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      The Effect of Daily Self-Measurement of Pressure Pain Sensitivity Followed by Acupressure on Depression and Quality of Life versus Treatment as Usual in Ischemic Heart Disease: A Randomized Clinical Trial

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          Depressive symptoms and reduced quality of life (QOL) are parts of the chronic stress syndrome and predictive of adverse outcome in patients with ischemic heart disease (IHD). Chronic stress is associated with increased sensitivity for pain, which can be measured by algometry as Pressure Pain Sensitivity (PPS) on the sternum.


          To evaluate if stress focus by self-measurement of PPS, followed by stress reducing actions including acupressure, can decrease depressive symptoms and increase psychological well-being in people with stable IHD.


          Observer blinded randomized clinical trial over 3 months of either intervention or treatment as usual (TAU). Statistical analysis: Intention to treat.


          Two hundred and thirteen participants with IHD were included: 106 to active treatment and 107 to TAU. Drop-out: 20 and 12, respectively. The active intervention included self-measurement of PPS twice daily followed by acupressure as mandatory action, aiming at a reduction in PPS. Primary endpoint: change in depressive symptoms as measured by Major depression inventory (MDI). Other endpoints: changes in PPS, Well-being (WHO-5) and mental and physical QOL (SF-36).


          At 3 months PPS decreased 28%, to 58, in active and 11%, to 72, in TAU, p<0.001. MDI decreased 22%, to 6.5, in active group vs. 12%, to 8.3 in TAU, p = 0.040. WHO-5 increased to 71.0 and 64.8, active group and TAU, p = 0.015. SF-36 mental score sum increased to 55.3 and 53.3, active and TAU, p = 0.08.


          PPS measurements followed by acupressure reduce PPS, depressive symptoms and increase QOL in patients with stable IHD.

          Trial Registration

          ClinicalTrials.gov NCT01513824

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          Most cited references 20

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          Sensitization in patients with painful knee osteoarthritis.

          Pain is the dominant symptom in osteoarthritis (OA) and sensitization may contribute to the pain severity. This study investigated the role of sensitization in patients with painful knee OA by measuring (1) pressure pain thresholds (PPTs); (2) spreading sensitization; (3) temporal summation to repeated pressure pain stimulation; (4) pain responses after intramuscular hypertonic saline; and (5) pressure pain modulation by heterotopic descending noxious inhibitory control (DNIC). Forty-eight patients with different degrees of knee OA and twenty-four age- and sex-matched control subjects participated. The patients were separated into strong/severe (VAS>or=6) and mild/moderate pain (VAS<6) groups. PPTs were measured from the peripatellar region, tibialis anterior (TA) and extensor carpi radialis longus muscles before, during and after DNIC. Temporal summation to pressure was measured at the most painful site in the peripatellar region and over TA. Patients with severely painful OA pain have significantly lower PPT than controls. For all locations (knee, leg, and arm) significantly negative correlations between VAS and PPT were found (more pain, more sensitization). OA patients showed a significant facilitation of temporal summation from both the knee and TA and had significantly less DNIC as compared with controls. No correlations were found between standard radiological findings and clinical/experimental pain parameters. However, patients with lesions in the lateral tibiofemoral knee compartment had higher pain ratings compared with those with intercondylar and medial lesions. This study highlights the importance of central sensitization as an important manifestation in knee OA.
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            Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability.

             Leonard Egede (2007)
            The objective of this study was to determine the prevalence and odds of major depression and the incremental effect of major depression on utilization, lost productivity and functional disability in individuals with common chronic medical disorders. Data on 30,801 adults from the 1999 National Health Interview Survey were analyzed. The 12-month prevalence and age/sex-adjusted odds of major depression were calculated for adults with hypertension (HTN), diabetes mellitus (DM), coronary artery disease (CAD), congestive heart failure (CHF), stroke or cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD) and end-stage renal disease (ESRD). The association between chronic condition status (with and without major depression) and utilization, lost productivity and functional disability was determined by controlling for covariates. The 12-month prevalence and age/sex-adjusted odds of major depression by chronic conditions were as follows: CHF, 7.9% [odds ratio (OR)=1.96]; HTN, 8.0% (OR=2.00); DM, 9.3% (OR=1.96); CAD, 9.3% (OR=2.30); CVA, 11.4% (OR=3.15); COPD, 15.4% (OR=3.21); ESRD, 17.0% (OR=3.56); any chronic condition, 8.8% (OR=2.61). Compared to adults without chronic conditions, those with chronic conditions plus major depression had greater odds of > or = 1 ambulatory visit [OR=1.50; 95% confidence interval (95% CI)=1.28, 1.77]; > or = 1 emergency room visit (OR=1.94; 95% CI=1.55, 2.45); and > or = 1 day in bed due to illness (OR=1.60; 95% CI=1.28, 2.00); and functional disability (OR=2.48; 95% CI=1.96, 3.15). The 12-month prevalence and odds of major depression are high in individuals with chronic medical conditions, and major depression is associated with significant increases in utilization, lost productivity and functional disability.
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              Depression as a predictor for coronary heart disease. a review and meta-analysis.

              To review and quantify the impact of depression on the development of coronary heart disease (CHD) in initially healthy subjects. Cohort studies on depression and CHD were searched in MEDLINE (1966-2000) and PSYCHINFO (1887-2000), bibliographies, expert consultation, and personal reference files. Cohort studies with clinical depression or depressive mood as the exposure, and myocardial infarction or coronary death as the outcome. Information on study design, sample size and characteristics, assessment of depression, outcome, number of cases, crude and most-adjusted relative risks, and variables used in multivariate adjustments were abstracted. Eleven studies met the inclusion criteria. The overall relative risk [RR] for the development of CHD in depressed subjects was 1.64 (95% confidence interval [CI]=1.29-2.08, p<0.001). A sensitivity analysis showed that clinical depression (RR=2.69, 95% CI=1.63-4.43, p<0.001) was a stronger predictor than depressive mood (RR=1.49, 95% CI=1.16-1.92, p=0.02). It is concluded that depression predicts the development of CHD in initially healthy people. The stronger effect size for clinical depression compared to depressive mood points out that there might be a dose-response relationship between depression and CHD. Implications of the findings for a broader bio-psycho-social framework are discussed.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                21 May 2014
                : 9
                : 5
                [1 ]Herlev University Hospital, Department of Endocrinology, Herlev, Denmark
                [2 ]Ull Care A/S, Hellerup, Denmark
                [3 ]Psychiatric Research Unit, Psychiatric Centre North Zealand, Hillerød, Denmark
                [4 ]Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
                [5 ]The National Research Centre for the Working Environment, Copenhagen, Denmark
                [6 ]Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
                University of Michigan, United States of America
                Author notes

                Competing Interests: Søren Ballegaard invented the instrument used to measure PPS (Ullmeter, patent numbers: PA 2004-00349; PA 2004-00550) and is a shareholder of the firm that owns the PPS instrument (Ullcare A/S). In order to avoid bias, he was not involved in patient contact, collection of data or statistical analysis and was prohibited admittance to the research site during the entire period of the study. His authorship does not alter the authors’ adherence to PLOS ONE policies on sharing data and materials. The other authors have no competing interests to declare and no relation to Ullcare A/S including employment, consultancy, patents, products in development or marketed products.

                Conceived and designed the experiments: SB, PB, AH, FG, JF. Performed the experiments: NB, JF. Analyzed the data: NB, JK, JF. Wrote the paper: NB, SB, JK, PB, AH, FG, JF.


                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 10
                This work was supported by the Johan Schrøder’s Family and Business Foundation. Natasha Bergmann held a pre-graduate scholarship sponsored by the Lundbeck Foundation. Grants from Else and Mogens Wedell-Wedellsborg’s Foundation, and Carpenter Sophus Jacobsen and Wife Astrid Jacobsen’s Foundation were used to cover travel expenses. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Research Article
                Biology and Life Sciences
                Medical Devices and Equipment
                Psychological Stress
                Medicine and Health Sciences
                Myocardial Infarction
                Clinical Medicine
                Complementary and Alternative Medicine
                Mental Health and Psychiatry
                Vascular Medicine
                Coronary Artery Disease
                Research and Analysis Methods
                Research Design
                Case-Control Studies
                Clinical Research Design



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