Measuring Immunity: Basic Science and Clinical Practice
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The content validity of the preliminary questionnaire was assessed by a panel of immunologists and a chiropractor. Each panel member assessed each scale item using 4 categories: The content validity index CVI for each item was derived by summing the values for each expert and dividing by the number of experts. Items with CVI in excess of 0. Factor analysis was used to explore the dimensionality of the questionnaire and reduce the data to extract the principal components.
A scree plot was generated and revealed 1 component with an eigenvalue of 1. Six out of 7 items strongly loaded on this component. Items with correlations greater than 0. Therefore, data from 6 multiple-choice questions MCQ were used in the analysis of immunology knowledge levels. Internal consistency was measured using Cronbach's alpha measurement. The validated questionnaire Appendix A was comprised of 6 MCQs to test students' retained knowledge and 3 questions on students' perceptions of the value of immunology knowledge.
Students were given 10 minutes to complete the questionnaire. Descriptive statistics were used to quantitate the mean scores of immunology knowledge and the level of agreement with statements regarding the value of immunology in chiropractic and the general population. Logistic regression was used to examine the association between the students' level of immunology knowledge and their perceptions of immunology. Binary logistic regression was performed with the dependent variable being the students' scores dichotomized into pass score of 3 or above out of 6 or fail score below 3.
The covariate was dichotomized data from a Likert scale question asking if students thought immunology knowledge was important to chiropractors. If students agreed or strongly agreed, data were coded to a number 1. If students were neutral, disagreed, or strongly disagreed, the data were coded to a zero. Internal consistency of the 6-question MCQ questionnaire was measured with Cronbach's alpha equal to.
However, post hoc power analysis revealed that with 90 participants in 3 groups, the study was underpowered at.
The immunology knowledge level of the fourth-year students was not significantly different from third- or fifth-year students. Mean score on the immunology knowledge test of chiropractic students in years 3, 4, or 5 of the Chiropractic Program at Murdoch University. Students' perceptions of the value of immunology knowledge to the chiropractic and general populations were examined Table 1.
Interestingly, 6 students believed that immunology knowledge is important for the general population but not for chiropractors. Only 1 student out of 28; 3. The other 27 out of 28; This is the first study to design a validated questionnaire to measure and compare the level of immunology knowledge in a population of chiropractic students 2 weeks, 1 year, and 2 years after completion of an immunology unit.
The study found that there was a significant difference of immunological knowledge between third- and fifth-year chiropractic students. While the immunology content taught to all 3 groups of students was identical, it must be acknowledged that the assumption being made is that immunology knowledge for all students started at a similar base immediately after completing the unit. The findings of the current study are similar to another study where medical students loss of immunology knowledge over 1 year was The difference in retained knowledge between third- and fifth-year students is possibly due to the absence of rehearsal or direct application of the knowledge.
Unlike the carpal bone study, 15 where initial learning was reinforced by clinical experience, there would have been little opportunity for the students in the current study to directly revisit the immunology knowledge they possess. The majority of students valued immunology knowledge and agreed or strongly agreed that it was important for the chiropractic and general populations. The proportion of students valuing immunology knowledge in the chiropractic population was significantly higher than the proportion of students valuing immunology knowledge in the general population.
Strength of agreement that immunology was important for chiropractors was not related to a high score on the immunology knowledge test. This is in contrast to the close association of immunology interest and knowledge proposed by Alexander and colleagues. The present study was cross sectional in nature and therefore did not measure the retention levels longitudinally in the same group of students. Increasing the number of MCQs would have increased the internal consistency measured by Cronbach's alpha of the questionnaire.
In addition, an exploration of the students' reasons for valuing immunology knowledge by using open-ended questions would have been an interesting addition. The study used a convenience sample limited by the total number of students able to participate enrolled in the unit and in attendance on the day the study was implemented. Ideally, a larger cohort might be used in future studies. Also, as previously, stated there is an assumption that all students start at a similar knowledge baseline.
This may be determined using a prestudy test. Perceptions of chiropractic students did not affect their score on the immunology knowledge test but did affect whether they applied their knowledge clinically.
Chiropractic students value the importance of immunology knowledge in chiropractic and general populations. This work was funded internally. The authors have no conflicts of interest to declare relevant to this work. National Center for Biotechnology Information , U. Journal List J Chiropr Educ v. Meyer , PhD, Barrett E.
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This article was received June 4, ; revised October 14, , and November 9, ; and accepted December 22, Attitude, Chiropractic, Education, Knowledge, Students. Development of the Instrument of Measurement A brief questionnaire was designed and consisted of 11 questions that tested students' immunology knowledge 7 questions and attitudes toward the value of immunology knowledge 3 questions for chiropractors and the general population.
Content Validity The lead author drafted 7 questions to measure immunological knowledge of students in alignment with the specific learning objectives of the unit. Factor Analysis and Internal Consistency Factor analysis was used to explore the dimensionality of the questionnaire and reduce the data to extract the principal components. A total of studies were selected for review.
Three hundred and forty were duplicates, were excluded due to outcome measures, 80 due to design, due to intervention, and 19 due to mind-body intervention being movement-based. In addition, one could not be located, and three could not be interpreted. One hundred and eleven studies with a total 4, combined subjects were reviewed to provide evidence regarding the state of research on mind-body medicine and immune outcomes included studies are listed after references.
The studies were published between and , with 47 studies published after Seventy-seven percent incorporated some method of blinding excluding pre-post studies. Sixty-seven percent incorporated one modality and the remaining used two or more e. Five studies were with children under 18 yrs of age. Among the subjects with chronic and acute disease, a diverse range of conditions was examined Table 3. Reporting of the actual intervention varied.
Seventy-five percent of the studies reported intervention session length, weekly frequency, and duration. Mean sessions were 78 minutes range 9— minutes with sessions ranging from 1 to 7 days per week, and interventions lasting 1 to 52 weeks long mean Ninety percent of the studies were controlled with a varying number of arms 74 with two arms, 22 with three arms, 2 with four arms, and two with five arms.
A majority of the studies with three arms had a no treatment and an active control group, while the remaining studies had two different active control groups. Fifteen studies with an active control group did not report control session details in terms of frequency and duration. Of those that did, the time for the active control matched the time for the intervention. The quality assessment items are listed in Supplemental Table A , along with the number of studies that included each criterion. The mean total quality scores representing different study designs were pre-post: Other study design category differences were not significant.
All assessed studies stated the purpose of the study, recruited subjects and collected data prospectively, and gave the total number of subjects. Ninety-seven percent of the studies defined the outcome variables prior to the study, asked suitable research questions, had standardized and consistent laboratory and other outcomes and described the evaluation methods adequately.
Ninety-three percent of studies used an appropriate treatment to answer the research questions, and clearly identified and appropriately used statistical tests. These particular studies were eliminated for a variety of reason. Some studies measured outcomes at inappropriate times, some had inappropriate outcomes for the disease studied, and others had protein levels that were significantly outside normal ranges suggesting mislabeled unit measures, or operator error.
Sixteen were assessed as unclear if appropriate and the rest were assessed as appropriate. Evaluating immune outcomes regardless of intervention type, only IgA demonstrated strong scientific evidence for positive effects resulting from mind-body interventions Table 4. IgA included both serum and saliva measures. When examined separately, only salivary IgA had positive evidence 7 positive, 1 negative, high quality studies whereas, serum IgA had negative evidence 1 positive, 3 negative, high quality studies Table 4D.
All other outcomes were scored unclear, conflicting, lacking evidence, or with negative evidence according to the grading criterion. Because the health of the subjects probably plays a large role in immune outcomes, grading was repeated separating healthy subject and patient population studies.
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Also, grading was repeated for all the studies, regardless of study quality. These additional assessments did not change the strength or direction of the evidence. The effect of interventions on all immune outcomes combined revealed that relaxation training had strong scientific evidence. Biofeedback, Humor, and Meditation lacked adequate data to grade due to a small number of studies included and all others had unclear or conflicting data Table 5. It was not surprising that relaxation therapy, CBSM, and hypnosis were the most studied as they have been practiced for a longer duration.
Music, disclosure, and humor were included as mind-body medicine based on the concept that their effects are mostly likely mediated through the mind however, there were limited studies on these interventions. During the literature search, studies on humor and music were unexpectedly found, although these search terms were not specifically included.
There was discussion within the team on whether to include the studies in the review. It was decided to include the studies although additional searches were not conducted to search for humor and music studies because it was not part of the original study design. As expected, most of the studies did not incorporate double-blinding in the traditional sense, where both the subject and investigator were blinded. The nature of mind-body interventions precludes blinding the subject to their group assignment. Efforts were made by most investigators to include some sort of blinding through data entry, laboratory personnel, and assessment.
Surprisingly, most studies did not include adverse events reporting. Whether this is because of a reporting failure or lack of adverse events is unknown. Even though mind-body medicine is a low-risk therapy, reporting adverse events data is essential. Approximately half of the studies utilized healthy subjects, which often results in negative trials. Interpreting efficacy from a negative trial using healthy subjects is problematic because the immune system response may be different in a healthy versus patient participant.
Regardless, no difference in evidence grades was found when healthy subject studies were graded separately from patient population studies. Often details of the actual intervention and home practice were not reported, nor were compliance measures assessed.
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Total exposure time may influence results and is important data to capture and should be reported in future studies. Many used an active and non-active control and when incorporated the active control group exposure time matched the intervention group time. For mind-body studies where placebo may play a pivotal role, both an active and non-active control group should be included Crow et al. The active control and non-active control group protocols should duplicate the time, attention, and home practice of the experimental group.
In this way, non-specific effects like placebo and expectancy can be assessed. Poor reporting was the major contributor in most quality score deductions. It is assumed that consent was obtained but was not reported, however, this is an unnecessary omission. Additionally, many studies did not report power calculations or rationale behind subject number. When a study does not report whether a power calculation was done or that adequate subject numbers were present to detect differences between groups, we must infer that these trials were not adequately powered or that they failed to report power calculations.
Either way, the reader is left with uncertainty. Pre-clinical studies not attempting to definitively assess efficacy may not need to report power calculations, yet the objectives of the study as a pilot should be clearly stated. Regardless of whether the improvement in study quality was a direct consequence of the publication or some other guidelines in quality study design and reporting, the results are hopeful. This study builds upon the Miller review by examining studies conducted through October , expanding the intervention categories, using alternative grading criteria, and contributing additional recommendations for future trials.
Meta-analytic methods were not used for this study because of heterogeneity not only between the intervention groups but also within the intervention groups. For example, relaxation training was held three times a week for 45 minutes for three weeks in one study and once a week for 20 minutes for four weeks along with focused breathing in another.
Even if these two studies had identical immune measures, the results could not be combined for meta-analysis because of the application differences. Comparisons may have been conducted if effect sizes were uniformly reported, but they were not. The study variability also highlights the fact that mind-body medicine research has a paucity of pre-clinical trials where dose response, optimal dose, and preliminary efficacy are established.
Investigators often attempt to conduct a Phase 3 definitive assessment of therapy efficacy in an under-powered RCT. Unfortunately, these studies undermine the field because they often yield negative results. Pre-clinical studies must be conducted to move the field forward. Most studies did not include power calculations and thus it is uncertain whether the studies could be considered definitive. Only IgA showed strong evidence for being affected by mind-body medicine.
This measure may not be ideal for every intervention or patient group but has shown strong evidence of effects resulting from mind-body interventions. Salivary IgA had positive evidence whereas serum IgA did not possibly reflecting the faster rate of change of salivary IgA and the less stressful collection method. Salivary IgA may be more reliable for mind-body intervention studies. Overall, relaxation training demonstrated the strongest evidence for a mind-body intervention to influence immune outcomes overall.
Incorporating some type of relaxation training into mind-body medicine therapies may help improve health outcomes through immune system mediation. Interpreting immune outcome results includes multiple factors to consider. The direction of change of the immune outcomes can be different for the same outcome with different populations.
Also, the immune outcome must be relevant to the research question and be able to be changed within the time-frame of the intervention. Immune outcome changes may differ in healthy versus patient populations and must be considered when making conclusions. Another issue in interpreting these findings is in the sensitivity, reliability, and validity of immune markers. Are the results of these studies truly negative due to lack of effect on immunity or because the markers employed lack sensitivity or are improperly used?
Some immune outcomes reliability and validity are not well-established and thus using these markers may not be viable. Immune markers are also influenced by nutrition, exercise, caffeine, sleep, and pharmaceuticals. The depth of controlling for or reporting these variables was limited in many of the evaluated studies. Further research is required to assess appropriate, sensitive, reliable, and valid immune outcome measures in mind-body medicine. Additionally, the immune outcome choice may not be relevant to the disease studied or sensitive to the intervention.
One major issue we experienced in conducting the review was the definition of mind-body medicine and which modalities should be included. Movement-based practices such as yoga and tai chi were excluded although some may argue that they should have been included in the study. However, the results would have been inconclusive because the immune changes may have been a result of the increased movement rather than the change of mental state.
Also, some modalities such as music and humor may not be considered mind-body medicine. Although they may change mental states for some, it arguable whether they are actually a mind-body medicine. Various biases must be considered when reviewing these results. There is a language bias in the study because although we attempted to include all languages we were unable to translate three of the articles and thus did not include them in the study.
There is also a possibility of publication bias as we only included published papers. We were unable to conduct a funnel plot analysis because the gradings were qualitative. Publication bias may be present although usually publication bias presents itself as greater positive trials being published rather than negative ones as was evidenced in this review positive and negative outcome measures. Another limitation of the study is its qualitative rather than quantitative nature. Ideally, a traditional meta-analysis would have been conducted. However, the extent of mind-body research is not yet vast enough to include multiple studies of similar design to allow for grouped analysis.
Because of this, the results from this study must be viewed with a cautionary note that these are observed qualitative trends rather than conclusions. In order to help improve future mind-body-immune studies, the following recommendations are made:. National Center for Biotechnology Information , U. Open Complement Med J. Author manuscript; available in PMC Dec 6. Author information Copyright and License information Disclaimer.
CR, Portland, Oregon , ude. The publisher's final edited version of this article is available at Open Complement Med J. See other articles in PMC that cite the published article. Summary This study is a systematic review of mind-body interventions that used immune outcomes in order to: Selection of studies Inclusion criteria included: Assessment of methodological quality Numerous authors have noted difficulty in finding appropriate quality assessment tools Juni et al.
Data Collection Uniformly trained research staff from the Helfgott Research Institute Portland, Oregon collected study data using a pre-tested data extraction form. Study Classification Twelve intervention study categories were developed Table 1. Table 1 Description, number of studies, and subjects in intervention categories. Category Description n of Studies Relaxation A therapy that promotes muscular and mental relaxation thought to increase parasympathetic activation and decrease sympathetic activation resulting in a slower heart rate, lower blood pressure, slower breath rate, and reducing muscle tension Benson, ; Jerath et al.
Open in a separate window. Evidence Grading Due to study heterogeneity, a meta-analysis was not possible. Lack of Evidence Unable to evaluate efficacy due to lack of adequate available human data. Table 3 Number of studies by condition. Quality Assessment The quality assessment items are listed in Supplemental Table A , along with the number of studies that included each criterion. Table 4 Strength of evidence for immune outcomes. Numbers in parentheses represent the number of outcomes in each category for all studies regardless of quality assessment score.
Table 5 Strength of scientific evidence by intervention. In order to help improve future mind-body-immune studies, the following recommendations are made: A new set of guidelines have recently been created for non-pharmacological treatments and is applicable to mind-body interventions Boutron et al. Create a dialogue with investigators studying similar interventions and attempt to create consensus on intervention session length, frequency, and duration through pre-clinical studies examining dosing parameters. Supplementary Material Supplemental Data Click here to view. References Ader R, Cohen N.
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