Laughter is like exercise because…

Kablooey! You have a bout of back pain. It’s unpleasant and so off to the…. (insert health professional) you go. You tell your story, they ask a bunch of questions, do an assessment, a bit of jiggery pokery and then give you a couple of exercises to do (be it stickmen, pictures or videos downloaded to your phone). Exercise is a go to for many musculoskeletal aches and pains.

Why do we prescribe exercises for aches and pains though?

A recent study wanted to try and answer this question. Wun et al., (2021) performed a review of the literature on the numerous mechanisms proposed by researchers as to why exercise improves pain and function in people with chronic low back pain (CLBP). Following their analysis of the literature (of which 110 studies were included) they identified 33 different types of mechanisms (Figure 1). That’s quite a lot and shows that you can’t pin it down to just one thing i.e. pain be gone by getting strong.

Wun and colleagues grouped the mechanisms into 5 themes:

1. Neuromuscular: “Effective in decreasing the incidence and duration of low back pain episodes by improving strength and endurance of trunk muscles, by increasing flexibility of soft tissue, by correcting postural alignment.”
2. Psychosocial: “Reductions in fear avoidance, anxiety, emotional distress, and perceived pain and disability and self-efficacy.”
3. Neurophysiological: “By influencing the dysfunctional descending pain inhibitory mechanism” and “the release of pain-relieving neuropeptides (endorphin and serotonin).”
4. Cardiometabolic: “Improvement in the aerobic capacity is clinically and statistically correlated to a decrease in the pain.”
5. Tissue Healing: “Blood flow and nutrients which accelerate the healing process and reduce stiffness that results in back pain.”

Through the various mechanisms exercise appears to have an effect, the authors concluded that by identifying how exercise works, treatments can be designed to maximise it’s benefits.  Helpful stuff indeed. 

But.

This wouldn’t be the naked physio blog without some left field thinking. So what has all this got to do with the title of the blog?

Well I decided to do my own little bit of research looking at the mechanisms involved in humour and seeing if I could group them into the same themes as shown above.

Before I do this a wee disclaimer in the form of a limerick:

I decided to write a proposal

I didn’t get ethics approval

I don’t know what I’m doing

It may end up confusing

At best it’s all anecdotal

Method

Using canine analysis – look at a bunch of research articles, place in a large pile, throw dog’s ball into pile in the hope dog jumps in, ruffles about and retrieves the ball, repeat til dog gets tired and has satisfyingly eliminated papers that didn’t fit inclusion criteria – to extract data and compare with themes of Wun et al. (2021).

Results

Many articles were retrieved (who’s a good dog), but did not meet inclusion criteria. Therefore, the blogger had to read all articles, link up mechanisms associated with humour and attempt to match them within each of the themes as presented by Wun et al (more training required for the dog!).

Table 2 shows comparisons of each.

	Exercise (Wun et al, 2021)	Humour
Neuromuscular	Muscular Strength, Muscle Power, Muscle Endurance, Flexibility, Biomechanics, Motor Control, Proprioception, Postural alignment, Muscle Tension, Stabilization	Stabilization (Wagner, Rehmes, Kohle, & Puta, 2014), Muscle Tension (van der Wal & Kok, 2019)
Psychosocial	Fear Avoidance, Mood, Social Support, Pain Tolerance, Disability Perception, Mindfulness, Pain Self-efficacy, Mastery, Coping Strategies, Kinesiophobia, Catastrophizing	Mood, Pain Tolerance, Coping Strategies, Social Support, Catastrophizing (Fry, 1992, 1994; Pérez-Aranda et al., 2019) Disability perception (van der Wal & Kok, 2019) Mastery / Memory (Badli & Dzulkifli, 2013)
Neurophysiological	Gate Control, Stress Response, Descending Inhibition, Endorphins, Sleep	Descending inhibition, Stress Response, Endorphins,  (Fry, 1992; Pérez-Aranda et al., 2019; Akimbekov & Razzaque, 2021) Sleep (Han, Park, & Park, 2017)
Cardiometabolic	Aerobic Fitness, Blood Flow, Body Composition, Body Weight	Energy Expenditure & Heart Rate (Buchowski et al., 2007), Blood Flow (van der Wal & Kok, 2019), Blood Pressure (Fry, 1992)
Tissue Healing	Inflammation, Bone/Ligament, Tissue Restoration	Immunity / Inflammation (van der Wal & Kok, 2019)

It was interesting to read through the selection of papers that demonstrated effectiveness similar to the of the Wun et al study. A number of papers, including a systematic review from van der Wal & Kok, 2019 showed the positive effects of Laughter-inducing therapies. Interestingly, a number of the research papers identified that simulated (self-induced or ‘fake’ laughter) laughter was more effective.

Reading through the systematic review by van der Wal & Kok, (2019), it is clear that we should interpret the reviewed papers with caution as there are methodological issues such as small sample sizes, non-randomization, lack of control groups and risk of bias.  Results are also to be interpreted with caution as effect sizes were small.

Conclusion

The saying ‘laughter is the best medicine’ appears to be less of a saying and becoming more of a science. Whilst this might seem a rather silly blog and also a silly comparison, there is some merit to it’s use. However, it shouldn’t replace exercise, activity or evidence supported approaches as they all bring health benefits. Yet, much of the work that health professionals do are to provide support, relief and strategies to enhance well being. As one participant from a piece of research from Gonot-Schoupinsky & Garip, (2019), (looking into the effects of simulated laughter) explained, “I want to do it alone with myself only, and it’s helped me. It’s my exercise.”

Bringing in those soft skills, taking out the seriousness of our physiotherapy sessions – i.e. focussing on perfect upright posture, setting shoulder blades, activating our core – and adding a bit of humour to our physiotherapy sessions could be a valuable complementary or in some cases even main therapy in different settings.

A simple strategy

The next time you want to set some homework for your client (say some exercises) perhaps ask the client to also think of 3 funny things – to write down the 3 funniest things they experienced during their day and the feelings during these experiences.

In addition, clients could also try counting all the funny things that happened during the day and note the total every night. Take time to notice the humor experienced during the day and add new humorous activities like reading comics, jokes, and watching funny movies.

These strategies have been proposed by Wellenzohn, Proyer, & Ruch, (2016). The authors speculate that the effectiveness of these interventions may relate to the savoring of present-time positive emotions rather than ruminating about the past or feeling anxious about the future. If it helps to enhance the enjoyment of doing activity or exercise and provides a more rewarding and memorable experience, how can that not be beneficial.

Thanks for having a read

TNP

References

Akimbekov, N. S., & Razzaque, M. S. (2021). Current Research in Physiology Laughter therapy : A humor-induced hormonal intervention to reduce stress and anxiety. Current Research in Physiology, 4(February), 135–138. https://doi.org/10.1016/j.crphys.2021.04.002

Badli, T. S.-Z. T., & Dzulkifli, M. A. (2013). The Effect of Humour and Mood on Memory Recall. Procedia – Social and Behavioral Sciences, 97, 252–257. https://doi.org/10.1016/j.sbspro.2013.10.230

Buchowski, M., Majchrzak, K., Blomquist, K., Chen, K., Byrne, D., & Bachorowski, J. (2007). Energy expenditure of genuine laughter. International Journal of Obesity, 31(1), 131–137. https://doi.org/10.1038/sj.ijo.0803353.Energy

Fry, W. F. (1992). The Physiologic Effects of Humor, Mirth, and Laughter. JAMA, 267(13), 1857–1858.

Fry, W. F. (1994). The biology of humor. Humor, 7(2), 111–126. https://doi.org/10.1515/humr.1994.7.2.111

Gonot-Schoupinsky, F. N., & Garip, G. (2019). Prescribing laughter to increase well-being in healthy adults: An exploratory mixed methods feasibility study of the Laughie. European Journal of Integrative Medicine, 26, 56–64. https://doi.org/10.1016/j.eujim.2019.01.005

Han, J. H., Park, K. M., & Park, H. (2017). Effects of laughter therapy on depression and sleep among patients at long-term care hospitals. Korean Journal of Adult Nursing, 29(5), 560–568. https://doi.org/10.7475/kjan.2017.29.5.560

Pérez-Aranda, A., Hofmann, J., Feliu-Soler, A., Ramírez-Maestre, C., Andrés-Rodríguez, L., Ruch, W., & Luciano, J. V. (2019). Laughing away the pain: A narrative review of humour, sense of humour and pain. European Journal of Pain (United Kingdom), 23(2), 220–233. https://doi.org/10.1002/ejp.1309

van der Wal, C. N., & Kok, R. N. (2019). Laughter-inducing therapies: Systematic review and meta-analysis. Social Science and Medicine, 232(March), 473–488. https://doi.org/10.1016/j.socscimed.2019.02.018

Wagner, H., Rehmes, U., Kohle, D., & Puta, C. (2014). Laughing: A demanding exercise for trunk muscles. Journal of Motor Behavior, 46(1), 33–37. https://doi.org/10.1080/00222895.2013.844091

Wellenzohn, S., Proyer, R. T., & Ruch, W. (2016). Humor-based online positive psychology interventions: A randomized placebo-controlled long-term trial. Journal of Positive Psychology, 11(6), 584–594. https://doi.org/10.1080/17439760.2015.1137624

Wun, A., Kollias, P., Jeong, H., Rizzo, R. R., Cashin, A. G., Bagg, M. K., … Jones, M. D. (2021, February 1). Why is exercise prescribed for people with chronic low back pain? A review of the mechanisms of benefit proposed by clinical trialists. Musculoskeletal Science and Practice. Elsevier Ltd. https://doi.org/10.1016/j.msksp.2020.102307