Objectives:Non-pharmacologic approaches are now considered best practice for the treatment of chronic pain. The purpose of this pilot study was to evaluate patient responses to a newly integrated clinic service called Mindful Awareness in Body-oriented Therapy (MABT) at a chronic pain clinic. MABT is designed to develop interoceptive sensibility for improved well-being and emotion regulation. Methods:A one-group repeated measures design was used to examine MABT referral and delivery follow-through feasibility and change on health outcomes among chronic pain patients. Upon referral, participants were scheduled for the MABT program involving eight individual sessions with one of the clinic massage therapists trained in MABT. Measures were administered at baseline, post-intervention (3 months) and at 6 month follow-up). Outcome measures assessed physical and mental health distress, interoceptive awareness, and emotional well-being. Analyses included descriptive statistics and repeated measures ANOVA. Results:Seventy patients were referred and 41 received at least one MABT session. Thirty patients (73%) completed the MABT intervention. Statistically and/or clinically significant improvements were identified for most subscales of the PROMIS-29 (the primary outcome), including Physical Function, Fatigue, Anxiety, Sleep Disturbance, Social Roles, and Pain Interference. Improvements in interoceptive sensibility and emotion regulation difficulties also demonstrated statistically significant and large effects. Discussion:This pilot study demonstrates the feasibility of MABT referral and delivery follow-through when delivered in a real-life context. Significant improvements with large effects on outcomes in response to the MABT intervention program offers a promising non-pharmacological approach for chronic pain patients.

Objectives: Pediatric chronic pain negatively affects emotional, psychological, and social function. This may be due to differences in interoception, the ability to notice and contextualize sensations arising inside the body, and alexithymia, the inability to identify and communicate emotions, as has been shown in adults. In children with chronic pain, interoceptive impairment include difficulties perceiving, interpreting, or responding to physical symptoms such as hunger or pain. Alexithymia symptoms include limited emotional vocabulary or reliance on complaining about physical symptoms to communicate emotional distress. Both alexithymia and interoceptive impairment could contribute to the development or maintenance of chronic pain and lead to issues with pain management. However, whether these are altered in pediatric chronic pain has not been investigated. Methods: The protocol was written prospectively and indexed online in the International Prospective Register of Systematic Reviews (PROSPERO; #42023439236). The literature search included the Cumulative Index to Nursing and Allied Health (CINAHL), PsycINFO, PubMed/MEDLINE, Scopus, and Google Scholar databases. Eligible studies included participants aged ≤18 years old with chronic pain conditions, assessed for symptoms of alexithymia or interoception. Study screening and data extraction were completed independently in duplicate. PRISMA guidelines were followed; the Newcastle-Ottawa Scale assessed risk of bias. Results: Fourteen studies assessing alexithymia in children/adolescents with/without chronic pain were identified. Of eight studies that reported mean alexithymia symptoms between groups, six reported significantly higher symptoms in the pain group. Alexithymia symptoms were associated with “pain bother” and “interference” but not “intensity.” Two studies also assessed interoception; one compared pain/non-pain groups, finding a significant association between decreased self-reported interoception and higher chronic pain. Conclusions: Alexithymia symptoms may be increased in children/adolescents with chronic pain. Our review was limited by incomplete reporting and inconsistent measures across studies, decreasing certainty in the overall strength of the evidence. There is a need to understand the role of interoception and alexithymia in pediatric pain to better mitigate and treat pediatric pain. More research is warranted.

Background and objective Medication for opioid use disorder (MOUD) treatment outcomes can be limited by co-occurring mental and physical conditions, and new adjunctive interventions are needed to improve treatment. Mindful Awareness in Body-oriented Therapy (MABT) teaches interoceptive awareness skills to promote well-being. This study evaluated the longitudinal effects of MABT as an adjunct to MOUD treatment. Methods Patients stable on MOUD recruited from six community clinics were randomly assigned to MABT+MOUD or MOUD. Five assessments delivered over one year (N = 303) examined abstinence from non-prescribed opioid and overall substance use (primary outcomes), and secondary outcomes of mental and physical health distress, interoceptive and mindfulness skills, and opioid craving. An intent-to-treat approach to examine change across time involved generalized estimating equations and linear mixed multilevel models. Results This sample demonstrated high percent days abstinence from non-prescribed opioids and other substances, resulting in no statistical between-group differences over time. Significant overall longitudinal effects for MABT+MOUD vs. MOUD were evident on secondary outcomes of physical symptom frequency, and interoceptive awareness. In addition, significant baseline to 12 month between-group improvements were evident on PTSD symptoms, emotion regulation difficulties, and mindfulness skills. Conclusions While stable on MOUD, this sample had high levels of chronic pain and mental health distress. The results highlight improved longitudinal health outcomes in response to MABT critical to support recovery on MOUD. The MABT completion rate and maintained use of MABT skills over 12 months demonstrates MABT implementation feasibility and positive intervention response as an adjunct to MOUD treatment. Preregistration ClinicalTrials.gov NCT04082637

Background:As regulation of opioid prescribing evolves, primary care and pain clinics are shifting to provide non-pharmacological and interdisciplinary chronic pain care. An under-utilized but growing area of health care for chronic pain is complementary and integrative health (CIH). However, there is limited availability of CIH approaches within the health care system. Mindful Awareness in Body-Oriented Therapy (MABT) is an evidence-based mind-body therapy, with a manualized protocol, that focuses on developing interoceptive sensibility for improved self-awareness and nervous system regulation. Prior MABT research shows MABT improves self-report and physiological indicators of interoception as well as mental and physical symptoms of distress. Methods:This pilot single-group study used a hybrid implementation-effectiveness design and mixed methods to study implementation strategies and outcomes for bringing MABT into an integrative chronic pain clinic. Administrative data, staff surveys, and focus groups were used to understand the implementation process and outcomes (see Additional files 2, 3, and 4). Descriptive statistics were used to analyze survey and administrative data. A content analysis approach was used to analyze qualitative data from focus groups. Results:7 staff surveys were administered over the 24-month study period and showed high acceptability and appropriateness that increased over time. Adoption, feasibility, and sustainability were also high. Clinicians made 70 referrals to MABT, 56 patients scheduled a session, 41 patients completed at least one session, and 71% of these completed the protocol. Focus groups identified MABT as a therapy that filled a gap in services, particularly for patients with a lack of body awareness and high emotion dysregulation. Conclusion:Implementation of MABT was highly successful in an integrative health clinic focused on chronic pain treatment. ClinicalTrialsgov registration:NCT05289024 Registered March 11, 2022 https://clinicaltrials.gov/study/NCT05289024?term=NCT05289024&rank=1.

Objectives:Our study sought to evaluate whether increased mindfulness and social support mediated the effect of the Amigas Latinas Motivando el Alma (ALMA) intervention on depression and anxiety among Latina immigrant women. Method:The study was a secondary analysis of data from a trial evaluating the ALMA intervention with a delayed-intervention comparison group design. Latina immigrants (n = 226) were recruited from local organizations in King County, WA, to participate in an intervention delivered by trained facilitators within community-based settings. The program integrated strategies to increase mindfulness and social support, was delivered in Spanish, and incorporated aspects of Latino culture. Participants completed surveys to assess mindfulness, social support, depression, and anxiety at baseline, post-intervention, and at a 2-month follow-up. We used multiple mediation models to test for mediation. Results:Intervention group participants reported decreased depression and anxiety scores post-intervention and at the 2-month follow-up. Mindfulness and social support mediated the effect of the intervention on both depression and anxiety. For depression, mindfulness mediated the effect through increased self-compassion, while social support mediated the effect through reduced social isolation and enhanced supportive networks. Results for anxiety indicated that increased self-compassion and reduced social isolation were the significant mediators. Conclusions:Community-based group interventions that increase mindfulness and social support can improve mental health outcomes among Latina immigrant women. Further research should evaluate the impact of mindfulness-based interventions in Latino communities.

Background:There is little study of lifetime trauma exposure among individuals engaged in medication treatment for opioid use disorder (MOUD). A multisite study provided the opportunity to examine the prevalence of lifetime trauma and differences by gender, PTSD status, and chronic pain. Methods:A cross-sectional study examined baseline data from participants (N = 303) enrolled in a randomized controlled trial of a mind-body intervention as an adjunct to MOUD. All participants were stabilized on MOUD. Measures included the Trauma Life Events Questionnaire (TLEQ), the Brief Pain Inventory (BPI), and the Posttraumatic Stress Disorder Checklist (PCL-5). Analyses involved descriptive statistics, independent sample t-tests, and linear and logistic regression. Results:Participants were self-identified as women (n = 157), men (n = 144), and non-binary (n = 2). Fifty-seven percent (n = 172) self-reported chronic pain, and 41% (n = 124) scored above the screening cut-off for PTSD. Women reported significantly more intimate partner violence (85%) vs 73%) and adult sexual assault (57% vs 13%), while men reported more physical assault (81% vs 61%) and witnessing trauma (66% vs 48%). Men and women experienced substantial childhood physical abuse, witnessed intimate partner violence as children, and reported an equivalent exposure to accidents as adults. The number of traumatic events predicted PTSD symptom severity and PTSD diagnostic status. Participants with chronic pain, compared to those without chronic pain, had significantly more traumatic events in childhood (85% vs 75%). Conclusions:The study found a high prevalence of lifetime trauma among people in MOUD. Results highlight the need for comprehensive assessment and mental health services to address trauma among those in MOUD treatment. Trial Registration:NCT04082637.

Objective While effective, medication for opioid use disorder (MOUD) treatment outcomes can be limited by co-occurring polysubstance use, mental health and chronic pain conditions. Interoceptive training may facilitate well-being and support medication treatment for MOUD. This study examined the pre-post effects of the mindfulness-based intervention Mindful Awareness in Body-oriented Therapy (MABT) as an adjunct to MOUD. MABT teaches interoceptive awareness skills to promote self-care and emotion regulation. Methods People stabilized on medication for OUD (N = 303) from 6 community clinics in Northwestern United States were recruited and randomly assigned to MABT plus MOUD or MOUD only. In a mixed-methods study, we used an intent-to-treat approach to examine the proportion of days abstinent from non-prescribed opioids, and other substance use (primary outcomes) at baseline and 3 months post-intervention. Secondary outcomes included symptoms of mental health distress; emotional regulation difficulties; pain and physical symptom indicators; interoceptive awareness and mindfulness skills. Participant experience of MABT was collected through post-intervention surveys. Changes in outcomes were assessed using linear mixed models; content analysis was used to analyze the qualitative data. Results Levels of overall substance use were low and did not differ between groups. Significant improvements in PTSD symptoms, interoceptive awareness, pain severity, pain activity interference, and physical symptom frequency were found for those who received MABT compared to MOUD only. Conclusion In this stable MOUD population, substance use outcomes were not improved, however MABT demonstrated significant positive changes across multiple health outcomes critical for improving MOUD treatment. Clinical Trials Registration: NCT04082637 on 9/3/2019

Amigas Latinas Motivando el Alma is a community-based intervention designed to increase social support and coping strategies among Latina immigrant women at risk for depression and anxiety. To assess satisfaction and perceived efficacy of the intervention, we conducted interviews with 32 participants that received the intervention in-person and online. Participants across both modalities found the program supportive in maintaining their mental health. They learned stress management techniques and found the support from facilitators and other participants helpful. Those receiving the intervention in-person were able to connect with other participants more easily than those that received it online. Those receiving it online noted distractions at home that made it challenging to fully engage. Community-based interventions that promote coping strategies and social support are a promising strategy for addressing mental health disparities among Latina immigrant women. TRN: NCT03749278, date of registration: November 21, 2018.

Background: The relationships between opioid use disorder (OUD), chronic pain, and mental health distress are complex and multidirectional. The objective of this exploratory study was to examine the relationship between mental health conditions and Chronic pain severity and interference among patients stabilized on either buprenorphine or methadone. Methods: We report baseline data from a randomized trial of a mind-body intervention conducted at 5 outpatient clinics that provided either buprenorphine or methadone treatment. Validated scales were used to measure substance use, mental health distress, and pain severity and interference. Statistical analyses examined the relationship between mental health conditions and pain severity and interference. Results: Of 303 participants, 57% (n = 172) reported Chronic pain. A total of 88% (n = 268) were prescribed buprenorphine. Mental health conditions were common, with one-quarter of the sample screening positive for all 3 mental health conditions (anxiety, depression, and posttraumatic stress disorder [PTSD]). Compared to participants without Chronic pain, participants with Chronic pain were more likely to screen positive for moderate-severe anxiety (47% vs 31%); moderate-severe depression (54% vs 41%); and the combination of anxiety, depression, and PTSD (31% vs 18%). Among participants with Chronic pain, mental health conditions were associated with higher pain interference. Pain severity was higher among participants with mental health conditions, but only reached statistical significance for depression. Pain interference scores increased with a higher number of co-occurring mental health conditions. Conclusions: Among individuals stabilized on either buprenorphine or methadone, highly symptomatic and comorbid mental health distress is common and is associated with increased pain interference. Adequate screening for, and treatment of, mental health conditions in patients with OUD and Chronic pain is needed.

Interoception, the representation of the body’s internal state, plays a central role in emotion, motivation, and wellbeing. Interoceptive attention is qualitatively different from attention to the external senses and may recruit a distinct neural system, but the neural separability of interoceptive and exteroceptive attention is unclear. We used a machine learning approach to classify neural correlates of interoceptive and exteroceptive attention in a randomized control trial of interoceptive training (MABT). Participants in the training and control groups attended fMRI assessment before and after an 8-week intervention period (N = 44 scans). The imaging paradigm manipulated attention targets (breath vs. visual stimulus) and reporting demands (active reporting vs. passive monitoring). Machine learning models achieved high accuracy in distinguishing between interoceptive and exteroceptive attention using both in-sample and more stringent out-of-sample tests. We then explored the potential of these classifiers in “reading out” mental states in a sustained interoceptive attention task. Participants were classified as maintaining an active reporting state for only ∼90s of each 3-minute sustained attention period. Within this active period, interoceptive training enhanced participants’ ability to sustain interoceptive attention. These findings demonstrate that interoceptive and exteroceptive attention engage reliable and distinct neural networks; machine learning classifiers trained on this distinction show promise for assessing the stability of interoceptive attention, with implications for the future assessment of mental health and treatment response.

This study examined the feasibility and accessibility of brief perinatal mindfulness-based interventions (1 prenatal, 2 postnatal) aimed at supporting the wellbeing of women and their infants living in the context of low income. First time expectant mothers (n = 202) were recruited through clinics and community-based organizations. We examined the feasibility of recruitment, research assessments and intervention implementation, and the acceptability of the intervention programs. Feasibility was assessed by recruitment and attendance numbers, and participant self-report on barriers and facilitators to participation. Intervention acceptability was assessed by class evaluation questions and qualitative interview. The study showed mixed feasibility with successful recruitment and retention in the study, attributable to incentives and strong community relationships which lead to high levels of completion of research assessments. However, there were low levels of group intervention attendance in the postpartum groups due to significant barriers to in-person program attendance. In qualitative interviews, participants indicated having an online or combined online and in-person option would address attendance challenges. Program evaluation and participant interview data show high levels of program acceptability, with over 95

Introduction: Latina immigrants are at increased risk of depression and anxiety and limited access to mental health care. This study evaluated the effectiveness of Amigas Latinas Motivando el Alma (ALMA), a communitybased intervention to reduce stress and promote mental health among Latina immigrants.Methods: ALMA was evaluated using a delayed intervention comparison group study design. Latina immigrants (N = 226) were recruited from community organizations in King County, Washington from 2018 to 2021. Although originally developed to be delivered in-person, due to the COVID-19 pandemic the intervention was adapted mid-study to be delivered online. Participants completed surveys to assess changes in depression and anxiety post-intervention and at a two-month follow-up. We estimated generalized estimating equation models to assess differences in outcomes across groups, including stratified models for those receiving the intervention inperson or online.Results: In adjusted models, participants in the intervention group had lower levels of depressive symptoms than the comparison group post-intervention (ll = -1.82, p = 0.01) and at two-month follow-up (ll = -1.52, p = 0.01). Anxiety scores decreased for both groups, and there were no significant differences post-intervention or at follow-up. In stratified models, participants in the online intervention group had lower levels of depressive (ll = -2.50, p = 0.007) and anxiety (ll = -1.86, p = 0.02) symptoms than those in the comparison group, but there were no significant differences among those that received the intervention in-person.Conclusions: Community-based interventions can be effective in preventing and reducing depressive symptoms among Latina immigrant women, even when delivered online. Further research should evaluate the ALMA intervention among larger more diverse Latina immigrant populations.

Interoception, the representation of the body's internal state, serves as a foundation for emotion, motivation, and wellbeing. Yet despite its centrality in human experience, the neural mechanisms of interoceptive attention are poorly understood. The Interoceptive/Exteroceptive Attention Task (IEAT) is a novel neuroimaging paradigm that compares behavioral tracking of the respiratory cycle (Active Interoception) to tracking of a visual stimulus (Active Exteroception). Twenty-two healthy participants completed the IEAT during two separate scanning sessions (N= 44) as part of a randomized control trial of mindful awareness in body-oriented therapy (MABT). Compared with Active Exteroception, Active Interoception deactivated somatomotor and prefrontal regions. Greater self-reported interocep-tive sensibility (MAIA scale) predicted sparing from deactivation within the anterior cingulate cortex (ACC) and left-lat-eralized language regions. The right insula, typically described as a primary interoceptive cortex, was only specifically implicated by its deactivation during an exogenously paced respiration condition (Active Matching) relative to self -paced Active Interoception. Psychophysiological interaction (PPI) analysis characterized Active Interoception as pro-moting greater ACC connectivity with lateral prefrontal and parietal regions commonly referred to as the dorsal atten-tion network (DAN). In contrast to evidence relating accurate detection of liminal interoceptive signals such as the heartbeat to anterior insula activity, interoceptive attention toward salient signals such as the respiratory cycle may in-volve reduced cortical activity but greater ACC-DAN connectivity, with greater sensibility linked to reduced deactiva-tion within the ACC and language-processing regions.

Although machine learning (ML) has shown promise in numerous domains, there are concerns about generalizability to out-of-sample data. This is currently addressed by centrally sharing ample, and importantly diverse, data from multiple sites. However, such centralization is challenging to scale (or even not feasible) due to various limitations. Federated ML (FL) provides an alternative to train accurate and generalizable ML models, by only sharing numerical model updates. Here we present findings from the largest FL study to-date, involving data from 71 healthcare institutions across 6 continents, to generate an automatic tumor boundary detector for the rare disease of glioblastoma, utilizing the largest dataset of such patients ever used in the literature (25,256 MRI scans from 6,314 patients). We demonstrate a 33% improvement over a publicly trained model to delineate the surgically targetable tumor, and 23% improvement over the tumor's entire extent. We anticipate our study to: 1) enable more studies in healthcare informed by large and diverse data, ensuring meaningful results for rare diseases and underrepresented populations, 2) facilitate further quantitative analyses for glioblastoma via performance optimization of our consensus model for eventual public release, and 3) demonstrate the effectiveness of FL at such scale and task complexity as a paradigm shift for multi-site collaborations, alleviating the need for data sharing.

This study examined specificity in the effects of three perinatal mindfulness-based prevention programs that differed in their timing (prenatal, postpartum) and target (maternal well-being, parenting). Effects on maternal mental health (depression, anxiety, resilience), mindfulness, and observed parenting, as well as observed, physiological, and mother-report indicators of infant self-regulation, were examined. The programs were evaluated in a racially and ethnically diverse sample of first-time mothers (n = 188) living in low-income contexts using intention-to-treat analysis. Mothers were assigned to a prenatal well-being, postpartum well-being, parenting, or book control group. Multi-method assessments that included questionnaire, observational, and physiological measures were conducted at four time points: during pregnancy (T1) and when infants were 2–4 months (T2), 4–6 months (T3), and 10–12 months. Compared to the postpartum intervention and control groups, the 6-week prenatal well-being intervention was related to decreases in depressive symptoms during pregnancy but not postpartum, higher maternal baseline respiratory sinus arrhythmia (RSA), fewer intrusive control behaviors, and lower infant cortisol levels in the early postpartum period. Compared to all other groups, the postpartum parenting intervention was related to decreases in maternal anxiety and increases in responsive parenting. Some differential effects across programs might be due to differences in attendance rates in the prenatal (62

Interoception, the representation of the body’s internal state, is increasingly recognized for informing subjective wellbeing and promoting regulatory behavior. However, few empirical reports characterize interoceptive neural networks, and fewer demonstrate changes to these networks in response to an efficacious intervention. Using a two-group randomized controlled trial, this pilot study explored within-participant neural plasticity in interoceptive networks following Mindful Awareness in Body-oriented Therapy (MABT). Participants (N = 22) were assigned to either 8 weeks of MABT or to a no-treatment control and completed baseline and post-intervention assessments that included subjective interoceptive awareness (MAIA) and neuroimaging of an interoceptive awareness task. MABT was uniquely associated with insula deactivation, increased functional connectivity between the dorsal attention network and the somatomotor cortex, and connectivity changes correlated positively with changes in subjective interoception. Within the MABT group, changes in subjective interoception interacted with changes in a predefined anterior cingulate seed region to predict changes in right middle insula activity, a putative primary interoceptive representation region. While the small sample size requires the replication of findings, results suggest that interoceptive training enhances sensory–prefrontal connectivity, and that such changes are commensurate with enhanced interoceptive awareness.

Objective: A few mindfulness-based interventions have been developed for Latina immigrant populations. We describe the feasibility and acceptability of Amigas Latinas Motivando el Alma (ALMA), a culturally grounded intervention developed to prevent and reduce depression and anxiety among Latina immigrants. We also compare participation in the intervention in-person with an online adaptation developed in response to the COVID-19 pandemic. Methods: ALMA was developed through several years of formative research in collaboration with community organizations serving Latino immigrants. The curriculum integrates mindfulness-based approaches with Latino cultural strengths to reduce stress, enhance coping strategies, and increase social support. Latina immigrant women who spoke Spanish were recruited from Latino serving organizations to participate in an intervention trial. The program consisted of eight sessions offered weekly in person to groups of ∼20 Latina immigrants. After the onset of the pandemic, the program was adapted to be delivered online via zoom. Attendance and fidelity were monitored by intervention staff, and a satisfaction survey was given to participants post-intervention. Results: We enrolled 226 Latina immigrant women with an average age of 40 years and an average of 15.0 years living in the United States. The majority of participants were monolingual Spanish speakers (59%) with a high school degree (66%), although almost half were living on less than $2,200 per month (48%). One hundred and seven (47%) attended the program in-person, and 119 (53%) participated online. Program attendance was similar across modalities, with an average of 58% sessions completed among in-person and 60% among online participants. Participant satisfaction and perceived efficacy of the intervention were high in both in-person and online groups. Discussion: Our findings indicate that the ALMA intervention is acceptable and feasible in this population. Future research should assess the efficacy of mindfulness-based interventions in Latina immigrant populations, including both in-person and online modalities. CTR# NCT03749278.

Interoception, the sense of the body's internal state, is closely related to emotion and well-being. Many mindfulness trainings cultivate interoceptive awareness to promote well-being. In this study, we apply machine learning techniques to fMRI signals in the brain to examine whether interoceptive training improves sustained attention on the body and/or promotes the use of such attention to regulate emotions in stressful situations.