Nonpharmacologic Modalities Research Articles

Optimal Perioperative Pain Management of the Transgender Patient for Gender Affirming Surgery: A Scoping Review.

As we increasingly encounter transgender patients in the perioperative setting, it is important to be cognizant of appropriate medical management of the transgender patient. There is limited literature on the appropriate perioperative techniques to implement for adequate pain control in the transgender patient presenting for gender affirming procedures. In this scoping review, the authors identify publications that address perioperative pain control techniques that can be implemented by the anesthesiologist such as regional anesthesia, multimodal medications, or non-pharmacologic modalities. This scoping review included two retrospective reviews, two case reports, and one letter to the editor. There are no prospective, randomized controlled trials on this topic. The limitations of this scoping review include the limited publications that are available to analyze as this is a growing area of medicine. There are numerous variables that may play a factor in the pain experience of the transgender patient including biological factors, psychological and social factors. Techniques that are necessary for comprehensive pain management include pharmacologic, injections, physical therapy, acupuncture, massage, and more. There are limited publications on the comprehensive pain management of the transgender patient; therefore, the authors advocate that as perioperative physicians, anesthesiologists implement comprehensive preemptive analgesia techniques to avoid progression to chronic pain. Clearly more research is necessary to standardize acute pain management techniques in the transgender patient.

Advances in Local Anesthesia and Pain Management for Practicing Dentists: A Comprehensive Review

One of the most frequent problems that patients bring to a dental clinic is pain in the orofacial region or within the tooth. To identify and solve the issue, a proficient practitioner needs to be equipped with the necessary information and resources. Comprehending the history of pain control in dentistry can provide valuable understanding into the development of the present techniques. Newer and more effective pain management treatments have been created as dentistry continues to advance. Several modalities have been developed to reduce and eliminate this, including pharmacological and non-pharmacological treatment modalities. The goal of the present review of the literature's findings is to provide dentists with reliable information regarding the application of contemporary local anesthetics, alternative methods, and strategies to reduce pain during anesthesia administration, thereby improving patient comfort. Keywords: Local Anesthesia, Anesthetic Agents, NSAIDS, Lignocaine, Management, Pain Control

Interventions for pediatric asthma a literature review of efficacy and safety in pharmacological and non-pharmacological modalities

Asthma continues to be a major global health concern due to its related morbidity and healthcare utilization, especially in children. Pharmaceutical treatments are crucial for managing asthma, but non-pharmacological therapies are now increasingly recognized for their complimentary benefits in enhancing quality of life and lowering medication reliance. This review examines the many methods for managing asthma that involve both non-pharmacological and pharmacological techniques. The review underscores the significance of environmental triggers, including dust mites, pet dander, and mold, and shows practical strategies for mitigating allergy symptoms and adjusting living environments. It also covers how enhancing indoor air quality using smoke-free zones and HEPA air filters might lessen asthma attacks, particularly in kids who are exposed to secondhand smoke and urban air pollution. The objective is to maximize the care of asthma and reduce the worldwide prevalence of this chronic respiratory disorder by implementing comprehensive approaches that incorporate both non-pharmacological and pharmaceutical interventions.

Low-carbohydrate diet as a disease modifier for relapse prevention of treatment-resistant depression. Spotlight on neuroplasticity and brain-derived neurotrophic factor

Depression is the most common mental disorder with a high treatment resistance rate that can affect patients at any age. Individuals who obtain insufficient and unsatisfactory responses after two treatment steps are considered as treatment-resistant-depression (TRD), and therefore seek other both pharmacological and nonpharmacological modalities that may offer not only alleviation of depressive symptoms, but also prevent relapse of the disease. Dietary interventions, whether focusing on supplementation or dietary restrictions seem to match these criteria. Low-carbohydrate-diet (LCHD), which is a close family to ketogenic diet, has been shown to improve neuroplasticity by increasing production of brain-derived neurotrophic factor (BDNF) that has been decreased in patients with depression, yet naive to depression treatment. Furthermore, links between neuroplasticity deterioration and diet rich in sweetened beverages have been demonstrated as impaired cognitive performance and increased risk of depression. Here, we hypothesize that BDNF could be the common end-point intervention in TRD, that could be relatively easily achieved by reduction in carbohydrate consumption.

Effects of an integrative multimodal inpatient program on fatigue and work ability in patients with Post-COVID Syndrome-a prospective observational study.

Post-COVID syndrome (PCS) is characterized by a variety of non-specific symptoms. One of the leading symptoms is fatigue. So far, there is no evidence-based causal therapy established and treatment of PCS is primarily symptom-oriented. The Clinic for Internal and Integrative Medicine in Bamberg, Germany, offers a comprehensive multimodal integrative inpatient therapy for PCS patients. Within a prospective uncontrolled observational study, the results of N = 79 patients were analysed. Post-COVID fatigue patients were hospitalized for up to 14 days. The treatment consists of individual modules depending on the patient's needs. It includes a wide range of integrative non-pharmacological treatment modalities. Outcomes were assessed before and after the inpatient treatment as well as 6 months after discharge from the hospital. Results show that fatigue of post-COVID patients in this study (M = 76.30, SD = 10.18, N = 64) was initially significantly higher than in the subsample "women aged 60-92years" of the general German population (M = 51.5, Schwarz et al. [Schwarz et al. in Onkologie 26:140-144, 2003]; T(63) = 19.50, p < .001). Fatigue was significantly and clinically relevant reduced directly after discharge (MT1 = 76.21, SD = 11.38, N = 42; MT2 = 66.57, SD = 15.55, N = 42), F(1, 41) = 19.80, p < .001, partial eta squared = .326, as well as six months after discharge (MT3 = 65.31, SD = 17.20, N = 42), F(1, 41), p < .001, partial eta squared = .371. Additionally, self-reported ability to work (NRS, 0-10) improved significantly from admission (MT1 = 2.54, SD = 2.23, N = 39) to discharge (MT2 = 4.26, SD = 2.60, N = 39), F(1, 38) = 26.37, p < .001, partial eta squared = .410), as well as to six months later (MT3 = 4.41, SD = 3.23, N = 39), F(1, 38) = 15.00, p < .001, partial eta squared = .283. The study showed that patients suffering from chronic post-COVID syndrome for several months can achieve a significant improvement in their leading fatigue symptoms and a significant improvement in the subjective assessment of their ability to work through a comprehensive two-week multimodal integrative inpatient program.

Evidence-Based Review of Nonsurgical Treatments for Knee and Hip Osteoarthritis.

Knee and hip osteoarthritis (OA) are highly prevalent joint diseases that lead to chronic pain, disability, and increased mortality. In this review, we provide a summary of nonsurgical treatments available for knee and hip OA that have evidence to support their use. We also provide a summary of the treatments available for knee and hip OA that do not have sufficient evidence to support their use. Treatments covered in this review include pharmacologic and nonpharmacologic modalities. Cite this article as: Misra D, Felson DT. Evidence-based review of nonsurgical treatments for knee and hip osteoarthritis. Eur J Rheumatol. Published online March 25, 2024. doi: 10.5152/ eurjrheum.2024.22096.

Menstruation-Related Angina-The Wee Hours.

Literature reveals two kinds of menstruation-related anginas-cardiac syndrome X (CSX) and catamenial angina. CSX generally occurs in perimenopausal or postmenopausal women; catamenial angina affects females from puberty to menopause with existing/preexisting or predisposed to coronary artery disease. CSX involves recurring anginal-type retrosternal chest pains during exercise or rest with no significant findings on angiogram. Catamenial angina is menstruation-associated recurrent nonexertional left-sided chest pain alongside diaphoresis, hot flushes, and persistent lethargy. Pathophysiology of both anginas revolve around decreased levels of estrogen. Estrogen is known to act via genomic and nongenomic pathways on cardiomyocytes, endothelial cells, and smooth muscle cells to exert its cardioprotective effect. These cardioprotective effects could be lost during the postovulation phase and at the end of menstruation as well as during perimenopause or menopause owing to the decreased levels of estrogen. Evaluation should begin with a history and physical examination and focus on noninvasive tests such as exercise tolerance test, electrocardiogram, and echocardiogram. Reducing symptoms that cause discomfort and improving quality of life should be the main goal in management. Nitrates along with β blockers and analgesics for pain are the main pharmacologic modalities. Exercise training, smoking cessation, weight loss, and dietary changes are nonpharmacological modalities. Proper awareness and effective communication with patients or caregivers can lead to early diagnosis and treatment initiation.

Virtual Reality is Beneficial in Decreasing Pain in Laboring Women: A Preliminary Study

(Aust N Z J Obstet Gynaecol. 2023; 63: 193–197) Labor pain is a highly variable experience, with a wide range of both pharmacological and nonpharmacologic methods available to help relieve pain during labor. Virtual reality (VR) distraction therapy is one of many nonpharmacologic modalities shown to assist patients in managing their acute pain in clinical settings. This has been tested in patients undergoing chemotherapy, physical therapy, treatment for dental work, and burn wounds, among other procedures. Those who use VR technology wear a headset to experience a 3D multisensory virtual world. Four published quantitative studies to date have used VR to determine the influence of VR on laboring women’s pain scores. This preliminary study is an open-label, randomized, controlled cross-over trial to examine how effective VR is in decreasing pain in laboring women.

Insights into the management of Lewy body dementia: a scoping review.

Lewy body dementia (LBD) is situated at the convergence of neurodegenerative disorders, posing an intricate and diverse clinical dilemma. The accumulation of abnormal protein in the brain, namely, the Lewy body causes disturbances in typical neural functioning, leading to a range of cognitive, motor, and mental symptoms that have a substantial influence on the overall well-being and quality of life of affected individuals. There is no definitive cure for the disease; however, several nonpharmacological and pharmacological modalities have been tried with questionable efficacies. The aim of this study is to figure out the role of different interventional strategies in the disease. Donepezil, rivastigmine, memantine, and galantamine were the commonly used drugs for LBD. Together with that, levodopa, antipsychotics, armodafinil, piracetam, and traditional medications like yokukansan were also used, when indicated. Talking about nonpharmacological measures, exercise, physical therapy, multicomponent therapy, occupational therapy, psychobehavioral modification, transcranial stimulation, and deep brain stimulation have been used with variable efficacies. Talking about recent advances in the treatment of LBD, various disease-modifying therapies like ambroxol, neflamapimod, irsenontrine, nilotinib, bosutinib, vodobatinib, clenbuterol, terazosin, elayta, fosgonimeton, and anle138b are emerging out. However, there drugs are still in the different phases of clinical trials and are not commonly used in clinical practice. With the different pharmacological and nonpharmacological modalities we have for treatment of LBD, all of them offer symptomatic relief only. Being a degenerative disease, definite cure of the disease can only be possible with regenerative measures.

Digital Therapeutics for Improving Effectiveness of Pharmaceutical Drugs and Biological Products: Preclinical and Clinical Studies Supporting Development of Drug + Digital Combination Therapies for Chronic Diseases.

Limitations of pharmaceutical drugs and biologics for chronic diseases (e.g., medication non-adherence, adverse effects, toxicity, or inadequate efficacy) can be mitigated by mobile medical apps, known as digital therapeutics (DTx). Authorization of adjunct DTx by the US Food and Drug Administration and draft guidelines on "prescription drug use-related software" illustrate opportunities to create drug + digital combination therapies, ultimately leading towards drug-device combination products (DTx has a status of medical devices). Digital interventions (mobile, web-based, virtual reality, and video game applications) demonstrate clinically meaningful benefits for people living with Alzheimer's disease, dementia, rheumatoid arthritis, cancer, chronic pain, epilepsy, depression, and anxiety. In the respective animal disease models, preclinical studies on environmental enrichment and other non-pharmacological modalities (physical activity, social interactions, learning, and music) as surrogates for DTx "active ingredients" also show improved outcomes. In this narrative review, we discuss how drug + digital combination therapies can impact translational research, drug discovery and development, generic drug repurposing, and gene therapies. Market-driven incentives to create drug-device combination products are illustrated by Humira® (adalimumab) facing a "patent-cliff" competition with cheaper and more effective biosimilars seamlessly integrated with DTx. In conclusion, pharma and biotech companies, patients, and healthcare professionals will benefit from accelerating integration of digital interventions with pharmacotherapies.

Engagement in Integrative and Nonpharmacologic Pain Management Modalities Among Adults with Chronic Pain: Analysis of the 2019 National Health Interview Survey.

To examine variables associated with engagement in (1) integrative health and medicine (IHM) and (2) nonpharmacologic modalities rather than opioids among United States adults with chronic pain. Using the 2019 National Health Interview Survey, we examined sociodemographic, pain, and mental health predictors of (1) the sum of IHM modalities (ie, chiropractic care, yoga/Tai Chi, massage, or meditation/guided imagery) used to manage pain and (2) exclusive engagement in nonpharmacologic pain management modalities (ie, IHM, a chronic pain self-management program, support groups, or physical, rehabilitative, occupational, or talk therapy) or opioids in the past 3 months. Metropolitan residency, higher family income, higher education levels, increased number of pain locations, and increased frequency of pain limiting life/work activities were associated with increased odds of IHM engagement. Older age, male sex, non-Hispanic Black/African American race/ethnicity, and daily opioid use were associated with decreased odds of IHM engagement. Older age, male sex, and increased depressive symptoms were associated with decreases in the count of IHM modalities used to manage pain. Metropolitan residency, higher family income, and higher education levels were associated with increased odds of exclusive nonpharmacologic modality engagement. Older age and increasing frequency of pain limiting life/work activities were associated with decreased odds of exclusive nonpharmacologic modality engagement. We identified several contrasts between factors prevalent among individuals with chronic pain and factors associated with engagement in nonpharmacologic and IHM modalities. These results support efforts to address barriers to accessing these modalities among subpopulations of adults with chronic pain (eg, older adults, individuals identifying as Black/African American, rural residents, and those with lower levels of education and income).

Therapeutic Potentials of Near-Infrared II Photobiomodulation to Treat Cerebrovascular Diseases via Nitric Oxide Signalling.

Endothelial dysfunction featuring insufficient endothelial nitric oxide synthase (eNOS) and accompanying nitric oxide (NO) deficiency is implicated in the pathogenesis of cardiovascular diseases. Restoring endothelial NO represents a promising approach to treating cerebrovascular diseases, including stroke. Low-power near-infrared (NIR) light shows diverse beneficial effects, broadly defined as photobiomodulation (PBM). The literature reports that PBM increases bioavailable NO. These lines of evidence indicate that PBM could be used to treat cerebrovascular diseases. Recent investigations revealed that PBM improved stroke outcomes in animal models via augmenting NO signalling and other pathways. However, clinical trials of PBM using NIR light in the NIR-I window (630-900nm) have yet to demonstrate the beneficial effect of PBM on ischaemic stroke. Since NIR light in the NIR-II window (1000-1700nm) with the largest penetration depth into tissues compared to NIR I has also been reported to augment NO bioavailability and cerebral blood flow ameliorating stroke injury, PBM using NIR-II light may be suitable for therapeutic use. This new non-pharmacological modality using a physical parameter of NIR-II laser could provide a new avenue for therapeutic strategies for cerebrovascular diseases. Since impaired NO production has been associated with neurological abnormalities, this novel therapeutic approach could be broadly explored to treat various disease conditions such as traumatic brain injury, stroke, and Alzheimer's disease. This review summarises recent findings on PBM in treating stroke and discusses its potential to treat other neurological diseases.

Effect of pranayama on pulmonary functions and heart rate variability in patients with mild-to-moderate persistent bronchial asthma

Background: The global burden of bronchial asthma is on the rise. Asthma is a disorder of airflow obstruction associated with deranged pulmonary functions and autonomic imbalance. Though past studies have shown the beneficial effects of various asanas and breathing exercises in bronchial asthma, the role of such non-pharmacological alternative modalities in reducing morbidity and financial burden in patients is far from clear. Aims and Objectives: To assess the effect of Pranayama techniques on pulmonary functions and heart rate variability parameters in bronchial asthma patients. Materials and Methods: In our present study, we have recruited patients with mild-to-moderate bronchial asthma after taking written and informed consent. These patients were then asked to perform three pranayama techniques, namely Suryanadi, Bhastrika, and Kapalabhati pranayama, for 30 min a day, 3 days a week, for up to 4 weeks. Pulmonary function test parameters (forced vital capacity [FVC], forced expiratory volume in 1st s [FEV1], FEV1/FVC, peak expiratory flow rate) and Autonomic function test parameters (Time domain: mean HR, mean RR, NN50, pNN50, SDNN; Frequency domain: very low frequency (LF), LF, LF/high frequency (HF) ratio, total power) were compared before and after the intervention using a paired t-test. Results: After the intervention, improvements were recorded in pulmonary functions. Furthermore, pranayama was found to cause a shift in the sympathovagal balance toward the parasympathetic system. However, the changes recorded were not statistically significant. This shows further research in this field is required with a larger sample size, which may yield statistically significant data. Conclusion: Thus, we conclude that pranayama can be a useful alternative therapy for reducing morbidity and mortality in bronchial asthma patients.

New Findings and Emerging Trends in Postpartum Mental Illness: Risk Factors and Treatments

Research on postpartum depression and co-occurring conditions, such as anxiety and posttraumatic stress disorder (PTSD), continues to accumulate at a rapid rate, with recent identification of new risk factors and treatments. This article highlights these recent findings. Recent studies have identified several groups of women more at risk for depression postpartum: women in the military; refugees, asylum seekers, and immigrants; women who gave birth during COVID, and women who smoke. In addition, there are several emerging treatments for depression that are promising that include non-pharmacologic and pharmacologic modalities. Among the non-pharmacologic treatments are acupuncture and repetitive transcranial magnetic stimulation (rTMS). New medications include ketamine and esketamine, and brexanolone and zuranolone. All these medications reduce symptoms quickly and have been approved to treat severe depression. Ketamine and esketamine have been approved for depression in general, while brexanolone and zuranolone specifically treat postpartum depression.

Effects of adjuvant yoga therapy on craving and perceived stress in alcohol dependence syndrome: A randomized control study

Abstract Introduction: Alcohol dependence syndrome (ADS) is a global health concern that causes a significant disease burden, with harmful alcohol use responsible for 2.5 million deaths annually. Stress is a known trigger for alcohol relapse, and effective management of stress can improve treatment outcomes in individuals with ADS. Materials and Methods: This randomized control study evaluated the effects of adjuvant yoga therapy on craving and perceived stress in 80 individuals with ADS undergoing deaddiction treatment. The yoga group received yoga therapy three times a week for 2 months in addition to medical management, while the control group received standard medical treatment. The Alcohol Craving Questionnaire and Perceived Stress Scale were administered before and after the study period. Results: The yoga group had significantly lower levels of alcohol craving (P &lt; 0.001) and perceived stress (P &lt; 0.001) as compared to the control group. Changes in those receiving additional yoga were more pronounced, and the intergroup differences were highly significant. Yoga induces a sense of self-discipline and relaxation, which may have contributed to these positive changes. Conclusion: Yoga therapy may be a valuable adjunct to deaddiction therapy for individuals with ADS, offering a cost-effective and safe nonpharmacological modality to reduce craving and perceived stress. Further research is needed to explore the long-term effects of yoga therapy on alcohol craving and stress in individuals with ADS.

Introduction.

Atopic dermatitis (AD) is a chronic relapsing condition that is characterized by itching and redness of the skin. Our modern usage of atopic dermatitis dates back to 1933, when Wise and Sulzberger first coined the term to signify the disease's close association with other respiratory atopy, such as bronchial asthma and allergic rhinitis. A recent systematic review of 69 cross-sectional and cohort studies has confirmed that AD is now a worldwide phenomenon with lifetime AD prevalences of well over 20% in many affluent country settings. Although there is no obvious consistent overall global trend in the prevalence of AD, studies have shown that climate, urbanization, lifestyle, and socioeconomic class influence the prevalence of atopic dermatitis. Despite the pervasiveness of the disease, an understanding of atopic dermatitis has been hampered by a number of factors. Data suggests that extrinsic environmental factors work in concert with intrinsic immune mechanism and genetic factors to drive disease progression. With such a complex etiology, management of atopic dermatitis currently at best achieves symptomatic control rather than cure. This approach poses a significant burden on healthcare resources, as well as patients' quality of life. Current management methods of AD often involve a combination of non-pharmacologic modalities and prescription medications. Though they can be effective when employed, there are significant barriers to treatment for patients including time, costs, and medication side effects. Our aim, throughout this text, is to explore the complexities of AD, providing the healthcare provider with tips and tricks to improve patient care and satisfaction and the most current trends and treatment approaches on the horizon.

A comprehensive overview of post-stroke depression treatment options.

Nearly one-third of all stroke patients develop depression at any time after a stroke, and its presence is associated with unfavorable outcomes. This narrative review aims to provide a synopsis of possible pharmacological and non-pharmacological treatment modalities for post-stroke depression (PSD). Several studies have demonstrated the efficacy and safety of selective serotonin reuptake inhibitors in treating the symptoms of this clinical condition. The treatment of PSD has been recently enhanced by innovative approaches, such as cognitive-behavioral therapy, virtual reality, telehealth, repetitive transcranial magnetic stimulation, and non-conventional therapies, which might improve depression treatment in stroke survivors. Future high-quality randomized controlled trials are necessary to confirm this hypothesis.

Mapping Evidence-Based Non-Opioid and Non-Pharmacological Pain Management Modalities Across Minnesota: The Non-Opioid Pain Alleviation Information Network Project.

Objective: The Non-Opioid Pain Alleviation Information Network (NOPAINMN) project was designed to identify, consolidate, and map evidence-based non-opioid and non-pharmacological pain management complementary and integrative health (CIH) modalities for chronic pain management across Minnesota into a searchable and informational website (www.nopainmn.org ). Methods: The Academic Consortium for Integrative Medicine & Health's Pain Task Force White Paper identifying evidence-based research of non-pharmacological pain practice (NPPC) was reviewed and referenced. National and state certifying boards and accrediting organizations for NPPC modalities were accessed to identify Minnesota-based NPPC providers' name, business/health-system affiliation, address, contact information, and credentials. The NOPAINMN website displays these data in a consumer-facing website with searchable fields such as NPPC modality type, and location with varying distances. The website was β-tested by practitioners and stakeholders for optimization. Eight main NPPC modalities and their respective subcategories were identified and mapped: Acupuncture; Integrative Medical Care (Functional medicine consultation and Integrative medicine consultation); Massage Therapy; Mind-Body Therapies (Biofeedback, Clinical Hypnosis, Mindfulness-Based Stress Reduction, and Music Therapy); Movement Therapies (Tai Chi, qigong, and Yoga Therapy); Psychology (Cognitive Behavioral Therapy); Rehabilitative Therapies (Physical and Occupational Therapy); and Spinal Manipulation. Results: All information compiled resulted in 17,155 providers/practitioners. Physical Therapy had the greatest number of reported providers (n = 5224), followed by Occupational Therapy (n = 3792), Psychology (n = 3324), Chiropractic (n = 3033), Acupuncture (n = 591), and Massage Therapy (n = 544). The Resource Map included 56 major health systems, 686 facilities, 2651 solo or private group practices, and 14 academic training schools. With web-based cross-referencing, providers and facilities were affiliated and linked with health systems to produce an interconnected mapping system. β-Testing with patients found that the website was reported as relatively easy to use and informative. Conclusion: The website was created to assist individuals, health care providers, insurance carriers, and health care facilities in finding evidence-based information and resources on NPPC to guide, support, and proactively manage and engage chronic pain patients across Minnesota.

An Evidence-Based Treatment of Myofascial Pain and Myofascial Trigger Points in the Maxillofacial Area: A Narrative Review.

Myofascial pain (MFP) is characterized by localized pain in the maxillofacial region attributed to the presence of hypersensitive spots known as trigger points (TrPs). This condition is particularly prevalent in the maxillofacial area, warranting a comprehensive examination of evidence-based management techniques. This review aims to equip healthcare professionals with a more profound insight into evidence-based MFP management techniques, facilitating improved patient care and treatment outcomes. In this review, we conducted a thorough literature search using Google Scholar, Scopus, Web of Science (WOS), and MEDLINE, with the keywords "Myofascial pain syndrome," "Pain," and "Orofacial pain." Articles were selected based on their relevance to the study's objective. Pharmacological interventions, such as analgesics and muscle relaxants, are frequently prescribed. Additionally, a range of non-pharmacological modalities, including transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, topical applications, dry needling, TrP injections, oral myofunctional therapy, and stretching exercises, have demonstrated efficacy in MFP management. The authors hope to give clinicians a more thorough understanding of the therapies for MFP by conducting a rigorous evidence-based evaluation of pharmacologic and non-pharmacological treatments. Our findings support the use of a combined approach that integrates both pharmacological and non-pharmacological strategies for the holistic management of TrPs.

Dynamic meditation as a non-pharmacological treatment modality for chronic migraine

Dynamic meditation as a non-pharmacological treatment modality for chronic migraine