Signature Block Acupuncture Medical Consent Made Easy

Signature block acupuncture medical consent

thank you all for coming to the next installment of the OSHA Center for Integrative Medicine Grand Rounds as you know we alternate every month between a research presentation and a case presentation and this month is on research and thanks to those of you who are participating virtually using our streaming option really excited that we can expand this out to the greater virtual community so today's seminar which is led by dr. Jon Kong addresses a topic that's near and dear to to my research interests which is the impact of mind-body practices on pain not only in terms of palliative care but also of using this interesting paradigm of mind-body practices to understand how cognitive and the more bottom-up processes interact impact pain and well-being and dr. Kong is particularly well-suited to to lead this program of research dr. Kong was trained in Medical Sciences in China and he's currently the an associate professor in psychiatry here at the Harvard Medical School he's also the director of the neuro imaging applications to pain alternative medicine and placebo programs which is jointly based at the Harvard Medical School and MGH is Martino's Center for neuroimaging he's been involved in well over 10 NIH studies many of which he's been principal investigator for and he's also highly published with over 145 peer review articles he's doing some really interesting work some of it is based here in at Harvard some of it's with collaborators in China and I'm really excited to see these data I've seen earlier versions of it a few months ago and it's it's really leading-edge research so without any delay please join me in welcoming dr. Kong [Applause] thank you for nice introduction thank you Peter so the topic I'm going to talk today is applying the power of the mind to many pain okay so medicine is about the cheating but we all know healing is a very complicated process generally speaking there may be a three-component there and the first one is self-healing property of the human body after thousands of years of evolution our human body to develop this ability to recover from disorders for instance if you get a quarry even not going to take any medication you're still going to recover from this disorder through the immune system for instance I call this a demonstration of the power of human body and another component which is after you know sound vs medical practice and application for technology on science we have this a specific fact of physical or psychological intervention I call it the power of the medicine and the third one is between the first and this medicine component is the nonspecific effect of the treatment some people called possible in fact and I would like accorded a demonstration of the power of the mind the reason I use the power of the mind because there's recibo knows about just by example and there's many other examples to demonstrate the power of mind for instance the imagery the meditation etc so in today's talk I'm going to focus on this component which our demonstration of the power of the mind believe or not actually we have known the power of mind for a long time for instance this is our sentence I found from the fountain age in which is believed to be the Bible or turn to medicine acupuncture and said if a patient does not consent to trade with positive engagement the physician should not proceed as a sera he will not succeed an interesting is almost the same time in the other side of the world Hippocrates also the father which is a father of the medicine also said the same thing I'm he said the patient don't conscious that his conditioning the parallels may recover his health simply through his contentment with the goonies of the physician and also the balance added that what matter what was not only the medicine all appeals but the whale about it gave them to the patient in fact the whole atmosphere enraged to the drug was given these are also demonstrated power of mind and here's a meta-analysis on 29 randomized clinical trials for about aging our chronic pain patient the conclusion is acupuncture is effective for the treatment of chronic pain and is therefore and reasonable referral-- options however factors in addition to the specific effect of in dueling are important contributors to the circuit event or acupuncture and I want to emphasize this nonspecific effect how to knot the effect is not only to limit to the acupuncture and here the book from doc Berman Kirsch who is a researcher here at how are my school and this in this our blurb of this book and said cursory research including a thorough analysis of tacit Food and Drug Administration theta has demonstrated what everyone knew about antidepressant was wrong instead of treating a depression with drug we have been treating it very suggestion the dragon cell for just four signals the circuitry could sugar peel and also here's another one I found for the any internal medicine instead untidy person are only one of many classes of drug with sensitivity problems analgesics and the latex antihypertensives hypnotics and you can say and the many other effective agent are often indistinguishable from personal email design conduct trials so I hope I'm convinced you that to announce specific fact is very powerful so then the next natural question is why this happened so this is an early study we did and the mo studied to investor why this Percival acupuncture can produce energy see effect so this is our conflict study I try to keep the simple in general is a three sessions study healthy subject were involved and we use experiment heat pain so apply the heat pain on their fore arm and the temperature of his pain was controlled by the computer in session one which is our training session we gave them a different level of pain and find individualized temperature for each individuals and then in session to record expectancy manipulation session and the aim of this session is try to make them believe acupuncture really work so this is a how we did it so basically so basically let me sit friends so basically with our beginning session to and make a story we said well based on the theory of acupuncture and acupuncture can only produce energies effect around meridians so which is not true so we told them we're going to do the acupuncture here and then we draw a line here you can see here on this side forum we told them if your respond to acupuncture you'll you know you will feel the pain and relief and one side was warm but not on the other side so in reality what we did abates with draw a line and came identical pain on both sides of forearm and to our receiver ocean acupuncture for five minutes then after that without staring subject we lower the temperature on the site where we told them acupuncture may relieve pain but use the same hand other side so after this manipulation everyone was very excited they feel the difference so then in section 3 then we say that's great then since you are respond to acupuncture and then this time we're going to scan your brain and see how we're going to response your brain will response to this treatment so in reality what we did is we the kingdom I think company on both side with only lower the temperature and one sport on the side of where we told them Meridian past o2 recorded our boost to make them believe acupuncture still work but then for the last of course sport anyway two on each side will identical pain as before so the pre post pain region and both sides will be the primary outcome for our study and then the first thing you can say here is we found signal pain rating difference on the placebo side where we make them believe acupuncture work from Harry the control side we are we make the main them have no effect then your addition we found actually to burn area the health plan will be de and your insular and another one is record rostro a CSA release is to error actually play an important role in the placebo analgesia effect so for in that study we did another study and basically this previous study with diamonds we invest Magnusson of placebo analgesia but this time we must make it often noticeable in fact no simple effect is someone corridor negative Kosovo effect so in clinical just in case for those who are not familiar with this in fact you know for instance ER crinkle randomised trials you know have subject we say we treat them and a half given the sugar peel if it's very beginning you tell them you know this drug is or socially its base side effect like a fatigue you know headache and you'll find you know about 20% of 20% sometimes the patient will come back lining they have that side effect and interesting you know even people who receive should appear which is possible treatment also will come back and claim they have that side effects that we called nocebo effect so you think study with you the similar model than two universities notes about effect what we did we tell them is you know it's also three sessions study session wine training and then we told them that basically acupuncture can relieve pain and in some special case and it can make you become a pain sensitive so then what we did is a similar to burry will study we can I think it we told them a story of moderated and we came I think you pay on both side and we told them acupuncture can only produce effect on one side of their forearm and after treatment without having subject we actually increase the temperature on the side we told them acupuncture may produce effect so in that way and everyone think you know actually acupuncture can enhance their experience and then in session three things like very previous study we actually are investigator that you know you know we give them identical pain and see how these expectancy can modulate their experience and here is the result and we have out here we have a to sign the current no simple no simple side we have a they believe or condition that acupuncture can enhance their experience and also have a control side you can say compare this to side actually there are n rating is singing different and also we found actually some during area which is not consistent with the area we found in placebo study the Prairie like those left toes right to us over and your cingulate a private or porcelain and also tempers ugly important role in this process and particularly we thinking important region you keep tempers because studies suggest its region is not only involved in memory and also involve the pain and the anxiety of the pain so this result actually consists of a some behavior study from da Peng daddy which showed that no simple item associate with anxiety then having do that I know we we said well that's great so things you know this expectancy or belief is powerful now how it can interact with acupuncture treatment so answer this question we did another study again this recession study and session one is a training session and in session two subject was randomized to one over the for group when you got through by crew design real and acupuncture by high and low expectancy for height pectins a group we just use this expectation money relation like we did before for lowest patterns say we just did not politely see patterns that we gave them identical pain before and after treatment on suicide and then we use the session three to invite the treatment effect and then you can say here the part we is pain rate indicated pain rating this is a plane region two identical sheet pain and the bar we used a post - pray so that means if the bar up indicate energy is in effect we have four group here through sable and the real acupuncture by high and low expectancy and also we have a reason sub the control that is within each group we have one side they deliver acupuncture work alongside the believe acupuncture will not work you can see here it's not matter to real acupuncture if they believe acupuncture work I really depend you can say energies expect it's indicated by our pain rating decrease so then what happened in the brain why this happens this is a very complicated story they still try to know exactly what that mean but basically here is we have a three color here the red color indicates pre area associates to pay intensity that is if it gave you different level pain this area tend to have different response so we paint recorded pain in coding for an area and the Green Carter here indicate the main factor acupuncture where you live real acupuncture of man use the single acupuncture you can see here this green color area which including the PA demon metallus telomers an insular overlap with that red color et al so that indicates that after acupuncture treatment you know the incoming pain signal actually will somehow inhibited and then that's the main effect of acupuncture and then the blue color indicated the main effect of expected saving you to expectancy high expecting growth - low expectancy group you can say here again we found that the row space they say in capes a like we did before and also we have another era called a negative and we all know that it's prone area actually associated way emotion regulation so our interpretation for this result is acupuncture is wandering up modulation and the same can inhibit the pain are you know income although our pen reading did not change a placebo expectancy it's more likely to work from a top-down new emotion modulation process so that is a study when it did in house a subject one question is can we repeat these findings in patient population so we actually repeat the same study in patients with knee osteoarthritis patient and then in this time I only have to group the reason I only include two root because we always have a reason subject control and then clear the results and we actually found at least behaviorally we can repeat previous study so that is after this expectancy manipulation we say strong expectancy effect but there's no difference between the real and the same acupuncture and also in this study we are we started attacking the resting state we get data and we want to know if we can use this resting-state connectivity which we collected data collected in the baseline at the beginning of this session 3 which is mi session and can use this data to predict our placebo or treatment response so this time we use our something we call it graph theory and so the basically we divided our brain region into about 100 for an area based on some Atlas and then we compute rates the connectivity between all these regions and then we calculated some parameters of this graph theory and to say we can the parameters can predict our treatment response we actually found our two parameters Y is called clustering coefficient another one called a low coefficient and from this to the premise actually can predict possible response and then in addition we also invited you know what happened when we give them experimental pain like what we did before and this time which is a little bit surprised to me it when you actually found that is bring network associated with expectancy when it's combined with real acupuncture is different from when it's a combined with Siebel acupuncture and you can say here there's some overlap also some you know difference there so don't bind that happen so we in this study actually used the acupuncture really electro acupuncture then we invited you know what happened during this continuous 20 minutes in actual acupuncturist you made the simulation we actually found actually during this continuous acupuncture stimulation the original coherence of lot of brain regions which is believed to be associated with a pain actually the is decreased compared with Shack so this area you could not go so ACC and insula Portland and it's two so in the so once I was excised here although study with you know focus on the you know classical expectancy or whatever you call it psychiatric psychological effects acupuncture but will also repeat the found it is you know strong robust modulation in fact of real acupuncture and here is just one example so demonstrating that it continues electro acupuncture stimulation actually can modulate the brain activity of pain related for an area and also I want to emphasize this a powerful modulation in fact of expectancy not something unique to acupuncture this is our study from bingos and Irene Tracy group and what they did is how the expectancy can modulate and noticed effect of opium in fact and in they study the use are similar but not the same model and they also use a permanent heat pain so you can say here they have a baseline no expectancy politics patients and activity is patency so what are the indeed is actually they gave that on rely and then the baseline indicated they didn't start administration grant right now so also just want to so basically and also want to say is the pain the same it's identical head pain and the power here indicated their pain rating and the baseline indicating no administration or in fact no and no expectancy indicated when they start administration from in fact no but they did not tell the patient that is their pain rating on that stage and positive expectancy indicates the pain rating while they told the subject that the administration of Rama Fang know and then the negative expectancy is they still give the administration of retinopathy told they have stopped administration so you can see here the pain rating of negative x expectancy is almost the same as a baseline so that indicated you know this expectancy is basically canceled out the energy spectrum fentanyl so which is a similar to our previous findings and also they also measure the post pain rating and the unpleasant rating and you can say the trend is very similar so then after doing that in addition to compare the difference between their other rail under share acupuncture we also want to invite his association between the between the real acupuncture and proceeded of acupuncture so the question we want to really ask is if an individual respond to real acupuncture will he or she will also tend to response to placebo acupuncture and in addition we want to know is if I individual is bound to possible acupuncture will she and she will also respond to perceive or feels any you you can say to answer this question the traditional randomize can trials cannot answer this question because you know why individual have to receive all these different treatments so in this study we used our cross over design and the very beginning is the session wise you know training session then they were randomized which they real acupuncture placebo pills we told them it's a run right now and they also share acupuncture and we can list basically they of doing nothing take a break in that session each session was separate at least one week and before and after each session with marinara pen threshold and to say how this treatment can modulate their pain sensitivity and after that you know after the whole study we also bring them to a for my skin and in this time we actually use a placebo like conditioning model to imagine a cue effect of this individuals and so in summary we found that there is a significant association between the genu acupuncture & sham acupuncture which is consistent with our heart craves hypothesis that is now specific that simply imported yo-you acupuncture treatment your addition we found there's no second association between the placebo pills try acupuncture and we kill conditions indication that the individual may respond to unique feeling rituals in different ways so then after that because it's a powerful placebo no civil model and then over also did is you know about six studies to universities conditioning factories are different tools and we actually found that first class even noticeable like condition fact can be obtained from it either personal experience and we also found this visual cue after both direct indirect conditioning chi influence our been reading consciously and unconsciously and also they found a complicate for network are involved in this process so then the next question will be you know why it matters right so so the aim of research actually is to enhance treatment effect so then how can we translate the findings are pre-funding to magical practice to enhance acupuncture that is something I mean very interesting and this is a pilot study we did so theoretically if we want to it has acupuncture treatment then either way it's just to enhance their expectancy new this expectancy manipulation model I mentioned before but what we cannot do is is from the chronic pain patient like nobody anyway there is no such thing or we cannot easily modulate the expectancy so then we think maybe we can still use is expecting some intimidation model using its apparent pain and with our hope is after we enhance their expectantly to acupuncture treatment - esperen brain maybe they are brewing an automatic transfer this expected say who the acupuncture a demented chronic pain that is our hypothesis and so in to test is a helper hypothesis we recruited a patient weighs neo a and then we randomized them to one over the four or three treatment group why are they called the first one we called up boosted acupuncture group and another one is a standard acupuncture and the last one is no treatment or gyro treatment group and so in in the post acupuncture treatment group we just uses expectancy manipulation model to make them believe usually determined pain to make them believe acupuncture actually really work for them and you can say the figure there and basically we this time to apply the a time and hit paint on their knee and we told them you know we're going to give you the treatment of the in session one we also give you we're going to treat your knee pain but in session I also test you know how I can counter treating you sheet pan but give you a technical pain our new sheet our yoni and then to say if you respond to a sheet pan if you respond to hit pain you were highly likely acupuncture will also relieve your knee pad that is what we told them and so the design is these are a 3m study and in session one we use this expectancy manipulation mode opinion make them believe acupuncture work and then they all receive one month of acupuncture treatment for their knee pain the after mark one month we actually debrief them we told them we in this puts acupuncture group we actually low the temperature but we also told them that if acupuncture really work to relieve any pain that really that effect should continue then we gave another additional one month of treatment to test after debrief will that effect remain so in the standard acupuncture treatment groups the all the treatment is the same we even gave them identical pain it has a boost acupuncture group by the way inform them after insertion while after two men we reload the temperature we say that have no relation with acupuncture we just want to English how your brain responds with different lengths and here is a clinical outcome which is a cruise pain some score and the bar are indicate improvement you can say after four week treatment we can say signe different between the standard acupuncture and the boost acupuncture group and then after debriefing you know after eight months after eight weeks we still can say the difference just keep in mind you know I don't the acupuncture is identical the only difference is we make them believe I can puncture really closely their expectancies beginning of this treatment so then why is happened so what happened a brain so the basically are in recent years are many Syria Kosovo expectancy once I think it's very interesting is people believe that expectancy of pain relief needs and reward and also Rick accumulated evidence suggests both descending a modulation system and reward motivation motivation play are important to know in this pain modulation process so in this study we investigate the Russian state Russian state functional connectivity of our key region of reward network that is nuclear accomplice shown in two figures and we actually found that compared with standard acupuncture treatment the boost acupuncture can produce to give them more functional connectivity between these nuclear combats and the rostral SI SE and also this connectivity change is also associated ways there could pain rating increase so indicating you know they suppose these you know reward motivation process or connection because we you know we all know that it's our AC AC and mph they actually play important role in descending payment sister so this study indicates that our result indicates that connectivity between as a reward network and descending plane modulation Edwards was signature enhanced so um here the summary of this part of the work so basically we are try to say that is you know the treatment effect it but not only on the treatment self and also on the expectancy don't believe the positive x NC can enhance treatment and active expectancy we are inhibited treatment others our complicated by a very network involved in this process so the second part of talk I'm going to focus another example demonstration of the power mind or that is a imagery so in this study we invited energies effect produced by real an engine acupuncture why we're doing this because we we all know that acupuncture is great but acupuncture like other treatment there are some potential limitations for instance you have to go to the clinic reject acupuncture you know it's very hard to get appointment for very known and famous acupuncturist and also you know when you need acupuncturist but maybe they are not available and some people also afraid of needles so the aim of this study is to say if we can develop some supplementary treatment of the acupuncture so the rationale we did raising is because we do find research by previous study indicate if you experience pain and you will have a hope for night work evolved in over an area but if you see other people experience pain you bring it also responds and there is overlap between these two networks so we also know that Korea studies shows from both our group and other group that acupuncture stimulation provokes a widespread for an activation and deactivation so the question is if we do you say the needle stimulation on your own body and as you imagine we are stimulating your own body well that produced some purring activity which is overlap with a real acupuncture treatment and who will let produce some energies effect that is hypothesis we want to test so this study is again important our healthy subject and so this is our five session study we use section one to train the subject get familiar its environment understanding the procedure and then the patient randomized we received real acupuncture acupuncture imagine acupuncture and imagine acupuncture control so imagine acupuncture which recorded the wicked with a radio guided imagery acupuncture treatment we in session one we gave them our give them our Creed acupuncture exposure then we use iPhone to tape these treatment procedures and then in the imagine acupuncture treatment we show them video of 20 minutes acupuncture stimulation from time to time on their own body and the awesome to imagine that we were stimulating this area in this need so then in the control condition with just ulis what to do the same procedure as imagine acupuncture we just generally touch their skin to as soon imagine we're touching them and then before and after we actually married their pain threshold and say well the different treatment can produce different effect so um the first thing we say will that imagine acupuncture produce some sensations because the acupuncture researcher will also say this dirty sensation is important to acupuncture treatment and then we actually compare the d30 sensation we use this time we use the scale way developed record Massachusetts General Hospital acupuncture sensation scales and we actually found that you know for the average sensation of course real acupuncture proteus greatest sensation follow the by the Shan acupuncture and followed by the way gate and then followed by the Regan control birds singing difference between the way gate or imagine acupuncture and imagined acupuncture control it's it's a tiny or mild sensation but it's there and almost of people I can report some sensation even they are watching this video and imagine you know that so the next questions will that change our playing experience in this time we actually use both hip and Maryland principals hip answer I showed and also us the mechanical pencil and the we also married especially in post local where we apply the acupuncture which on their leg and also decent area on the contralateral side of their forearm on male and we actually found that for the mechanical pencil both Eastern and local and we found basically the imagine acupuncture and real pop acupuncture energy CA is almost the same there are no difference both is better than control conditions for the heat pain threshold and the way we've found significant difference between your initial acupuncture but we only found that trend for the imaginary puncture compared with imagine acupuncture control so then what happening in the brain so you owe this for treatment eventually the whole 20 mins treatment we actually used a my to scan their program and see their brain response and this leader program respond to different treatment the red color indicates a for my signal increase or activation the blue color indicates a for my signal decrease of the activation and you can see there's some overlap for deactivation here like anterior insula and also we defend some common area for my signal increase activation which is insular and also we use this arm out you are very tight analysis to explore the brilliant activity change and the energies in fact already detected we found actually all the response the insula was related to the mechanical pencil change Merrill in the leg and some for drill acupuncture and all response in the RACs a the same originally found in our first possible acupuncture study is actually associated with no pain threshold change lived in imagine acupuncture treatment and then we think it's very interesting because this modulation in fact of the rsam PSA may indicate lot of potentials because this air is not only our period of the formal network dissonant pain modulation system and also recent study have shown this edge actually are involved in in your pathology of the chronic pain there are many studies on this topic this is just one example one study from our lab we actually found the connectivity it's area visit other different network was altered impatient rates of chronic low back pain patient and also here is another study we'll use a different method again we found the both active current activity and the structure of this are a CA and MKC or changed compared housing subject which indicated maybe a lot of control potentials for this we get for the treatment of chronic pain and also we have this by-product or of treatment okay so then they study so we because we use across over Geelong and then because then we can you know you know compare real on the shank of hunger we know the real acupuncture admitted fact and then we want to take one to G to investigate if the caffeine can modulate the apartment just in case enough familiar with this story is in 2010 there's a Nature Neuroscience paper indicating that adenosine mediating effect of acupuncture and then after that there's a news in nature someone said if config caffeine plot and then as the receptor then I should be able to block acupuncture energies effect when there are two animal studies I'm sure that actually caffeine intake can modulate the acupuncture and no TV in fact and then in they study we also measured their caffeine intake and duration your question there and then we you dismiss model regression to invited it you know you have an intake I influence analgesic effect because we think it's important some acupuncturist start telling the subject or patient do not drink coffee people they come to clinics and so we're at you found that the duration of a caffeine consumption daily consumption amount and daily amount of duration all not associates the country daily caffeine intake indicated at least maybe that daily intake every half a mil not influence the acupuncture and oh geezr in healthy subjects so then we also you know compare the you know high dose and low dose of caffeine intake and also from no singing difference and then why that's a case so our interpretation is you know attendance there may be just one of the many acupuncture and also because all these animal studies actually use the acupuncture needle for human beings I be thinking if you compare the body surface of the rat and human being you will say big difference I think that invasiveness is important for the country in Beijing in fact of you tithing in the rack and finally I just take 2-3 mins quickly go through some title study we did mine for the intervention which is Tai Chi and this time we will focus on fibromyalgia and the Tai Chi is because you know there are two study from dr. Baumann child here in the audience from parsley demonstrated that you know tightly actually Kyrie leaves the symptoms of patients with femoral earlier so the question will be why why and then this is a very pilot study we actually recruit 24 patient and 24 healthy controls and then this is a single arm study by only scanned from a signal change before and after Tai Chi treatment there is no control group and then we found that after three months of Tai Chi practice we say significant clinical pain symptom relief in this patient and then we want to know which is repeat of her previous study some new questions why this happened so the challenges are different it's really about the mind-body the one I like the most is from the family and molecules the basic say there's three mechanisms for this mind body one is attention control line is emotion regulation and why is self-awareness and here's another study from the can see push no they also emphasize - this is from 944 chronic pain she actually emphasized to maximize attention modulation wise emotion modulation which is two of them in moderate where in Syria also press professor talents I just mentioned so then in they study we actually choose one region of interest that's the dorsal lateral prefrontal area because this area is not only involved in attention control but also in world in the emotional regulation and then we say you know what happened compared to this difference before and after tai chi and as well as how's it different from the healthy control so the resulting is the interesting that is quite a surprise the reason I say is surprising because we first compare their productivity change between the Fabri manager patient and a control we actually found that the connectivity in the patient between the dlp of say and this RSA saying if they increased so the after Tai Chi practice we we were expecting that connectivity you know decreased or normalized and actually we found is a further increased which is a big surprise to me and then we're still trying to say what does that mean but here is our hypothesis we believe this may indicate a phenomenon of these hello spaces so so the basically a dimension of beginning our human body to have this ability of self modulation and then when we have the Fabri manager or without any treatment our brains start this self-regulation process already and the indicate in has made between this do pmc and the glossary CC and then after this piety or tality or maybe other treatment just a way to further enhance this self-regulation projects so that's why after tidy you know will not be touching anything in connectivity crease rather it's an increase and also this is consistent with previous studies indicating the important roles ethiopian say in pain modulation process and also consistent with our previous study rates showed that first you know there's connectivity between our SI SE and the Phe our key region in different implementation system and also fibromyalgia patient and was associate away is a brain function and structure change in this area and then one thing is you know we do the brain imaging study we know when the design become complicated or when the treatment in world it's very hard to replicate findings and but fortunately another cohort study this is a study with collaborative radar Fujian University in China and then we actually found them after three months of Taiji and poverty in treatment of unio a with different population and we also found that the resting state connected between the do PFC and this are a CSA were increased which is consistent with what we found in this tidy treatment of fibromyalgia patient and finally I just briefly mentioned I know I don't have time e1y is a very interesting recently is well differed mind-body interventions work through the same magnesia this is a recent study we published basically we compared the you know when the relation factors would be formal network by post IG and packaging to popular mind-body exercise that you found different mechanism in this process indicating I think it's open a lot of potentials indicating we make you know individualized or modified different mind-body treatment for different individuals so this is summary of my talk basically we have mine we have body and like in and young and also so we can use this important protein modulation like acupuncture tensed of physical exercise we enhance our mind modulate our mind and also we can use this top-down modulation expectancy believe imagery to modulate our 40 and then we have also have some this direct interaction between the mine and the mobile body and sorry and brain play important role in this process linking this to important part and like to take the chance to thank all of my collaborators post our research assistant and students and also general support from h and thank you of irritation [Applause] so that was a fabulous talk thank you dr. Kong and you can tell he's been very busy these are really elegant studies done rigorously with large teams of people and I know if you notice many of them were published in the last year or two so you've been a very busy person so I'm wondering um you will intense lessons some questions from the audience hey good morning thank you for a wonderful talk I am just kind of curious what you think the clinical implications are in terms of so I'm an acupuncturist Boston Medical Center and we work with chronic pain groups so how can we condition our patients to expect a better outcome thank you this is a great question that's actually we're thinking you know how to what we should do to enhance treatment in fact something I did not mention we also tried this enhances doctor-patient relationship by its contact modulation and for instance feel the pulse and sure MC and we enhance the you know the doctor-patient relationship and on chronic low-back and patient unfortunately we failed we found this contact manipulation does not enhance or treat in fact the question is you can still try but you know just single for any way you can enhance expectancy that's the only thing I can tell sorry cannot don't have other information yeah thank you and I follow up on that yeah and um as you know in in in these mind-body practices one of the roles of the teacher is to enhance expectancy and even the Taichi classics say your mind or your Yi moves your Chi and your Chi moves your body so you tell people to look for feelings and I'm wondering in your research you're one of your main points is that some of what's happening is expectancy and top-down but some of it is actually moving the body or physical manipulation with needles have you started to think about how you might explore the role of intention versus just physical exercise in understanding the sort of neural basis of things like high G and audre gin as compared to for example you have the cycling example there yeah so actually we found actually thank you for the question the first thing is expectancy is important if I was thinking mind-body interventions I hear mindfulness I think it's attention control and the emotional regulation is more important in my opinion and particularly when you have the chronic pain you just keep sinking you know this pain condition and anxious and vanity actually is a distraction of focus too from this pain suffering to some other part like yes when the flow of the Chi and your body postures that's really important it's a tension actually this shift changes a whole network coherence of the body and also that actually can modulate the emotion process and just mentioned this do people say actually can it's clear written for both dissonant pain modulation attention control and the emotion modulation and so that I do think that attention control but I would imagine that there's some kind of synergy between just doing a psychotherapeutic mindfulness and doing that with the movement yes exactly so you can say here interest yeah there's some common Network but we also found actually we also have some inflammation marker and showed actually the exercise can produce the greatest change in information markers compare the way is my body which I think it's less intensive I think of the post counts for each of these mind-body information including the exercise hi great talk I'm interested in chronic pain because I'm a clinician and it seems like we're in an epidemic of non-communicable chronic diseases and probably everybody over 40 you could say has either some kind of joint pain some kind of back pain or some kind of head pain head and neck half the population probably fix that and they have pain for years and it's often episodic and I wonder if any of the studies point to long term pain it would be wonderful to know to be able to say to someone you're gonna need acupuncture once a month for the next 20 years but it'll work or we don't have any information like that so is there anything is there anybody looking at episodic chronic pain and following people for say more than a year I don't know we didn't do that sorry sorry the we only did for two months and then for this mind-body interventions study with collaborating weights from the University and it's I think it's a three months so maybe talk laundry training you study is a strip with three months or full up for another three months half a year right so yeah yeah six months total so that's maybe six month I don't know any studies longer than six months maybe it turns in there sorry I didn't well as I have to say something yeah the study we mentioned about document it's not a new way compromise is studying what compare five different dosage and Taichi for two weeks twenty four weeks once week twice a week compare the standard aerobic exercise actually would do fine the longer study and patient practice more twenty four weeks get much better and without reduced pain anxiety depression quality life similar everything so currently there's not enough not insufficient evidence for long term and my body study supporter only short-term shorten and studying as support can reduce pain improve her life but for our study we do finally six months and it seems much better but as a longer practice will follow-up one year the longer practice seems a much better take advantage of results yeah we talked thank you i I know in the acupuncture literature a variety of different types of sham acupuncture have been used some of which are thought to perhaps be a little bit more active than others and I'm wondering if you notice differences in brain activation depending on the type of sham that's used if you've looked at that at all so we we always use a striper of a needle at a sham point so that is pretty much our standard sham procedure so we sorry we showdowns already now compare yeah yeah yeah we believe that a better Shan I'm curious if you mentioned and I think in your last slide you've put in tens as is it another one from bottom up oh okay this one I'm right ten yeah yeah so so I'm curious it actually made me think about you know have you studied electro acupuncture versus sort of stand on your chair as well as just thinking about like moxa and how it's used and that creates is that Max's effect an expectation versus or is there something additional yes thank you so we did some study to compare electro acupuncture and the menu acupuncture we did found the upper response is different and also the crossover design indicates some money we tend to respond to menu and someone control electro so the making is different we did not have compared to the master we never we do not have a chance to do any post Bastian study hi I'm the Reiki coordinator here at Brigham and Women's and I'm curious if you've had any attention at all from early education folks and if mindfulness meditation Tai Chi and other types of all kinds of things like that are started at an early age you know have people come forward tell me more because I'm in early education and I would like to start this at an earlier age yes I I know some study the planning to do some less mind-body in patient with ocular and also I know some group in China is doing some Tai Chi in you know teenagers to you know do something I know yeah there's some study on in college student teenagers and maybe child on going in there I think they have a different he has a combination you know that's Kendall stuff yes there's something going on there I'm not you know I don't have any close connection made not yeah well thank you again for such a fabulous and provocative presentation please join me in thanking dr. Kong [Applause]