This assignment will critically investigate the influence of mind-body therapies that might be used as an intervention for the treatment of irritable bowel syndrome (IBS). This assignment will explore recent available research on meditation and IBS, whilst addressing the implications for consumers, complementary therapists and conventional medicine.
Irritable bowel syndrome (IBS) is the most common chronic gastrointestinal (GI) disorder affecting approximately 10- 15 % of people in Europe (Quigley et al 2006), this is confirmed by Wilson et al (2004) who stated that the prevalence of IBS in the UK is 10.5%, with a ratio of 2:1 with women affected twice as frequently as men (Heitkeeper 2007) who continues that this may be because women access health services more often than men although as Wilson et (2004) estimate only 57% of affected patients seek medical services within six months of presenting symptoms, suggesting the number of IBS sufferers is much higher. Although no specific cause or cure has been found for IBS, conventional medicine aims to treat a vast array of fluctuating symptoms that include; abdominal pain, distension, cramping, bloating, excessive wind and a change in bowel habits resulting in either diarrhoea or constipation (Talley 2002) .
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Historically, conventional medicine treated IBS systematically and is dependent on the nature and the severity of the associated symptoms (Talley 2002). The pharmacologic agents used to treat the predominant symptoms of the patients complaints, include smooth muscle relaxants and tricylic antidepressants (TCA's) and bulking agents, however it has been suggested by Hussain & Quigley (2006) that the success rate of treating IBS is low
and has even been shown to exacerbate the degree of symptoms in IBS and the NICE (2008) guidelines suggest the inclusion of TCA's if laxatives, antispasmodics or loperamide does not alleviate symptoms. More recently if unsuccessful selective serotonin reuptake inhibitors (SSRI's) can be prescribed although as Talley (2007) states, there is currently no evidence on their efficacy. Other interventions include the use of Cognitive Behavioural Therapy, relaxation, biofeedback and hypnotherapy, which all have been found to have a positive effect for IBS patients immediately following treatment. However a systematic review of randomized controlled trials found a higher quality of randomized controlled trials using antidepressants stating that the psychological therapy evidence appears to be of low quality (Ford et al 2008) however other trials have indicated that there is no reliable evidence available for the success in treating IBS with antidepressants or bulking agents (Snelling 2006) .
While the aetiology of Irritable bowel syndrome is not completely understood research suggests, that it is multifactorial and heterogeneous in nature, making it difficult to treat with conventional medicine (Barreau 2007) and as far back as two decades ago, research suggested a link between gastrointestinal disorders (GI) such as IBS with the prevalence of psychological disorders experienced with many IBS sufferers including coping difficulties, depression and anxiety (Drossman 1988, Walker 1990). Current research indicates a strong correlation between the symptoms of IBS with social, physical and psychological stressors (Blanchard et al 2008). The relatively new science of psychoneuroimmnuology (PNI) has sought to provide evidence that a bi-directional relationship exists between the immune, nervous and endocrine system; and the physiological pathways in which they can influence health and disease (Ader 2007).
Although the exact action of PNI is yet to be established, there is increasing evidence that stress activates the hypothalamic-pituitary-adrenal axis (HPA-axis) and the sympathetic -adrenal-medullary axis (SAM-axis) in the limbic brain area; resulting in dysregulation of glucocorticoids and catecholamine's which are known to be involved in this bidirectional communication (Padgett, Glaser 2003). Research indicates that IBS sufferers have reportedly shown elevated stress levels of hormones in comparison to healthy subjects (Posserud et al 2004). The limbic system response to stress activates the HPA-axis and the autonomic nervous system (ANS) via neural relay, which in turn stimulates the secretion of corticotrophin releasing factor (CRF) and adrenocorticotropic hormone (ATCH) from the adrenal glands. This action stimulates the sympathetic nerve endings of the ENS to secrete noradrenalin and adenosine directly into the intestinal mucosa (Ader 2007).
However it is not only physical symptoms that are of concern with IBS, as sufferers report a reduction in their health related quality of life (HR-QOL) compared to normal subjects (Chang 2004) as the chronic and fluctuating symptoms of IBS can often be embarrassing and painful which in turn effect their sleep and their social interactions. Edell-Gustafson (2002) investigated self reported sleep quality and illness found that women suffering from GI complaints were sensitive to reduced sleep quality and this issue of sleep was further investigated by Thompson (2003) who wanted to understand how depressive symptoms affect autonomic and endocrine function in women with IBS and found a correlation between depression and poor/fragmented sleep, suggesting that depression possibly intensifies sleep disturbances. Disturbed sleep is considered to be a stressor that activates the HPA-axis, ANS and immune system, as during tiredness or exhaustion, emotions are increased causing a reduction in stress resilience (Demasio 2000, McEwen 2000, Edell-Gustafson (2002), which in turn exposes individuals to a reduction in coping ability.
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Despite the medical profession considering the socioeconomic burden and ineffective conventional treatment for IBS, the condition continues to be managed more than any other GI disorder (Inadomi et al 2004) which reflects the £46.5 million annual expenditure on IBS management within the NHS reported in 2003(Inadomi et al 2004) this alongside the 8.5 - 21.6 days of absenteeism from work annually for IBS related problems demonstrates the burden on local economies (Maxion-Bergemann et al (2006).
The immune system is primarily involved in providing a defence for the host, against disease caused by pathogenic organisms via recognition and elimination of the pathogen (Wood 2006). Many cells and proteins are involved in defending the host against invading pathogens and when provoked, an immediate innate immune response occurs involving Leukocytes; T-cells, B-cells and natural killer (NK) cells ( Lydyard et al 2004). Leukocytes are the main cells involved in an antigen specific immune response. They circulate in the blood and lymphatic system and provide the body with a first-line defence in eliminating the pathogen (Wood 2006). A review of brain imaging studies used to investigate visceral functions in IBS patients in comparison to healthy subjects (Rapps et al 2008) have indicated the presence of abnormal brain activation following visceral stimulation of IBS patients, however the researchers state that the results comparing healthy subjects and IBS patients were overall inconsistent and contradictory as the results of the review suggest the possibility of multiple mechanisms such as nerve hypersensitivity in the gut or abnormal processing in the brain or central nervous system (CNS), coupled with the psychological factors that were not reported to be considered in some studies, but are generally considered to be a large factor in IBS.
Traditionally the immune system has always been seen to work autonomously and was not considered to be a factor in IBS as IBS was historically viewed as a psychological disorder, despite this the various symptoms expressed by patients have been investigated without much success in establishing a physiological cause of IBS (Blanchard 2008). The relatively new science of Psychoneuroimmunology (PNI) has sought to provide evidence that a bi-directional communication between the immune and neuro-endocrine system exists and how these interactions influence both health and disease (Ader 2007).
During a stress response via the limbic system, the hypothalamic- pituitary- adrenal axis (HPA-axis) and the autonomic nervous system (ANS) become activated resulting in the secretion of corticotropin releasing hormone (CRH ) which activates the pituitary to release adrenocorticotropic hormone (ACTH) via the HPA-axis which stimulates the release of cortisol and adrenaline which are synthesised in the adrenal cortex, in addition to this, noradrenaline and adenosine are secreted into the mucus membranes via the sympathetic nerves of the enteric nervous system, this is accompanied by mast cells which lay in close proximity to lymphocytes and enteric nerves, when activated mast cells degranulate releasing neuromediators into the intestinal mucosa which stimulates mucus production and increases intestinal permeability (Medscape 2010). Li et al (2003) suggests that the continual increased intestinal porosity is thought to be responsible for diarrhoea associated with the symptoms of IBS. Mast cells are immunocytes that have been found to be substantially increased in IBS patients in comparison to healthy subjects (Palsson et al 2001, Rijnierse et al 2007), and has demonstrated its ability to increase and enhance the concentration of the neuropeptides Vasoacative Intestinal Peptide (VIP) which relaxes smooth muscle and Substance P (SP) which is related to perception of pain , which in increased numbers are collectively believed to be the cause of abdominal cramping/pain and hypersensitivity in IBS (O'sullivan 2000) and prompts the release of proinflammatory cytokines IL-6 and IL-8 (Scully et al 2010) which causes further enhancement of the inflammatory response as macrophages react to the visceral activity, resulting in the low grade inflammation expressed in IBS patients and a reoccurring cycle of inflammation of the GI tract (Spiller, Garsed 2009), this is further supported by Dinan et al (2006) who reported low grade inflammation of mucosal membranes in IBS patients, due to the presence of IL-6 and its receptors, which are the result of Substance P stimulating macrophages to enable them to emit IL-1 and IL-6 (Ader 2007). Li et al (2003) who's study observed the bi-directional communication between mast cells and neuropeptidergic terminals and demonstrated their partial membrane to membrane interaction and further demonstrated that Substance P (SP), Vasoactive Intestinal Peptide (VIP) and Calcitonin Gene-Related Peptide (CGRP) are able to modulate MC activity in intestinal mucosa, they do however state that CGRP demonstrates less importance in the pathophysiological actions believed to be responsible for IBS, suggesting that the close proximity of the membranes results in the deregulated motor response and visceral perceptions experienced in IBS. Ader (2007) states that the same neuropeptide receptors are expressed on the cells of the immune and nervous system, suggesting direct communication between the two systems, he goes on to say that VIP has been found to play a significant role in various inflammatory conditions, however in healthy subjects, VIP encourages the production of regulatory T-cells and Th2 effectors whilst prohibiting the stimulation of macrophages, microglia and dendritic cells via receptors found on their surface.
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The Department of Health (DOH 2009) report discussing personalised care plans for patients with chronic illness, suggests that patients want to feel more in control of their illnesses and want information about self care to use in combination with conventional treatment. Meditation as a therapy has been found to be a useful intervention for stress reduction and IBS care (Keefer and Blanchard (2001,2002). A study performed 15 years ago (Solberg et al 1995) observed how meditation alters immune responses following physical stress and reported a significant reduction in CD-8 T-cells for the intervention group in comparison to the control group, therefore suggesting that meditation has a positive effect on immune function. More recent studies (Davidson et al 2002) investigating mindfulness meditation and the biological processes involved with mental and physical health changes and found that the intervention group exhibited significant increases in the brain activation which they state has been previously associated with the positive effects of meditation, the study also reported an increase in antibody titers to the influenza vaccine for the meditation group, the study suggested that a short programme of mindfulness meditation would produce positive and provable results on brain and immunological functioning, however the study does not report how long the results lasted in the intervention group but does address the need for additional research. Previous to this study, Keefer and Blanchard (2001) performed a trial to asses if relaxation response meditation (RRM), had any significance on alleviating IBS symptoms. Participants were asked to practice RMM for 15 minutes a twice a day for the duration of treatment, following a three month review, results suggested a significant reduction in belching, bloating, flatulence and diarrhoea Keefer and Blanchard (2001), however a review at one year displayed the significance of the results, as all symptoms returned in 10 out of the 13 participants (Keefer and Blanchard (2002). This suggests that meditation can be an effective therapy in treating IBS symptoms with the provision of follow up treatments and self maintenance. Although there are a limited number of studies investigating meditation as a treatment for IBS, this study suggests that meditation performed each day for a short duration can help to maintain the reduction of IBS symptoms experienced by patients. As demonstrated by Keefer and Blanchard 2002, the success of using meditation as an intervention for IBS is only achievable if the patients continue to practice it regularly in order to prevent the stressors returning or improve coping ability, therefore interventions like meditation should be sought that effectively work on the well- being of IBS patients and should be practiced over a continual duration to reduce or remove the stressors thought to exasperate the symptoms of IBS, however despite the success of the study the trial was small which suggests the need for further studies to be performed to provide more insight into the mechanism of treating IBS with an intervention such as meditation.
To conclude, meditation is a therapy that has demonstrated its potential in alleviating one of the most prevalent but unsuccessfully treated GI diseases in the United kingdom. When practiced over a relatively short time it has been shown to significantly reduce the stimulation of CD 8 T-cells, stress, pain, bloating, belching, flatulence and diarrhea that is associated with IBS and is also found to improve quality of life and promote sleep. There is much research that still needs to be conducted on meditation and many unanswered questions regarding the pathology of IBS, however pioneering research in PNI has allowed conventional and complementary medicine to further understand the cause and therefore the treatment for IBS. A positive step in finding a successful treatment for IBS would have a huge positive impact on the NHS financial budget, trained CAM therapists (in meditation ) could offer this as part of their services thus allowing primary care to focus on other health matters. The implications of IBS patients receiving meditation therapy and self care meditation would allow for patients to feel they are in more control of their illness which would essentially improve the quality of life in IBS patients.
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