy,including mindfulness-based stress reduction therapy,mindfulness-based cognitive therapy,dialectical behavior therapy,acceptance and commitment therapy.Mindfulness therapy alleviates the symptoms of mental illness by regulating the cognitive and emotional systems.A large number of studies have shown that mindfulness therapy is helpful in the treatment of depression,anxiety,substance dependence,post-traumatic stress disorder,eating disorder,schizophrenia,bipolar disorder and other mental diseases.The therapeutic effect in depression and anxiety is the same as that of first-line treatment,which provides a new idea for the treatment of mental diseases.

Psychotherapy for Irritable Bowel Syndrome: A Systematic Review.

Psychotherapy has many forms, such as cognitive behavioral therapy (CBT), mindfulness therapy (MFT), and hypnotherapy, to name a few. Cognitive behavioral therapy is the gold standard in therapy-based treatment and is used for cognitive restructuring to reduce safety-seeking and avoidant behaviors. While the main application of psychotherapy is psychological disorders, recent studies have found that it is beneficial for somatic and physiological symptoms such as chronic pain or even irritable bowel syndrome (IBS). Irritable bowel syndrome is a common but debilitating gastrointestinal condition that has a prevalence of 12% in the United States and costs the average patient $9,776 annually in 2023. Irritatable bowel syndrome is a condition of exclusion but consists of abdominal discomfort or pain and must be associated with altered bowel habits as stated in the Rome IV criteria. At least half of these patients also exhibit extracolonic symptoms, most commonly psychological disorders like anxiety and stress. The true etiology of IBS is not understood, but ideas such as the brain-gut axis, stress response system, and gut microbiota have been evaluated. Treatment of IBS is extensive and heavily relies on the patient-physician interaction, but pharmacologic therapies have been employed and are sometimes unsuccessful. Irritable bowel syndrome impacts an individual as a whole, making them hesitate whether or not they eat a particular food or even go out to do an activity because of the unpredictable bowel pattern. Finding a better solution is essential to improving the patient's quality of life (QoL), especially by addressing how they perceive the illness, how they adjust to it, and even how they determine what foods to consume. This paper aims to evaluate whether or not psychotherapy can be employed to improve all aspects of IBS, as well as if it can reduce the cost of IBS treatment.

The Effectiveness of Mindfulness-Based Cognitive Therapy in the Management of Tinnitus.

Mindfulness-based cognitive therapy (MBCT) has been suggested as an effective modality in reducing the effects of tinnitus and improving quality of life. This article aimed to compare the effectiveness of MBCT with that of standard treatment in the management of tinnitus in Thai patients. All participants were voluntarily divided into experimental MBCT and control groups depending on their availability. In addition to educational sessions and standard treatment, the MBCT group completed four weekly 120-minute sessions of mindfulness practicing skills. The Thai version of the Tinnitus Handicap Inventory (THI-T) and Hospital Anxiety and Depression Scale (HADs-T) were administered at baseline, 4th week, and 12th week. Tinnitus intensity (dB) was measured at baseline and 12th week. All data were compared between the different time points, within each group, and between the two groups. A total of 45 patients were enrolled, 24 in the MBCT group and 21 in the control group. When comparing baseline to post-treatment measurements, statistically significant improvements were observed in all outcomes except tinnitus intensity in both groups. The THI-T and HADs-T scores in the MBCT group were significantly lower than those in the control group at the 12th week. The reduction in the THI-T scores, HADs-T scores, and tinnitus intensity tended to be greater in the MBCT group after the 4-week course and at the 3-month follow-up assessment. The MBCT showed benefits in the management of tinnitus in terms of improved THI-T and HADs-T scores, and overall quality of life.

The feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness therapy for caregivers of adults with cognitive impairment.

Objectives: To examine the feasibility, acceptability, and preliminary efficacy of Mindfulness Coach, an mHealth Mindfulness Therapy intervention.Methods: We recruited 58 informal caregivers of older adults with cognitive impairment for this pilot feasibility trial. Participants completed measures of caregiver burden, stress, anxiety, and depression at baseline, 2 weeks, 4 weeks, and 8 weeks as well as acceptability and usability data at 8-weeks. The mobile app collected in-app use data including minutes spent using the app and number of unique visits to the app.Results: Users found the app acceptable to use and were satisfied with its design and usability. Over the course of the study period, depression, anxiety, caregiver burden and perceived stress improved. These outcome variables also improved more as caregivers spent more time using the Mindfulness Therapy mHealth intervention.Conclusions: Our results suggest that mHealth mindfulness therapy with caregivers of older adults with cognitive impairment is both feasible and acceptable to users, and that it successfully reduces psychological symptoms. Future work should focus on determining the appropriate doses of the mHealth therapy for particular outcomes and strategies to integrate it into routine care. Mindfulness Therapy delivered in an mHealth format may increase access to psychological treatment for caregivers.

Effects of mindfulness-based childbirth on procedural fear， pain and outcome in pregnant women / 四川精神卫生

ObjectiveTo analyze the effects of mindfulness-based childbirth on procedural fear， pain and pregnancy outcome in pregnant women， so as to provide references for clinical application of mindfulness-based childbirth. MethodsA total of 100 pregnant women in the Third Hospital of Mianyang from January 2018 to January 2019 were selected， and divided into experimental group and control group by random number table method， each with 50 cases. All pregnant women received routine nursing， based on this， experimental group received an 8-week mindfulness-based childbirth intervention. Then pregnant women were evaluated with Childbirth Attitudes Questionnaires （CAQ） and Numerical Rating Scale （NRS）， meantime， the labour course and mode of delivery were recorded. Thereafter， the two groups were compared in terms of fear， pain， labor course and delivery mode. ResultsThe scores of CAQ ［（30.46±9.27） vs.（43.24±14.54）， t=-5.242， P<0.01］ and NRS ［（6.64±0.80） vs.（7.32±0.77）， t=-4.331， P<0.01］ yielded statistical differences between experimental group and control group. The labor course of experimental group was shorter than that of control group ［（10.10±1.91）h vs.（13.28±3.28）h， t=-5.921， P<0.01］. The vaginal delivery rate was 84.00% in experimental group and 60.00% in control group， and the cesarean section rate was 16.00% and 40.00%， respectively， with statistical difference （χ2=7.143， P<0.01）. ConclusionMindfulness-based childbirth may alleviate the labor fear and pain， shorten the labor course and promote vaginal delivery.

Identifying patients with benign chronic intestinal failure on home parenteral nutrition in whom a psychological support intervention may improve quality of life.

RATIONALE: Home parenteral nutrition (HPN) is the ultimate treatment for patients who suffering from chronic intestinal failure (CIF). We tested the feasibility and effects of Mindfulness Based Cognitive Therapy (MBCT) in patients on HPN. Because of the high dropout rate, however, we were next urged to develop and test a web-based coaching program (web-based MBCT). The aim of the present study was to compare the effects of MBCT with this web-based MBCT. METHODS: A quasi-experimental pilot study was conducted in a tertiary referral center for CIF in the Netherlands to evaluate the feasibility of both a MBCT and the internet-based MBCT intervention. In 2016 we included 17 patients in the MBCT group. These patients followed MBCT training. End of 2016 an internet-based online MBCT program was constructed for which we invited 14 patients and their caregivers. RESULTS: In the MBCT 5 out of 17 patients (29%) completed their therapy. Patients attributed positive effects to their acquired mindfulness skills and reported a better QoL. In the internet-based mindfulness therapy group 2 out of 14 patients (14%) fulfilled the training sessions. Also, six caregivers started the training in this latter group and one caregiver fulfilled the training. CONCLUSION: The study suggests that both MBCT and the internet-based MBCT are no feasible strategies to decrease disease burden and improve QoL for CIF patients and their caregivers due to the intensity of these programs on one side and the experienced physical limitations on the other. The patients who fulfilled the program were positive and use MBCT in daily practice.

Effects of body mass management and mindfulness therapy on obese polycystic ovary syndrome patients / 中国实用护理杂志

Objective:To investigate the effect of body mass management and mindfulness therapy on obese patients with polycystic ovary syndrome (PCOS).Methods:A total of 68 patients with PCOS admitted to Haikou People's Hospital(Haikou Hospital Affiliated to Central South Xiangya Medical College) from January to December 2018 were divided into observation group and control group by random digits table method, 34 cases in each group. The observation group was treated with body quality management combined with mindfulness therapy, and the control group was treated with routine nursing intervention. The total cholesterol (TC), triglyceride (TG), fasting blood glucose (FPG), 2 h postprandial blood glucose (2 hPPG), insulin (PINS), fasting insulin (FINS), Self Perceived Burden Scale (SPBS), quality of life score in the two groups were evaluated.Results:There was no significant difference in TC and TG between the two groups before intervention ( P>0.05); after 12 weeks of intervention, TC, TG were (4.21 ± 0.20), (1.60 ± 0.20) mmol/L in the observation group and (4.50 ± 0.31), (1.95 ± 0.55) mmol/L in the control group, there were significant differences between the two groups ( t values were 4.584, 3.487, P<0.01). There was no significant difference in FPG, 2 hPPG, PINS and FINS between the two groups before intervention and FPG, 2 hPPG after 12 weeks of intervention ( P>0.05); PINS, FINS were (72.60±28.46),(16.02±3.00)mU/L in the observation group and (102.61±50.10),(18.10±4.22)mU/L in the control group, there were significant differences between the two groups ( t values were 3.037, 2.342, P<0.01 or 0.05). There was no significant difference in the SPBS score between the two groups before intervention ( P>0.05); after 12 weeks of intervention, the SPBS score was (26.15 ± 2.02) in the observation group and (31.03 ± 1.00) in the control group, there was significant difference between the two groups ( t value was 12.624, P<0.01). There was no significant difference in the quality of life score between the two groups before intervention ( P>0.05); after 12 weeks of intervention, the scores of quality of life energy, sleep emotion, social life and physical activity were (80.62 ± 3.50), (79.10 ± 3.62), (75.02 ± 3.00), (77.26 ± 2.87) in the observation group and (71.23±4.02),(72.59±3.65),(69.20±4.11),(69.20±4.47) in the control group, there were significant differences between the two groups( t values were 7.234-10.272, P<0.01). Conclusions:The application of body mass management and mindfulness therapy can effectively improve the glucose and lipid metabolism level of obese PCOS patients, reduce the burden of psychological self perception, and improve the quality of life.

Supportive care for oral cancer survivors in COVID-19 lockdown.

OBJECTIVE: Availability and accessibility to routine health care services for cancer patients were a cause of concern during the COVID-19 pandemic, which induced stringent enforcement of lockdown and social distancing in Sri Lanka. Oral cancer patients who have undergone surgery recently encountered problems such as pain, difficulty in swallowing. However, accessing routine treatment and obtaining medication emerged as the most pressing concerns among them. Therefore, we aimed to provide supportive care for affected oral cancer patients. METHODS: A rapid situational analysis was conducted among 25-randomly selected oral cancer patients of an ongoing interventional study aimed at improving life situation of oral cancer patients. RESULTS: Over-the-phone supportive care tailored to the needs of oral cancer patients, provided by a health professional, deemed a simple but helpful intervention. CONCLUSIONS: Facilitating patients to navigate the health care system to ensure that they can continue in receiving timely treatment was the most critical aspect of the intervention. Interventions tailored to patients' needs could offer better supportive care for cancer patients in COVID-19 pandemic scenario.

Telephone-Based Mindfulness Therapy Intervention for Patients with Chronic Pancreatitis.

BACKGROUND: Patients with chronic pancreatitis (CP) have substantially impaired quality of life (QOL) both physically and mentally. Mindfulness therapy is a form of treatment that has been shown to be beneficial in many medical conditions but has not been evaluated in the CP patient population. AIMS: The aims of this study were (1) to test the feasibility and usability of a novel telephone-based mindfulness therapy service for patients with CP and (2) to determine whether there was any effect on CP quality of life. METHODS: We recruited ten patients with suspected or confirmed CP and five controls who were asked to utilize our telephone-based mindfulness therapy service daily for 28 days. Feasibility of the service was defined as the fraction of subjects with a ≥50% compliance rate. Usability was assessed using a System Usability Scale (SUS). QOL was evaluated using the SF-36 questionnaire and the Pancreatitis Quality of Life Instrument (PANQOLI). Paired t tests were used to compare the SF-36 and PANQOLI pre- and post-intervention. RESULTS: There was an overall compliance rate of 67%. The mean SUS score for all participants was 79.3, above the average published score of 68. Results showed a significant improvement in the SF-36 Mental Component Summary scores after 28 days of mindfulness therapy for patients with CP, t(9) = 2.48, p = 0.035. There was also a significant improvement in the mean total PANQOLI scores in CP patients, t(9) = 2.41, p = 0.04, most notably in the social domain. CONCLUSION: Our telephone-based mindfulness therapy service represents a feasible and easily usable treatment adjunct for patients with CP, which may provide benefit in QOL by improving mental health-related domains.

Mindfulness Therapy for Maladaptive Interpersonal Dependency: A Preliminary Randomized Controlled Trial.

Existing treatments for maladaptive interpersonal dependency and dependent personality disorder do not meet basic scientific standards for effectiveness. The present investigation tested the efficacy of a mindfulness-based approach: mindfulness therapy for maladaptive interpersonal dependency (MT-MID). Forty-eight participants who reported consistently high levels of maladaptive dependency (i.e., scored higher than 1 standard deviation above the mean on the Interpersonal Dependency Inventory at two separate assessments) were randomized to either 5 sessions of MT-MID or a minimal contact control. Five self-reported outcomes (mindfulness, maladaptive interpersonal dependency, helplessness, fears of negative evaluation, and excessive reassurance seeking) were assessed at pretreatment, posttreatment, and a 4-week follow-up. Intent-to-treat analyses indicated that MT-MID yielded greater improvements than the control on all 5 outcomes at posttreatment (median d=1.61) and follow-up (median d=1.51). Participants assigned to MT-MID were more likely than control participants to meet criteria for clinically significant change at posttreatment (56.5% vs. 0%) and follow-up (42.9% vs. 0%). There was also evidence that increases in mindfulness mediated the dependency-related improvements. These results provide preliminary support for the efficacy of a mindfulness-based approach for treating the symptoms of maladaptive dependency.

Searching for existential security: a prospective qualitative study on the influence of mindfulness therapy on experienced stress and coping strategies among patients with somatoform disorders.

OBJECTIVE: The aim was to explore how mindfulness group therapy for somatoform disorders influenced the patients' stress experiences, coping strategies and contextual psychosocial processes. METHODS: A longitudinal pre- and post-treatment design, using 22 semi-structured individual pre- and post-treatment interviews. Data-analysis was based on a thematic methodology. RESULTS: Pre-treatment patients were struggling in an existential crisis, feeling existentially insecure about their social identity, the causes, consequences and management of their illness; experiencing difficulties identifying and expressing stress-related cognitions, emotions and feelings, and low bodily and emotional self-contact; often leading to avoidant coping, making these individuals highly stress-vulnerable. Post-treatment, the overall change was conceptualized as increased existential security, defined by patients being more self-confident; more clarified with their social identity, the nature, management and future prospects of their illness; generally using more flexible coping strategies to reduce their daily stress experiences. Four related subthemes were identified contributing to increased existential security: 1) more secure illness perceptions - feeling existentially recognized as "really" ill, 2) enhanced relaxation ability - using mindfulness techniques, 3) increased awareness - connecting differently to mind and body 4) improved ability to identify and express needs and feelings of distress - more active communicating. Patients suggested that mindfulness therapy could be expanded with more time for group-discussions followed by additional individual therapy. CONCLUSION: Generally, treatment positively influenced the patients' illness perceptions, stress-experiences, body- and self-awareness, coping strategies, self-image, social identity and social functioning. However, patients identified potentials for treatment improvements, and they needed further treatment to fully recover.