Lasers Work for Fibromyalgia, But Why So Pricey?

By Ryan Baker, Guest Columnist

I’ve had severe fibromyalgia for 14 years, and I’ve been disabled as long. Without a doubt, the pain is certainly a central issue, along with the severe fatigue, flare ups, and crashes.

It’s an absolutely miserable disease that’s intrusive and destructive. I broke commitments that really shouldn’t be broken, which put a strain on personal relationships. The pain is a level of suffering that can easily push one to insanity or worse.

I found laser therapy last October at my chiropractor’s office, where they have a $25,000 K-Laser. While it worked great, I could not get enough coverage all over my body as often as I needed, and it was just too expensive for office visits.

I was getting good results, so I dove into trying to find a laser I could use at home, and settled on a very effective unit for $2,500. Pricey, but worth the convenience of having one I could use whenever I wanted.

Since receiving the TQ Solo laser in late January, I have not taken any prescription pain pills. My hydrocodone, methocarbamol, and Klonopin, which I had whittled down long before the laser to “emergency use only” (once every 3-7 days), have gone untouched since I’ve had the laser.

I have taken 2 ibuprofens for a dehydration headache, but no other OTC meds, aside from vitamins. I take a sleep aide and blood pressure medication, that’s it.  

TQ SOLO LASER

It still astonishes me how well laser therapy works. I still suffer from fibro fog, low energy, and all of the other problems associated with fibromyalgia, but my pain levels have dropped from a constant 7-9 out of 10, to a much more tolerable 2-4. I use the laser between 20 minutes to an hour or more a day, and rather than become resistant, my body seems to respond better after getting used to treatment.

Some areas are completely free of pain at times, which hasn’t happened in 14 years, but if I stop treatment the pain returns. It’s not a cure, my fibro is still terribly limiting, but it’s an amazing treatment for the pain. The decrease in my personal suffering has been outstanding.

The laser is like an alarm clock for under active mitochondria, only stimulating the cells in need. Properly functioning tissue (not in pain) have little to no response, while damaged or inflamed tissue “wake up” and begin healing. Some areas need daily treatment, like my calves and back, while other areas can go days between treatments.

If you’re a fan of science fiction, this is the coolest thing since the smartphone made Captain Kirk’s communicator look silly.

I find the 5 hertz setting, the deepest setting, to be the most beneficial. It’s like a massage, but deeper, and there’s no pain from working tender tissue. In fact, there is very little sensation during treatment. If I can feel the treatment at all, it’s usually a mild tingle or twitch, which I consider a signal to treat more intensely.

The laser does not hurt or burn. It’s very comfortable and soothing, and treating before bed is fantastic for sleep. I don’t wake up with that stiff, poisonous feeling ache anymore.  

I began researching all sorts of red light therapy. I’ve tried several, along with some LED only therapies. I even tried a heat lamp. While the heat lamp and LED therapies felt okay, they were no match for the laser.

While searching for other light therapy devices, I found the Handy Cure. It has a striking resemblance to the TQ Solo I had purchased, but it was selling for under $600. Same frequency settings, same power, same everything. Only the handle was different, as far as I could tell.

I looked it up, and it was made by the same company that makes the TQ Solo. But why so much cheaper? Was it a knock off? Was it less potent, or somehow lower quality? I put an order in.

After using the Handy Cure side by side for weeks with the TQ Solo laser, I can’t tell any difference. It’s just as effective. I’d overpaid by $2,000. I’m not wealthy, and I assume most fibro patients aren’t either, so that hurt.

I started looking into other lasers and found the Game Day laser. It looks exactly like the Handy Cure, no doubt about it, only the labels were different. Instead of variable, 50 hertz, and 5 hertz, the menu is a simple 1, 2, and 3. It appears to me that the Game Day is simply a rebadged Handy Cure.

handy cure laser (left) and TQ solo laser(right)

You’d think the Game Day would be priced more like the Handy Cure, but it’s listed for $2,995! My jaw dropped when I saw that, but the picture became crystal clear. All of these lasers had the same manufacturer and, except for subtle differences, appear to be essentially the same products.

But one sells for under $600 and the other is marked up to nearly $3,000. Why?

I’m not against the profit motive, but I am when people are suffering and treatment is unnecessarily kept out of reach.   

One month later, I have become a distributor for the Handy Cure, making YouTube videos to bring laser therapy to the attention of fellow fibromyalgia patients. It’s been a big adjustment, but a meaningful one. I have no idea what I’m doing, I just know lasers work, and they take some of the “crazy” out of fibromyalgia.

Fibromyalgia pain is real and physical, not some form of hypochondria or mental illness. If it was, the laser would have no physical effect. But it works reliably for my pain, even when I’m particularly depressed.  

I feel vindicated, because something finally works for the pain when powerful opiates barely made a dent. It’s not in my head. 

(Editor's note: Since this article was first published, Pain News Network has been contacted by Max Kanarsky, President and CEO of Multi Radiance Medical, the maker of the Handy Cure laser. Mr. Kanarsky maintains that the "Handy Cure" featured in this article is a counterfeit reproduction of his product, is not FDA cleared, and "might present a hazard to users.")

Ryan Baker lives near Sacramento, California. You can learn more about laser therapy by visiting his website, Chronic Pain Laser.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Do You Have Dormant Butt Syndrome?

By Pat Anson, Editor

It’s probably not a condition or therapy they’ll be teaching in medical schools anytime soon.

But if Chris Kolba has his way, millions of Americans will get off their rear ends and start exercising their gluteus maximus, gluteus medius and gluteus minimus.

Those are the three muscles that make up the buttocks and sitting on them all day long can lead to back pain, hip pain and knee injuries -- what Kolba calls “dormant butt syndrome.”

“The entire body works as a linked system, and a lot of times when people come in with knee or hip injuries, it’s actually because their butt isn’t strong enough,” says Kolba, who is a physical therapist at Ohio State Wexner Medical Center.

“The rear end should act as support for the entire body and as a shock absorber for stress during exercise. But if it’s too weak, other parts of the body take up the slack and often results in injury.”   

Dormant butt syndrome (DBS) refers to the tightness of the hip flexors and weakness of the gluteal muscles.

When gluteal muscles are weak, muscles and joints in the hip, legs and knees  absorb more strain during exercise, sometimes leading to injuries so severe they need surgery.

But it’s not just weekend athletes who should worry about DBS. Even people who live sedentary lives due to illness or inclination can suffer from it.

“It’s actually caused quite often by inactivity and the way we sleep,” Kolba said. “Sitting for periods throughout the day weakens the gluteal muscles and puts strain on other parts of our core, as does sleeping in the fetal position.”

Kolba says making an effort to stand and walk around as much as possible can help strengthen the gluteal muscles and avoid pain and injury in other parts of the body.

In this video news release, Kolba offers tips to a marathon runner who suffered a severe knee injury he blames on DBS: 

Experts say "Dormant Butt Syndrome" affects millions, caused by weak glute muscles (COLUMBUS, Ohio) - If you're one of the millions of Americans who suffers from hip, knee or back pain, experts say your butt may be to blame.

Pain Companion: Losing Your Smarts to Pain

By Sarah Anne Shockley, Columnist

In my last column, When Pain Hijacks Your Brain, we looked at a couple of ways that living with chronic pain affects cognitive ability; specifically, blank spaces and brain freeze.

This month we’ll look at memory loss and overall loss of brain power, and share some tips I’ve learned about mitigating their impact.

What to Do About Memory Loss            

Can’t remember what you did yesterday or even two minutes ago? Short-term memory loss is common for people in pain. I believe it is because the body and brain are simply overloaded having to deal with compromised health, and the overall stress and exhaustion that pain creates in the system.                   

Sure, forgetting things happens to everyone. But for those of us living with chronic pain, it seems to happen more often and it takes longer for our brains to come back online.                 

Write yourself notes and stick them everywhere. Write the note immediately or you will forget not only what was supposed to go on the note, but that you were writing a note at all. (No kidding)                               

I keep the smallest size of Post-it Notes in my car and stick notes on the dashboard so I don’t forget where I’m supposed to be later or what I need to do when I get home. I leave these little pads all over the house with pens nearby.                   

I have Post-its all over my computer, my desk and my kitchen, and I just throw them out when I’m finished with them. I have gotten into the habit of writing EVERYTHING down the minute it comes into my head and sticking it immediately where I will find it later.                   

What about the problem of walking over to the Post-it pad and forgetting what you’re supposed to write there on the way? (You’re only laughing because something similar has happened to you, I’m sure!)

Go back to the physical spot where you were when the thought came to you and put yourself in the exact same position and wait a moment. Somehow, the body and brain sort of coordinate in resetting yourself back in time, and then your brain often sends you the same message again.                   

Oh, and don’t forget to have the Post-its and pen already in hand.        

What to Do About Loss of Brain Power                   

My brain in pain can barely make sense of how to balance my bank accounts. Truly. It scares me to look at a row of numbers. Not because numbers are scary to me or I’m terrible at math – I aced all my graduate finance and economics courses – it scares me because, when in pain, I can’t make heads or tails of them. It’s like looking at Egyptian hieroglyphs.                   

It is incredibly disconcerting to lose your smarts to pain. Focusing on anything becomes nearly impossible. I remember having a vocational aptitude test done after I was injured and not being able to read a high school level paragraph or answer the questions appropriately.

I sat there and reread the same three-sentence paragraph about four times and simply couldn’t make any sense of what they were asking me to do with it. If you’ve had an experience like this, you know how frightening it can be to realize you just don’t have access to your normal cognitive functioning. It’s like someone turned the lights off upstairs.

Your brain in pain is simply not firing on all cylinders or most of its energy is going to dealing with the pain you’re in and healing your body. There just isn’t much brainpower available to you for normal cognitive processes.                   

This was true for me during the most acute part of my pain and it went on for quite some time. Thankfully, I have been able to recover much more access to my cognitive processes since then. So, please know that if you are going through the worst of this kind of side effect right now, it can get better as you move out of the most acute pain. You can get your brain back.             

For the purpose of regaining a modicum of brainpower, and for using some of my unused mental energy, I started doing extremely easy Sudoku puzzles, a popular Japanese number game.                   

At first, doing Sudoku worked like a sleeping pill because I quickly wore my brain out just trying to make sense of the very easiest puzzles and basically knocked myself out. I kept at it as a nightly sleep aid and eventually I was able to complete the easy puzzles. I usually had to erase what I’d already filled in and start over about 3 or 4 times in order to finish one small puzzle.                

I found that, in addition to acting like a benign sleeping pill, Sudoku helped bring my brain back online over time. I was able to progress from Easy to Medium to Hard. (I have not graduated to the Evil level yet.)

This tells me that even if the brain is hijacked by pain, it is possible to bring it back by starting small. Simple crossword puzzles can work too, but initially I found that even these were too demanding and frustrating. I could come up with a number from 1 to 10 more easily than a specific word.      

There are other ways to bring the brain back online as well: Scrabble, Monopoly, cribbage, backgammon or any other game requiring some counting, but are not overwhelmingly complex.

Jigsaw puzzles, origami, scrapbooks, photo collections; anything that requires organizing visually can also be useful. If you have enough mental energy for it, small amounts of foreign language study can also do the trick. Many public library systems have easy and free courses you can use online.

These ideas seem really simple, I know, but that’s exactly where to start. Really easy and really simple.

Sarah Anne Shockley suffers from Thoracic Outlet Syndrome, a painful condition that affects the nerves and arteries in the upper chest. Sarah is the author of The Pain Companion: Everyday Wisdom for Living With and Moving Beyond Chronic Pain.

 Sarah also writes for her blog, The Pain Companion.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Talking Turkey: How Food Plays a Role in Pain

By Pat Anson, Editor

There’s a nugget of truth to the old saying, “You are what you eat.” And no, we don’t mean chicken nuggets. We’re talking turkey.

Researchers at Brigham and Women's Hospital in Boston say changes in diet and gut bacteria appear to influence the activity of brain cells involved in controlling inflammation and neurodegeneration. They’ve published their study in the journal Nature Medicine

"For the first time, we've been able to identify that food has some sort of remote control over central nervous system inflammation," said corresponding author Francisco Quintana, PhD, an investigator in the Ann Romney Center for Neurologic Diseases at Brigham and Women’s Hospital.

"What we eat influences the ability of bacteria in our gut to produce small molecules, some of which are capable of traveling all the way to the brain. This opens up an area that's largely been unknown until now: how the gut controls brain inflammation."

While studying laboratory mice, Quintana and his colleagues found that gut bacteria produce molecules that influence astrocytes -- star-shaped cells that reside in the brain and spinal cord.

The molecules, which are derived from tryptophan (an amino acid found in turkey and other foods), act as fuel that helps the astrocytes limit brain inflammation.

In blood samples from patients with multiple sclerosis (MS) – a disease that attacks the body’s central nervous system -- the researchers found lower levels of these tryptophan-derived molecules.

"Deficits in the gut flora, deficits in the diet or deficits in the ability to uptake these products from the gut flora or transport them from the gut -- any of these may lead to deficits that contribute to disease progression," said Quintana.

MS is a chronic and incurable disease that causes numbness in the limbs, difficulty walking, paralysis, loss of vision, fatigue and pain.

In addition to turkey, tryptophan is found in other high-protein foods such as chicken, beef, nuts and cheese. Its a myth that eating lots of turkey will put you to sleep, according to the American Nutrition Association. But tryptophan does help produce serotonin, a neurotransmitter that regulates mood and mental activity,

Scientists are just beginning to recognize that food and gut bacteria play a role in multiple sclerosis and other chronic pain conditions.

Researchers at New York University’s Langone Medical Center recently found that some intestinal parasites and bacteria play a beneficial role in helping to balance the immune system, and reduce rates of inflammatory bowel diseases (IBD) such as Crohn’s disease and ulcerative colitis.

Sanitary practices have sharply reduced intestinal worm infections in developed nations, which now have some of the highest rates of Crohn’s and colitis. Scientists believe the worms help produce a certain type of bacteria that helps control inflammation. This “hygiene hypothesis” may also apply to MS, rheumatoid arthritis, type 1 diabetes, and other autoimmune diseases.

Making Everyday Life Less Painful

By Barby Ingle, Columnist

Every day is a challenge to remain independent when living with chronic pain. Normal activities such as walking, taking the stairs, squatting, sitting for long periods, and getting in and out of vehicles can be quite challenging and painful.

To get more out of life, I had to learn how to minimize disruptions in my daily routine and how to be a time and energy saver. That meant making some changes around the house.

Every pain patient and their family should assess their surroundings, perhaps with the help of professionals, and prioritize the modifications needed. This can help the patient maintain their independence and function.

Some of the lifestyle modifications you may wish to consider include: 

 Clothing

•  Flat shoes instead of heels for patients with lower extremity issues
•  Slip-on shoes
•  Velcro or zipper closures for shirts or sweaters
•  Velcro or zippers for shoes instead of shoelaces

 Bathroom

•  Elevated toilet seat
•  Grab bars in the bathtub, shower, and next to the toilet
•  Long-handled comb or brush so the patient does not have to raise his or her arm high
• Tub or shower bench 

Bedroom

• Blanket support frame so that blankets or sheets do not rest directly on the feet of a patient
• Nightlights in the bedroom and other rooms where the patient may walk if they awaken during the night

 Automobile

•  Car doors that are easy to open and close
•  Handicapped parking stickers
• Modified controls to facilitate driving
•  Seat positions that are easy to manipulate

Kitchen

• Easy grab handles for cabinets
• Large knobs on appliances requiring manipulation (stove, dishwasher, washing machine)
• Lightweight appliances (vacuum cleaner)
• Lightweight dishes and pots
•  Lightweight flatware with long handles
• Long handled cleaning appliances (brooms, dustpans, sponges)
• Long-handled "grabbers" for removing items on high shelves or picking up items from the floor
• Sliding shelves or turntables on kitchen shelves so the patient does not have to reach into cabinets to access items in the back 

Miscellaneous

• A note from your doctor recommending special accommodations, such as an aisle seat in airplanes
• Electric wheelchair to avoid upper body strain or injury
• Medical support professionals or accountants to budget medications, special appliances, home-nursing care, and other medical-related supplies and expenses
•  Nursing or home health care
• Use of wheelchairs in airports, train stations, or malls
• Voice activated lights, appliances, or computer
• Wheelchair-access modifications at home

Undoubtedly, there has been progress made in recent years by healthcare professionals and patients towards understanding and properly managing pain. Unfortunately, pain still poses a problem for patients who are under-diagnosed, over-diagnosed or misdiagnosed.

Controlling the pain you are in is essential to quality of life. Knowing the characteristics of pain and why it is happening give you an advantage in dealing and controlling aspects of pain. Taking control of your life and being responsible for yourself will assist you in lowering your pain.

I see these life changes as a way to improve my daily living -- not as defeats. Using tools in life help those with disabilities from pain have a better life. If a tool can help us accomplish more and increase independence, we should not be ashamed of using it.

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Study Finds Friendship ‘Stronger than Morphine’

By Pat Anson, Editor

People with more friends and large social networks have a higher tolerance for pain, according to a new study by researchers at Oxford University.

Scientists believe that social bonding activities such as music, dancing and laughter activate the body’s endogenous opioid system, releasing natural endorphins that not only make you feel better when seeing friends, but can also relieve pain.

“Endorphins are part of our pain and pleasure circuitry -- they're our body's natural painkillers and also give us feelings of pleasure,” says Katerina Johnson, a doctoral student at Oxford University, who is studying whether differences in neurobiology can explain why some people have larger social networks than others.

“To test this theory, we relied on the fact that endorphin has a powerful pain-killing effect -- stronger even than morphine.”

Johnson and her colleagues enrolled 107 healthy young adults in a squatting exercise to test their tolerance for pain. Participants were told to squat against the wall with their knees bent at a 90° degree angle, and to hold that position and endure the discomfort for as long as possible.

Questionnaires were also completed by the participants to measure their personality traits and physical fitness, and to see how often they interacted with friends.

Not surprisingly, people who were more fit were able to hold the squatting position longer. But so did people with larger social networks.  

“Obviously we had to bear in mind that fitter individuals may be able to endure this physical pain test for a longer length of time.  However, even when we take this into account, our results show that pain tolerance still significantly predicts network size,” Johnson wrote in an email to Pain News Network.

An unexpected finding was that fitter people in the study tended to have smaller social networks.

“It may simply be a question of time -- individuals that spend more time exercising have less time to see their friends. However, there may be a more interesting explanation -- since both physical and social activities promote endorphin release, perhaps some people use exercise as an alternative means to get their 'endorphin rush' rather than socializing,” she said.

Since only healthy people participated in the study, Johnson admits her research may not apply well to chronic pain patients. But since many pain patients are disabled and unable to work or participate in many social activities, there could be some lessons to learn.

“When considering chronic pain, it seems like it may be a vicious circle whereby the more an individual is in pain, the less interested they are in interacting socially with others and their smaller social networks may in turn result in reduced activity of the endorphin system (thereby worsening their pain).  Perhaps also individuals that are genetically predisposed to reduced endorphin activity (and lower social motivation) are more likely to develop chronic pain conditions,” Johnson wrote.

“Another finding of our study was that individuals with smaller social networks tend to be more stressed, and stress is also thought to exacerbate pain.  However, clearly the underlying neurochemistry in pain responses is complex, though the endorphin system is heavily implicated in pain responses given its potent analgesic properties.”

The study findings are reported online in the journal Scientific Reports. 

Improving Posture for Pain Relief

By Pat Anson, Editor

It sounds a little hard to believe. Can something as simple as changing your posture put you on a path towards pain relief?

That’s the premise behind an eight-part video series called “Becoming Pain Free” that was created by Sonima.com, a health and wellness website.

The series follows Steven Shea, a 34-year old filmmaker who suffers from chronic joint pain, as he is put through the basics of the Egoscue Method, a therapy program for chronic pain taught at over two dozen clinics around the world.

The program, which focuses on improving posture, claims to have a 94% success rate in relieving pain without the use of drugs, surgery or spinal manipulation.

scene from "becoming pain free"

“When I started talking about posture 40 years ago, you would have thought I shot the Pope. I was completely dismissed,” says founder Pete Egoscue, a 70-year old Vietnam veteran and blunt talking former Marine. “The key to an excited, engaged present life is the ability to maintain your energy, which requires the musculoskeletal system functioning at its optimal design posture. Period. Once you do that, the whole world changes for you." 

Egoscue, who is a fitness expert for Sonima, says the healthcare system is going broke because of a misguided focus on treating chronic pain with medication and surgery.

“They assume that the source of the pain and the cause of the pain are the same thing. So if you have a herniated disc, they think that’s the source of the problem. If you have a torn cartilage in your knee, they think that’s the problem. If you have migraine headaches, they look at your brain. It goes on and on and on. What’s dropped out of the diagnostic process is the ‘Why’ of things,” Egoscue told Pain News Network.

Egoscue says most forms of chronic pain are not disease or age-based, but are self-induced – the body’s way of telling us that we’re physically off balance. And instead of asking, “What wrong with me?” – he says pain sufferers should be asking, “What is my body trying to tell me?”

In most cases, Egoscue says the body simply wants to be returned to its proper alignment. That was the case with Steven Shea, who is shown in the first installment of “Becoming Pain Free” that his body is misaligned – his shoulders slumped over and his chin tilted to one side.

Chronic or severe pain affects nearly 50 million American adults, reports a new study prepared by National Institutes of Health's National Center for Complementary and Integrative Health, which was published in The Journal of Pain last summer. About half of these people are suffering from chronic pain every single day.

“By the time you see the 8th episode, you will see a completely different guy. He’s totally changed. Did that have anything to do with Egoscue? Not really. It had to do with him. He’s the guy who was driven to find the knowledge base and the actual confirmation that what he was doing was in his best interest,” Egoscue says.

Once their posture starts to improve, Egoscue says clients are energized to do other things, such as exercising more and watching their nutrition. Avoiding sugar is a priority.

“The devil of all things that the body just cannot deal with is sugar. Sugar is a killer. It’s so clear, it’s patently obvious. It kills us,” Egoscue says.  

Part two of the “Becoming Pain Free” video series can be seen by clicking here. A new episode will be shown each week on Sonima.com.

Does Washing Your Hands Raise Risk of IBD?

By Pat Anson, Editor

Many of us were taught as children to always wash our hands before leaving the bathroom and before meals. But that basic sanitary practice may be contributing to an increase in inflammatory bowel diseases (IBD) such as Crohn’s disease and ulcerative colitis, according to a new study published in the journal Science.

Researchers at New York University’s Langone Medical Center tested the so-called “hygiene hypothesis” – the theory that some intestinal parasites and bacteria are beneficial because they help balance the immune system and reduce IBD rates. Sanitary practices have sharply reduced gut worm infections in developed nations, which now have some of the highest rates of Crohn’s disease and ulcerative colitis.

“Our findings are among the first to link parasites and bacteria to the origin of IBD, supporting the hygiene hypothesis,” says parasitologist P’ng Loke, PhD, an associate professor at NYU Langone.

“The prevalence of IBD is much less in regions of the world which have heavy worm infection. In fact, I got interested in the question of how worms can be beneficial when I was contacted by an individual who had deliberately infected himself with worms to treat his symptoms of IBD and was able to put his disease into remission.”

Loke and his colleagues found that laboratory mice infected with intestinal worms experienced a thousand-fold decrease in Bacteroides — a type of bacteria linked to people with higher risk of IBD. At the same time, the number of Clostridia, a bacterium known to counter inflammation, increased tenfold in the mice.

RESEARCHERS P'ng Loke and Ken Cadwell, NYU Langone Medical Center

Researchers believe the immune response to the worms triggers the growth of Clostridia, which then either outcompete Bacteroides for nutrients or release toxins that are harmful to them.

In a second phase of the study, researchers gave mice an infusion of Clostridia – without the use of parasites – and found that it reduced the presence of Bacteroides.

“That gives us a lot of hope in terms of IBD therapy because maybe we don’t need to give people parasitic worms, which can be harmful and cause disease, and instead target the harmful bacteria by replacing them with healthy bacteria,” says microbiologist Ken Cadwell, PhD, an assistant professor at NYU Langone and the Skirball Institute of Biomolecular Medicine. “Our study could change how scientists and physicians think about treating IBD.”

Researchers say the hygiene hypothesis may also apply to other autoimmune diseases, including multiple sclerosis, rheumatoid arthritis, and type 1 diabetes, in which processes meant to attack foreign invaders instead become oversensitive and trigger an immune response to the body’s own cells.

IBD is a chronic or recurring immune response and a painful inflammation of the gastrointestinal tract. Inflammation affects the entire digestive tract in Crohn’s disease, but only the large intestine in ulcerative colitis.

According to the Crohn's and Colitis Foundation of America, IBD affects about 1.6 million Americans and tends to run in families. Caucasians are more likely than other ethnic groups to have IBD. The diseases are especially prevalent in Jews of European descent (Ashkenazi Jews). African Americans and Hispanics in the United States are also increasingly affected.

Learning Mindfulness and a Positive Attitude

By Barby Ingle, Columnist

Mental health can be disrupted when living with chronic pain. Anxiety, depression, isolation, and feelings of hopelessness and helplessness can increase to dangerous levels. Life can become overwhelming -- particularly for people who have been suffering with chronic pain for a long period of time. The idea of living with this horrible disease with no cure is astounding.

When my chronic pain started doctors often told me, “Just do this and you will be okay.” I would build up my hopes and follow their directions. But when I did not get better, I came crashing down and so did life around me.

When I finally realized there was no cure for my chronic pain and that my future would include pain on a daily basis, I began to have dark thoughts. I went through a grieving process in the course of coming to grips with my new reality. It is hard for many pain sufferers to accept their changing life, and the loss of independence and function.

It is very important for you and your family to recognize the symptoms of diminished emotional well-being and take action or you may end up at risk of suicide. There are going to be good and bad days, and if this is a bad day for you, remember to focus on the good days, good feelings and positive past and future experiences.

It was when I began looking for solutions, and displayed a positive attitude, self-esteem and confidence, that I began to attract other people who wanted to help me accomplish my needs and goals. Be sure to surround yourself with a team that is on your side, or you will be in a fight in which you will have trouble winning.

Creating a positive attitude starts with being inspired. You can begin by finding new interests and hobbies you can enjoy. A few suggestions are joining a non-profit cause, solving puzzles, writing a journal, joining or starting a support group, or even starting a blog. Creating a purpose can assist with your self-esteem and confidence.

I have learned that every person has a value no matter how big or small they seem. Believing in yourself and in your abilities, choosing happiness and thinking creatively is good motivation when it comes to accomplishing your goals. Learn to expect success when you are going through your daily activities. It might take you longer or you may need to use more constructive thinking to achieve success, but it is possible. 

There are great benefits to having a positive attitude, especially when things are not going your way. Staying optimistic will give you more energy, happiness and lower your pain levels. Success is achieved faster and more easily through positive thinking, and it will inspire and motivate you and others. I have found that when I am letting the pain get the better of me, it comes across to others as disrespect and brings those around me down.

No matter the challenges of today, they will pass, and will not seem as bad as time moves on. Challenges often turn out to be a bump that looked like a mountain at the time. You can be mentally positive and happy even when there are large obstacles to overcome.

No person or thing can make you happy and positive. Choosing to be happy starts with mindfulness.  

You can learn about mindfulness and moving beyond psychological suffering in a free two-part webinar I’ll be hosting, featuring Dr. Melissa Geraghty on April 28 and Dr. Karen Cassiday on May 13.  You can register for the webinars and learn more about treatments for anxiety and depression by clicking here.

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation (iPain). She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

The Advantages of Having a Service Dog

By Ellen Lenox Smith, Columnist

I chose to apply for a service dog after meeting someone else with Ehlers Danlos syndrome (EDS) who had been given one by the National Education for Assistance Dog Services (NEADS), also known as Dogs for Deaf and Disabled Americans.

At first, I was nervous that I would not be able to handle the responsibility, afford the cost, and that I would not qualify for a service dog. But the decision to apply and later bring “Maggie” into our lives was one of the best I’ve ever made.

Six days after coming home from a two week training program, Maggie saved my life. To this day, she senses when I have my breathing cut off and alerts me.

Maggie can somehow tell in the morning that I am headed for a bad night. She will look me in the eyes, nudge against me, lick my legs and not leave me alone. She was not trained to know this, but we somehow bonded so well in the first few weeks that she can sense when my oxygen levels are too low.

At night when she senses this, Maggie wakes me -- first by pacing on the bed, then whining, and if that does not work, she licks or nudges me until I awake.

I met Maggie when I was barely able to walk. She quickly helped me learn to live life in a wheelchair.

Imagine what it is like to drop an object and not be able to get down and pick it up. Maggie will pick up whatever she finds on the ground and bring it to me. She can retrieve the phone and pick up paper, pens, and almost any size object. She can even be sound asleep and hear me drop something and come right over to get it for me.

I also find her support with balance. Although NEADS does not train dogs to wear harnesses for balance, they do help you to utilize the dog for simple tasks, like getting up safely from a chair, out of a car and even off the toilet seat.

Maggie provides amazing pain relief and comfort, too. The heat from her body when she spoons against me, provides soothing comfort that goes way beyond any medication. To have her by my side helps me to gain confidence with my constantly slipping body.

I am always loved, cared for and never alone. As a service dog, Maggie can be by my side wherever I go -- whether it is the hospital, airport, train, pool, store, car, hotel, restaurant, and even the White House. She is welcome all places except a military base or private home. Those are the only places I must get permission for her to be with me.

Caring for Your Service Dog

I was concerned that I would not be able to care for my dog. But NEADS will train you to learn how to take care of the dog you are matched with no matter what your physical challenges might me. Do not stress about that - they will guide you and your dog through the process.

You will be taught how to care for the dog, how to feed, groom and exercise them, despite your obstacles.

Can You Afford a Service Dog?

An average NEADS dog costs over $42,000, but they only ask clients to raise a minimum of $8,000. I was so concerned I would never be able to raise the money for my dog, but NEADS put my mind at ease, explaining that they set up an online fundraising page for you to send out that tells your story and asks for support.

I sent the link to friends and also posted the story in local stores. In three months, all the money for Maggie was donated by people, many of whom I didn’t even know. Do not stress about the cost. NEADS will work that out if you qualify for a dog. They just ask that you help them defer the cost.

To apply for a dog, go to the NEADS website, fill out the application and then expect a call for an interview. Always feel free to contact their office to be sure the request has come through and to get an update on the status of your application.

I always encourage those that are considering a service dog to go ahead and apply, even if they have reservations, to get on the waiting list. The worst that can happen if you change your mind is that someone else gets the dog selected for you.

The wait can take from a few weeks to up to a year and a half. So why not get in line?

Ellen Lenox Smith suffers from Ehlers Danlos syndrome and sarcoidosis. Ellen and her husband Stuart live in Rhode Island. They are co-directors for medical marijuana advocacy for the U.S. Pain Foundation and serve as board members for the Rhode Island Patient Advocacy Coalition.

For more information about medical marijuana, visit their website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Study Finds Meditation Effective for Low Back Pain

By Pat Anson, Editor

A form of meditation called mindfulness-based-stress-reduction is more effective in treating chronic low back pain than the “usual care” provided to patients, according to a new study published in JAMA. The study also found that cognitive behavioral therapy also lessened pain and improved function better than standard treatments for patients with low back pain.

Mindfulness-based stress reduction (MBSR) is a mind-body approach that focuses on increasing awareness and acceptance of moment-to-moment experiences, including physical discomfort and difficult emotions. Although MBSR is becoming more popular, few studies have been done on its effectiveness in treating low back pain.

Cognitive behavioral therapy (CBT) is a form of psychotherapy, in which a therapist works with a patient to reduce unhelpful thinking and behavior.

Researchers in Washington state enrolled 342 people in the study with chronic low back pain and divided them into three groups that received yoga, training and treatment with MSBR, CBT or usual care.

After 26 weeks, 61% of the patients in the MSBR group reported clinically meaningful improvement in function, compared to 58% in the CBT group and 44% of those who received usual care. Similar results were also found in pain relief.  

Participants in the MSBR and CBT groups also reported less depression and anxiety than the usual care group. 

The researchers said the results were “remarkable” because nearly half of the patients enrolled in the MSBR and CBT groups skipped several of the group sessions they were assigned to.

“In a time when opioid prescribing is on the decline I would think this would be exciting and welcome news for those of us who suffer severe, chronic pain,” said Fred Kaeser, who battled severe back pain for many years, and eventually found relief through a combination of meditation, exercise and changes in diet.

“Very encouraging to think that we are getting very close to being able to say that MBSR and CBT are empirically valid, pain-reducing, complimentary therapies to whatever medical care one might usually receive for the mitigation of pain.  The thought that one might also be able to reduce one's intake of pain medications and possibly other intrusive pain interventions by engaging in a therapy that is extremely safe with no side-effects is exceptionally encouraging,” Kaiser wrote in an email to Pain News Network.

“Hopefully, people who have previously dismissed the idea of mindfulness meditation or CBT as a valid pain reducing strategy will re-think their position and give these, as well as other promising complimentary pain reducing modalities, a try.”

Recent studies by researchers at Wake Forest University found that mindfulness meditation appears to activate parts of the brain associated with pain control.

Lower back pain is the world’s leading cause of disability. About 80 percent of adults experience low back pain at some point in their lives.

A Migraine Sufferer Finds Hope Again

By Paul Hannah, Guest Columnist

On a Sunday morning 33 years ago, I was reading a newspaper in bed and was suddenly struck with a headache. I hadn't really had many headaches before, so I expected that this would pass with some non-prescription medication and an hour or so in bed.

I was very wrong.

I still have that headache today. If it would have stayed at a 1/10 pain level, I probably would not have done much about it. However, it didn't stay that low and that was where the problem lies.

When the headache moves to 4/10 or 5/10 I get concerned, because if I don't stop it at that point, it will rapidly scale up to a full migraine.

I have read other accounts of migraines, but very few accord with mine. My neck gets stiff, the trapezius muscles lock up, and my eyes start to hurt. I become rapidly photophobic and the pain gathers and localizes in the frontal lobe of my brain.

Once it reaches 6/10, I get a syringe from my migraine drawer and inject Maxolon into my arm muscle and immediately lie down. As a result of the photophobia, I have built myself a four poster bed so that I can draw the curtains and be in total darkness. After the Maxolon kicks in, I drink some liquids, often very strong coffee, and take as many of the various painkillers as I dare.

PAUL HANNAH

About fifty percent of the time, that is enough and spending the next five or ten hours in bed gets me well enough to function again. The other fifty percent of the time, it gets worse. Much worse.

It feels like someone is reaching into my skull and squeezing the frontal lobe of my brain with each beat of my heart. At this point, it becomes imperative, as bizarre as it seems, for me to concentrate. This is because the pain momentarily stops when I sub-consciously hold my breath, and then when I do finally breathe, it gets worse.

These migraines happen so frequently and unpredictably that I have given up traveling. I joke and say that I have seen the inside of too many foreign hospitals - but it is no joke, I love traveling. I miss it terribly.

I have a sympathetic doctor who will write scripts for pethidine (Demerol) every six weeks. It took literally years of doctor shopping to find him. If I have any pethidine left, I give myself an injection. The wave of relief that passes through me with that drug is hard to describe. I heard an opium addict describe her relief like this: "The pain is still there, you can still feel its presence, but it doesn't hurt anymore." It is like that for me.

Every migraine sufferer I have discussed this with has resonated with three annoying things that people come up with. Some women (and it always has been women in my experience) place two fingers to their temples and say, "I have a migraine". Anyone that has ever experienced a 10/10 could no more speak and function as 'normally' as that, than fly. They simply have no idea how bad it is. Fingers are regarded as among the most sensitive to pain areas of the body and anyone hitting a thumb with a hammer can attest.

Eighteen months ago I had an accident in my workshop and cut off my left index finger, half of my thumb and mashed up the other fingers in that hand. The pain level was 5/10. I took the painkillers the paramedics offered, but I didn't need them. The painkillers I took in hospital were for my head, not my hand.

The second annoying thing is when we are asked, "Have you looked into the cause?" I am barely able to contain my sarcasm when confronted with this. I desperately want to say something like "Well goodness me! That IS a good idea, why didn't I think of this thirty years ago?" But I don't, I just look away and say something equally inane.

Just as annoying are those that have an aunt who was cured by giving up coffee (tried it for 9 months, no change), going through menopause (strangely enough, not all that helpful to me) or taken some homeopathic/natural or equally nonsense cure (One said a foot massage was sure to fix it).

I am fortunate in that I live in Australia, a place where universal free healthcare is considered a citizen's right and a government's responsibility. So I have had several MRIs, X-rays and even an EEG, nothing has ever shown up as anything but normal.

When Francis Collins finished the Human Genome Project I thought it was marvelous from a human achievement point of view, but nothing more. I had no idea that it was going to change my life. But change it, it did and in all the right ways.

When I heard about this from another genuine migraine sufferer I took a blood test and for the first time in 33 years I had a non-normal result. It seems there is a genetic mutation called MTHFR, and if a person has one of them, it makes it difficult to process vitamin B. I have two of the sods.

I have spent my life being deficient in Vitamin B2, all the while my blood was full of the stuff. Both of those conditions can cause migraines. For the last eight weeks I have been taking a number of supplments and a cream - DHEA/CHYSIN, zinc, B-2, 5-MTHF and D-3. So far, I have had nothing worse than a 4/10 headache and I have every reason to suspect that this improvement will continue.

The Human Genome Project has given me something I thought I would never have again: hope. And hope to the hopeless is a marvelous thing. Truly marvelous.

I urge every migraine sufferer who can afford it to take the test. This isn't foot massage or acupuncture nonsense, it might actually work.

Paul Hannah lives in a small town just north of Brisbane, Australia on a few acres of bush populated with wallabies, koalas and a wide variety of native birds. He is retired and enjoys writing, history, astronomy and woodwork. 

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Study May Explain How Meditation Relieves Pain

By Pat Anson, Editor

Some pain sufferers report success using cognitive behavioral therapy and mindfulness mediation to reduce their pain. But how those techniques work is a bit of mystery and has led to speculation that they have a placebo effect on pain.

But a new study by researchers at Wake Forest University suggests that meditation really does provide pain relief – but not by utilizing the body’s natural endogenous opioid system.

“Our finding was surprising and could be important for the millions of chronic pain sufferers who are seeking a fast-acting, non-opiate-based therapy to alleviate their pain,” said Fadel Zeidan, PhD, assistant professor of neurobiology and anatomy at Wake Forest Baptist Medical Center.

Zeidan and his colleagues enrolled 75 healthy, pain free volunteers in a study. Some were injected with naloxone, which blocks the pain reducing effects of opioids, while others were injected with a placebo saline solution.

Participants were then divided into four groups: meditation plus naloxone; no meditation plus naloxone; meditation plus placebo; or no meditation plus placebo.

Pain was induced in all four groups with a thermal probe that heated their skin to over 120 degrees Fahrenheit (49 degrees Centigrade), a level of heat that most people find very painful.

The group that meditated and was injected with naloxone had a 24 percent reduction in their pain ratings, showing that even when the body’s opioid receptors were chemically blocked, meditation still was able to significantly reduce pain. Pain ratings were also reduced by 21 percent in the meditation group that received the placebo injection.

By comparison, the two control groups that did not meditate  reported increases in pain regardless of whether they got the naloxone or placebo-saline injection.

“Our team has demonstrated across four separate studies that meditation, after a short training period, can reduce experimentally induced pain,” said Zeidan. “And now this study shows that meditation doesn’t work through the body’s opioid system.

“This study adds to the growing body of evidence that something unique is happening with how meditation reduces pain. These findings are especially significant to those who have built up a tolerance to opiate-based drugs and are looking for a non-addictive way to reduce their pain.”

The next step for researchers is to determine how mindfulness meditation can affect a spectrum of chronic pain conditions.

“At the very least, we believe that meditation could be used in conjunction with other traditional drug therapies to enhance pain relief without it producing the addictive side effects and other consequences that may arise from opiate drugs,” Zeidan said.

An earlier study by Zeidan found that mindfulness meditation activates parts of the brain (orbitofrontal and anterior cingulate cortex) associated with pain control, while it deactivated another brain region (the thalamus) that regulates sensory information. By deactivating the thalamus, meditation may cause signals about pain to simply fade away.

In addition to relieving pain, there is increasing evidence that mindfulness meditation is effective in treating a broad range of mental health issues, including anxiety, depression and stress. One study, published in the British Medical Journal, found that online mindfulness courses were often just as effective as face-to-face meetings with a therapist.

You can sample a relaxing online pain management meditation at Meditainment.com (click here to see it). The initial course is free.

Pain Companion: Talking About Pain

By Sarah Anne Shockley, Columnist

A lot of us don’t like to talk about our pain, understandably. It often seems easier just to live with it in silence than to discuss it with anyone. Ever.

If others have never experienced long-term pain or are pain-avoidant, it can be nearly impossible for them to understand what we’re talking about. We may be answered with blank stares or outright disbelief.

Or, what often happens is that others feel they must try to fix us. We are offered all kinds of medical advice, given the business card of a favorite massage therapist, or web address for the latest miracle supplement. Or we’re told exactly what we don't need to hear: buck up, carry on, be more positive, grin and bear it. Fending off the well-meaning fixers can be exhausting, so we just keep quiet.

And, when we do talk honestly and openly about our pain, sometimes it feels like we’re walking right into the center of it. We become very present to it, and if it also feels like we’re not really heard or validated, we’ve added another level of emotional pain and disappointment to our physical pain. So why bother?

These are all perfectly understandable reasons for not talking about pain.

So why would we talk about it?

Because the alternative - never fully expressing to anyone what we are going through at the deepest levels - is much harder in the long run.  As you probably know quite well, living with pain can be extremely isolating. We are alone in our unique and deeply intimate experience of pain.

While we have very good reasons not to talk about our pain with everyone, if we never talk about it we can feel increasingly disconnected from others, from life, and from ourselves. And I know from personal experience that this can be a very difficult way to live.

For eight years, the only person who understood the full extent of the pain I was in was my neurologist. For all of the reasons listed above, I simply never told anyone else how bad it really was. And I can say at this point that living with pain doesn't get easier and life doesn’t get better by not talking about it. That choice only increases the feelings of invisibility, isolation, and disconnection.

However, talking openly about pain is a tricky business. Finding someone who can be with us and just listen is challenging because so many think they are being helpful by trying to distract us from our pain, or help us overcome, avoid, or downplay it.

People are so geared toward ending pain that they are not always prepared to just be with us and be a compassionate witness. And some people are living with their own unexpressed pain, whether physical or emotional, and they just don’t have the capacity to hear about ours.

So, I would not advocate talking about your pain to just anyone.  It requires a somewhat selective process. There are friends and family that you would like to be able to share with who will not be willing or able. Think about the people in your life that you consider good listeners and who you can trust to truly have your best interests at heart.

Even if there is no one you know who has experienced physical pain in the way that you have, there will most likely be someone who has experienced a deep loss or had to face very trying circumstances that will give them a deeper sense of compassion for what you are going through. They may have been dealing with their own private pains and you may be surprised to find out that they understand about hiding, isolation and loneliness. If you feel there is no one like that in your life, then a trained therapist can be a good choice.

Once you’ve ascertained that this person is an appropriate choice and they are agreeable, then help them understand that what you need is a pair of receptive ears and a receptive heart, and that talking about your pain won’t make it worse, but will actually help you.

Tell them that what you are going to share may be difficult for them to hear, but that you really need them to just be there and hear it without offering anything back for now. Ask them to please hear you out without trying to change anything, fix anything, offer advice, or console you.

Before you have your talk, see if they are willing to agree to the following ground rules:

• Listen to your story without interrupting
• Be present with you in your pain without pity and without fixing
• To not offer advice, just witness

Let them know that the most supportive thing they can do for you right now is not to try to make it all better or make it all go away, but to just be present with you and let you have your pain and not try to change anything for now.

You may want to tell several people, but you may also find that one trusted person who can see you, hear you, and be with you in it is enough. Then, of course, express your gratitude in whatever way you feel is appropriate and let them know what a great gift they have given to you.

And, perhaps when you are done telling your story to this person, on another day, you can offer receptive ears and a receptive heart to them.

Sarah Anne Shockley suffers from Thoracic Outlet Syndrome, a painful condition that affects the nerves and arteries in the upper chest. Sarah is the author of The Pain Companion: Everyday Wisdom for Living With and Moving Beyond Chronic Pain.

 Sarah also writes for her blog, The Pain Companion.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Plasma Therapy Helps Rotator Cuff Injuries Heal

By Pat Anson, Editor

Kobe Bryant, Peyton Manning and Alex Rodriguez have used it to treat chronic injuries and extend their athletic careers. But does platelet-rich plasma therapy (PRP) work for amateur athletes and weekend warriors?

According to a small pilot study published in PLOS ONE, a single PRP injection helps reduce pain and heal injured tissue.in patients with chronically sore shoulders caused by rotator cuff tears. 

"We studied patients 35 to 60 years old with rotator cuff tendinopathy due to normal aging. For the first time, we were able to not only find reported improvements in pain and mobility, but also in the tissue - the MRI before and after showed structural change and a decrease in the size of tears," says lead author Marni Wesner, sports medicine physician at the University of Alberta’s Glen Sather Sports Medicine Clinic.

PRP therapy is an emerging therapeutic procedure for the treatment of both acute and chronic soft tissue injuries. The procedure involves withdrawing blood from the patient and then spinning it to produce a high concentration of platelet cells. The plasma is then injected back into the patient at the injury site, speeding up the natural healing process.

The pilot study involved only a small number of participants – 7 patients with rotator cuff tendinopathy received a PRP injection and 2 received a placebo injection. All participants then took part in a 3-month home-based daily exercise program.

"Based on MRI findings before and after the injections, we saw improvements in the tissue six months later in five of seven patients undergoing PRP and an appropriate rehabilitation program. The healing in the tissue appeared to correspond with the reported improvement of the pain and also with the clinical assessment of function," explains Doug Gross, interim chair of physical therapy at the Faculty of Rehabilitation Medicine.

One of the patients who benefitted from the treatment was Debbie Brown, a retired police officer.

"For the past two years, I have tried everything for my right shoulder. Physio would help for a bit but then the problem would still be there. I tried acupuncture, Kinesio tape, cortisol injections - you name it, I've tried it," says Brown. "Once I did the PRP, it really did fix everything!"

At age 58, Brown says her injured shoulder feels like new.

"I can shoulder-check now and brush my hair. I can work out and be active again," she says.

Researchers admit the small size of the study and other factors may have affected the results.

“Patients considered for this study had very high expectations of PRP treatment, with 70% willing to pay out-of-pocket for the therapy to avoid the possibility of receiving a placebo injection. This presented a serious challenge for recruitment and will likely limit the ability of future investigators to enroll sufficiently large and representative samples of patients for PRP trials. High patient expectations and the placebo effect on clinical outcomes also cannot be discounted,” said Wesner.

In fact, one of the patients who received placebo treatment reported improvements in both pain and physical function – which could have been a placebo response to the injection or because of the home exercise program they participated in.

Los Angeles Lakers star Kobe Bryant was one of the first professional athletes to receive PRP therapy, traveling to Düsseldorf, Germany for a more refined version known as the Regenokine treatment.  Peyton Manning, Alex Rodriquez, Vijay Singh and other professional athletes soon followed.

Only a few small clinical trials have been conducted on the effectiveness of PRP therapy. Patients with knee osteoarthritis showed significant improvements as long as two years after PRP injections, according to a study published in The Journal of the American Osteopathic Association.