Video Aided Mindful Deep Breathing for Pain Management
Condition: Musculoskeletal Pain; Ankle Injuries; Joint Instability
MeSH terms: Musculoskeletal Pain; Joint Instability; Ankle Injuries
Study type: Interventional

Summary: 
      Chronic ankle instability (CAI) is the most common musculoskeletal injury in sports and the
      rate of CAI accounts for 85% of ankle injuries. It has been estimated that 23,000 ankle
      sprains occur each day in the United States, representing approximately 1 sprain per 10,000
      people per day and nearly one in five ankle injuries result in chronic symptoms. Numerous
      researchers applied mindfulness for improving the performance of various sports such as table
      tennis, shooting, cricket, archery, golf, swimming, and cycling. Since many of the players do
      not possess effective pain coping skills, they are at risk for lifelong impairment of their
      emotional, social, and physical functioning. Mindfulness-centered interventions may well
      serve to mitigate pain-related disability. Training in mindfulness meditation improves
      anxiety, depression, stress, and cognition. Mindfulness-related health benefits are
      associated with enhancements in cognitive control, emotion regulation, positive mood, and
      acceptance, each of which have been associated with pain modulation. Since mindfulness has
      been proven effective in managing various health disorders and in enhancing sports
      performance, our study aims to apply the mindfulness approach in rehabilitating the most
      common sports injury, CAI. The improvement in CAI due to the mindfulness approach will be
      assessed by the improvement in pain response through the Cumberland ankle instability tool,
      Functional ankle disability index (FADI), Visual analog scale (VAS), Brief Pain Inventory
      (BPI), Y-balance test, Mindfulness attention awareness score (MAAS), Oxford Happiness
      Questionnaire (OHQ) quantitative electroencephalography (Q-EEG). This study finding will be
      useful in assessing the effectiveness of mindfulness in rehabilitating CAI and identify the
      correlation of CAI pain response with VAS & BPI, quantitative electroencephalography - Q-EEG.
      In this clinical trial, the investigators wish to use noninvasive methods such as
      quantitative EEG (electroencephalogram) to find the brainwave patterns during the different
      stages of mindfulness intervention (pre and post). The outcome of this study will eventually
      lead to the identification of a better assessment method to indicate the pain response for
      the appropriate physiotherapy management. The application of mindfulness technique in CAI
      management and the usage of Q- EEG to assess the pain response in chronic ankle injury
      athletes are the novel approaches of this research study.
    

Detailed description: 
      Background:

      Inversion Ankle injuries (IAS) are among the most common musculoskeletal injuries in sports
      and the rate of IAS accounts for 85% of ankle injuries. The hallmarks of chronic ankle
      instability (CAI) include repeated ankle sprains that have led to an altered patient activity
      level. Important factors include injuries sustained, frequency of events, localization of
      pain, and prior treatment modalities. The degree of disability appreciated by the patient is
      one of the most important factors and can be significant in both high- and low-demand
      individuals. The most commonly cited characteristics of CAI include giving way to the ankle,
      mechanical instability, pain and swelling, loss of strength, recurrent sprain, and functional
      instability. Residual problems can persist for decades, with up to 72% of people unable to
      return to their previous level of activity, such as fear of the ankle giving way. Functional
      ankle instability includes a perceived or actual giving way of the ankle (or both) and other
      characteristics previously associated with CAI in general: pain, swelling, and recurrent
      sprain. Functional insufficiencies among individuals with either CAI have been demonstrated
      by quantifying deficits in ankle neuromuscular response times, postural control, and
      strength.

      Researchers have found that injured athletes experience clinically significant depression 6
      times as often as non-injured athletes. Injured athletes also exhibit significantly greater
      anxiety and lower self-esteem than non-injured. Athletes with more severe injuries are more
      likely to become depressed than the non-injured. Since many of the players do not possess
      effective pain coping skills, they are at risk for lifelong impairment of their emotional,
      social, and physical functioning. Mindfulness-centered interventions may well serve to
      mitigate a pain-related disability. Training in mindfulness meditation improves anxiety,
      depression, stress, and cognition. Mindfulness-related health benefits are associated with
      enhancements in cognitive control, emotion regulation, positive mood, and acceptance,
      happiness each of which have been associated with pain modulation. Successively mindfulness
      has been proven effective in managing various health disorders and in enhancing sports
      performance. This study aims to apply the video-assisted mindfulness deep breathing training
      (VAMDBT) approach in rehabilitating CAI, the most common sports injury. In addition, applies
      Quantitative Electroencephalogram (QEEG) as one of the parameters to measure the pain
      response of collegiate athletes.

      Literature Chronic ankle pain can affect all age groups, ranging from young athletes to
      elderly patients with degenerative joint and soft-tissue disorders. Although physical
      activity brings a range of lifelong health benefits, it may also lead to injuries that pose a
      significant threat to health. Among 90 Plus League volleyball players age 18-37, over 87% of
      the respondents suffered from at least one sport-related injury. In total, 362 injuries
      occurred, on average 4.02 injuries per one volleyball player. The most commonly involved
      sports injuries were ankle sprains (46 injuries), knee and lower leg muscles (30),
      interphalangeal articulations of fingers (30) as well as the shoulder joint. More than half
      of the injuries (57%) occurred twice or three times.

      The pattern of musculoskeletal injuries sustained by Malaysian badminton players who attended
      the National Sports Institute (NSI) Clinic, Kuala Lumpur, Malaysia. The mean age of the
      players who attended the clinic was 19.2 (range 13-52) years. Approximately 60 percent of the
      injuries occurred in players younger than 20 years of age. The majority of injuries (91.5
      percent) were categorized as mild overuse injuries and mostly involved the knee and ankle.
      The prevalence of sports injuries among 475 male professional athletes participating in ball
      sports who are aged 15 years and older, from 5 sports clubs in Kuwait. About 452 athletes
      from four ball games (football (soccer), basketball, handball, and volleyball) were included
      in this study. The study found that the overall 12-month and lifetime prevalence of sports
      injuries were 73.8 and 89.8%, respectively. Lower limbs (73.1%) were the most common site of
      injuries and joint injuries (43.6%) were the most common type of injury reported. The study
      analyzed the characteristics of injuries and associated personal and training characteristics
      in young basketball players of both sexes. A conducted one-year retrospective cross-sectional
      survey with 581 basketball players (350 males and 231 females) participated in the school
      games and high school Olympics in the state of São Paulo, Brazil. The study used a
      questionnaire that contained items addressing anthropometric data and characteristics of
      injuries that have occurred in the previous 12 months. Results showed a total of 167 of the
      athletes reported injuries and the male gender exhibited a greater risk of injury than the
      female gender. The most affected anatomic sites were the ankle/foot and knee. A study that
      investigates the pattern of muscle injuries and the factors that predict the return-to-play
      duration among Malaysian athletes who attended the National Sports Institute Clinic. About
      397 muscle injuries were diagnosed among 360 athletes from the period June 2006 to December
      2009. The median age of the athletes with muscle injuries was 20.0 years. Muscle injuries
      were mostly diagnosed among national-level athletes and frequently involved the lower limb.
      There is a twofold increased risk for ankle injury recurrence for at least one-year
      post-injury. In up to 50% of all cases, recurrences result in disability and lead to chronic
      pain or instability, requiring prolonged medical care. Therefore, ankle sprain recurrence
      prevention in athletes is essential. A study that measured preseason anxiety and depression
      reported a total of 597 injuries with 40.6% preseason injuries, 28.8%, and 21.7% of athletes
      suffered from anxiety and depressive symptoms. Another study stated depression and anxiety
      disorders have a negative effect on subjective well-being. The Oxford Happiness Scale, Life
      Satisfaction Scale response among 284 patients shows that participants were found to be
      moderately happy and satisfied.

      Chronic Ankle Injury Rehabilitation Ankle sprains are a common problem seen by primary care
      physicians, especially among teenagers and young adults. Early mobilization speeds healing
      and reduce pain more effectively than prolonged rest. A previous ankle sprain is the greatest
      risk factor for an acute ankle sprain, it is important to counsel the recovering patients on
      prevention strategies. Ankle braces and supports, ankle taping, a focused neuromuscular
      training program, and regular sport-specific warm-up exercises have proven to protect against
      ankle injuries, and have to be considered for patients returning to sports or other high-risk
      activities.

      Mindfulness Recent attention in healthcare research has been paid to the concept of
      mindfulness and its contributions to clinical practice. Mindfulness refers to the way
      individuals pay attention to their experiences from moment to moment with non-judgmental
      attitudes. The cultivation of mindfulness requires regular practice of mindful breathing and
      different types of meditation. Mindfulness meditation has been found to improve a wide
      spectrum of cognitive and health outcomes. Training in mindfulness meditation improves
      anxiety, depression, stress, and cognition. Mindfulness-related health benefits are
      associated with enhancements in cognitive control, emotion regulation, positive mood, and
      acceptance, each of which has been associated with pain modulation. Thus, it seems reasonable
      to hypothesize that mindfulness meditation itself would attenuate pain through some of these
      mechanisms. A mindfulness training for eight weeks duration was shown to improve pain
      acceptance in lower back pain patients. Neurophysiological changes are consistent with a
      bio-psycho-social formulation reflecting the underlying mechanisms associated with sensory
      and motor findings, psychological traits, and perceptual changes associated with chronic
      musculoskeletal conditions. These changes, therefore, have important implications in the
      clinical manifestation, pathophysiology, and rehabilitative treatment of chronic
      musculoskeletal disorders. Musculoskeletal rehabilitation professionals have at their
      disposal tools to address these neuroplastic changes including top-down cognitive-based
      interventions (such as education, cognitive behavioral therapy, mindfulness meditation, and
      motor imagery), and bottom-up physical interventions (such as motor learning, peripheral
      sensory stimulation, and manual therapy) that induce neuroplastic changes across distributed
      areas of the nervous system and impact outcomes in patients with chronic musculoskeletal
      disorders. Mindful exercise executed with profound and nonjudgmental attention to breathing
      and proprioceptive awareness of muscles and movements.

      Assessment of Mindfulness Approach:

      A pilot study using an 8-week mindfulness-based stress reduction (MBSR) program on a sample
      of low back pain patients was conducted in order to assess the feasibility and effectiveness
      of the intervention as well as changes in an EEG pattern called thalamocortical dysrhythmia
      which is associated with chronic pain. The study involved 22 patients with chronic low back
      pain who participated in an MBSR program. The result showed a medium-sized effect for
      psychological functioning, pain severity, and quality of life. However, EEG analyses revealed
      no differences between the pre-and post-intervention. The major concerns from the previous
      mindfulness studies about the participant's compliance reported were time constraints and
      personal commitments. The high demand in time and the need for guidance from a coach can
      discourage the community from taking up these practices as well. For a full MBSR course, it
      can take up to eight weeks, with weekly meetings that last for about three hours and the
      daily practice of about an hour. This can be difficult to adhere to especially in the current
      fast-paced lifestyle of young people. With due consideration of participants' compliance, the
      mindfulness intervention practice of the present study has been modified to 5- min
      video-assisted mindfulness deep breathing. Furthermore, the follow-up of participants' home
      practices will be monitored with the use of a smartphone app that has the facility to send
      reminders as text messages to fill in the practice diaries or online portals to record the
      frequency of home practice of our intervention. A recent study on short-duration,
      video-assisted deep breathing among healthy young adults showed that the participants engaged
      for 5 min deep breathing revealed profound NoGo N2 amplitude increment as compared to the
      control group in the follow-up session. Results indicated the possibility of performing
      short-duration deep breathing guided by video-assisted deep breathing to achieve an enhanced
      conflict monitoring as an alternative to other mindfulness practices. Therefore the objective
      of this study is to find the effectiveness of VAMDBT in the recovery of chronic ankle
      instability among collegiate athletes.
    

Intervention name(s): standard ankle physiotherapy or rehabilitation for chronic ankle instability
Intervention type(s): Other
Intervention description(s): 6 weeks of combined interventions of video aided mindful deep breathing and standard ankle physiotherapy in rehabilitating the chronic ankle instability for participants with chronic ankle instability
Other intervention name(s): Video aided mindful deep breathing with standard ankle physiotherapy or rehabilitation for chronic ankle instability
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Supportive Care
Keywords: Mindfulness; Breathing; Rehabilitation; Athletes; Physiotherapy; Electroencephalography