We all tend to think of “emotion” as those feelings we experience under certain circumstances. The “bad” emotions of a person who suffers emotional trauma tend to range from anxiety, to frustration, to fear, to sadness, to depression, to anger, to rage. These words, I think, best portray a sequence of emotions that we will express as the severity of emotional trauma increases. I think they also depict the strength of response by the individual that is demanded by the brain as unrelenting bad conditions occur.
Updated 15 Aug 2012
Emotions and Hierarchy of Physiological Responses
We consciously associate all emotions with something that happens outside of our bodies, and no doubt such an association has to occur first before we have any physiological response. I think we have to look at these emotions as the top of a hierarchy of physiological responses, where we finally become aware that something is terribly wrong with the inside of our bodies. In this way, the progression of bad emotional strength reflects the widening of the effects of circuits breaking down in the brain. Because there are so many parts of the brain dependent upon what happens outside of our bodies, they also become dependent on a hierarchy of nervous responses to any change. Emotions are a way of tying in the unconscious hierarchies with the conscious hierarchies. For this reason, I think there are emotion centers throughout the brain and include both conscious and unconscious emotion.
Why Have Unconscious Emotions?
There is evidence of this duality. We all identify an angry person only when they communicate that anger. There are also circumstances that even if they feel it, they may choose not to communicate it. We only assume that “it will all come out eventually” but we have no proof that will happen. We all have moments when we feel an emotion and do not express it, and no one is the wiser. The subject never comes up again, either in conversation or in private thought. We also have seen actions in people that we recognize as reflecting anger even though the person showing these actions is completely unaware of his/her anger. We have to teach our children how to recognize when they are sad, depressed, anxious, frustrated, afraid. They continue to learn how to recognize different emotions in people as they grow up, and eventually learn how to recognize rage, although that concept is often not learned by many adults. Our sensitivity to these emotions, as a social species, is critical. Being able to recognize different emotions is necessary for adapting behavior toward a person showing them. As a result there are critical social norms that we as humans demand of each other. These depend upon our becoming conscious of the emotions, but as we have seen above, there are many times we are completely unconscious of our emotions.
However, there are other functions of emotion. We all have seen how dogs can “smile”. At least we interpret a “smile” when their lips bare their teeth but their eyebrows are not drawn together and ears pulled back. Do dogs feel the same as humans when they “smile”? Probably not, but we know they can feel tremendously happy when we say to them “Want to go for a walk?”. We have a much harder time detecting any emotion in say, a rat, or a lizard. They just do not communicate it to us in any way we recognize. Do they lack emotion? Highly unlikely, since, as we have seen, unconscious human emotion is not always expressed. Furthermore, most of these animals do not have the extensive anatomical adaptations of facial expression that humans do. They may be using emotions for things that we cannot see in them. By the same token, we are probably also using emotions for things of which we are completely unaware.
Emotions do not occur spontaneously but as a result of the unconscious brain signaling our conscious brain of a change in state. If we finally get to see our child when it is born, we may feel incredible happiness, but we all know that the anticipation for the child has been building for some time. During that wait period, anticipation for something has caused all sorts of physiological events (blood racing to all organs, heart beating a bit faster, ions rushing to muscle, bone, tendon, ligament, and cartilage, cessation of hunger and gut metabolism, increasing metabolism in the limbs, etc.). Anticipation increased thought processes so much they were tumbling over each other. Programs in the nervous system set up the birth of the child as the end point, and when reached should “satisfy” the program. To say we are “satisfied” at the birth of the child sounds like an understatement, but pretty much sums up what that decision-making center in the frontal lobe concludes when it gets pinged by all the centers in the brain which are finally “satisfied” with the outcome.
The same is true for “bad” emotions. In fact, bad emotions are so important for alerting us that something is wrong internally, the brain set up a center that filters and fine-tunes the effect of them in the amygdala, locating it in the temporal lobe with strong links to the anterior hypothalamus which regulates how our bodies react to good or bad external environments.
The amygdala operates by magnifying a signal that something is wrong, gradually increasing the magnification until we consciously do something about it. Thus the first signal that something is wrong happens to cause us anxiety or frustration, but these emotions can become sadness or anger after some time, generally with continued disappointment in the outcome. Anger comes when you feel that the event is something you could have prevented, and sadness comes when you feel powerless to prevent the event. You can feel both emotions at the same time because upon conscious analysis, you figure out that the event was too complicated to be able to predict. If the sadness/anger continues over time, it appears to “accumulate” and generate either depression or rage.
We all experience physiological changes in our bodies with feeling of emotions. We have to. Our heart will beat faster, respiratory rate will increase and blood pressure rises when we feel angry or very happy about something. In fact, the physiological changes often alert us to a sudden change in emotion, so the interaction between emotions and physiological state is a two-way street. Our bodies have to be ready for what we decide to do in response to the emotion, whether it means hugging someone or running out the door.
Besides these physiological responses, there are more subtle changes that have to take place, since our entire bodies have to become ready to respond with changes in activity associated with communication or self-protection. The hunching over and crossing of the legs of a person who is very afraid demands changes in muscle, bone, tendon, ligament and internal organs to accommodate the position, in addition to changes in heart, lung and blood vessels. Furthermore, all of these physiological changes must start to change with the first inkling of an emotional state change, long before we are even aware of its occurrence. The only way such changes can occur so rapidly, and involving such a huge amount of tissues and organs in the body, is if there are centers responsible for keeping tabs on emotional state right there near the centers responsible for physiological change.
Emotion centers should be scattered all over the unconscious brain as well as present in the conscious brain. Since the unconscious emotion centers are further down the line in a circuit linking all of them to the conscious center, they allow us to have graded physiological responses to different emotional situations. This, in turn, keeps our bodies from having to be fully revved up all the time a certain emotion is felt. We learn to detect our emotional status by the unconscious detection of our body’s physiological response to the emotion. Thus, we can feel very strong anger (our jaw muscles tighten), and slightly weak anger (our eyes rotate upward, increasing tension in the all ocular muscles).
Another kind of evidence which can show the link between unconscious emotion and basic physiological responses in the body can be seen in how physical disorders are associated with emotional trauma. A number of troubling results come from a major study of people with early childhood trauma, as part of the Adverse Childhood Experiences (ACE) study of more than 17,000 adults. Middlebrooks & Audage (2008) summarized the results of the ACE program: the effects on children, throughout life, of violence or maltreatment of them, or witnessing close adult relatives’ violence, and reported that “toxic stress” (e.g., that originating from childhood maltreatment) can change the course of child development. Perry et al. (1995) described how much the brain changes during the first three years of life, stating that any trauma suffered by the child during that time will alter the child’s entire lifetime from that moment.
Specific studies within the ACE study are important to mention here. Anda et al., (2008, 2010) demonstrated a significantly higher number of prescriptions written, and increased number of migraine headaches for those who had a high early childhood trauma score. An increased risk of lung cancer was found in the adults who had experienced early childhood trauma (Brown, D. et al., 2010). Significantly greater chronic pain was felt by adults who had suffered from child sexual abuse (Brown, J. et al., 2005). Dong et al. (2003, 2004), showed a strong correlation between ACE and liver disease, and a dose-response relationship with ischemic heart disease. Hospitalizations for autoimmune disorders were more likely to occur in those who suffered early childhood trauma (Dube et al., 2009).
Other studies also support a strong link between emotional trauma from sexual, physical, and/or verbal abuse and physical symptoms. Adults who reported abuse of any kind had significantly more hospitalizations for illnesses, more physical and psychological problems and were more likely to have poorer overall health than adults who did not so report (Moeller et al., 1993). Romans et al. (2002) discovered that women who had suffered from one or more types of abuse were more likely to become afflicted with specific physical disorders: chronic fatigue (also found by Heim et al., 2006), bladder problems, headaches, asthma, diabetes and heart problems.
Pain, in particular, showed a strong link with early childhood adversity. A study of widespread body pain in children demonstrated correlations with previously small areas of pain events, behavioral problems, the prevalence of depression, and greater occurrence of mood disorders and anxiety (Jones et al., 2003). Kopec & Sayre (2005) showed that those who suffered early childhood trauma were more likely to develop low back pain. In a British study, a dose-response increase in the cumulative percentage of adults with adult-onset headache correlated with the number of childhood family adversities in their histories (Lee et al., 2009). Similar results for migraine headache in depressed women were found by Tietjen et al. (2007). Patients with fibromyalgia report the highest number of early childhood adversities, and those with somatoform pain disorders slightly less (Imbierowicz & Engle 2003).
Specific studies on PTSD also showed a relationship between its incidence and childhood trauma. A study done on members of the British military demonstrated that those who suffered childhood trauma were more likely to have serious psychological difficulties, including PTSD, after experiencing the trauma of war, than those who had not experienced serious trauma before enlistment (Iversen et al., 2007). Sledjeski et al. (2008) found a good correlation between number of traumas a person was exposed to and the prevalence of PTSD and/or the number of chronic medical conditions.
Experimental studies also supported the link between emotional brain and the immune system. Belova et al. (1988) discovered a greater amount of blood vessel breakdown in blood vessels and autoimmune response in the brains of rats subjected to emotional stress. Hadamitzky et al. (2012) summarized studies on the bidirectionality of behavior and immunosuppression. In particular, taste aversion studies in rats are linked with evidence that immune expression is reduced in spleen and immune cells. Zhao et al. (2011) induced trauma in rats and found an increase in the gene expression of immune activity in the brain at first, followed by a decline, showing modulation of the immune system by the brain.
Other studies, despite more nuanced outcomes, showed a link between emotions and physical problems. A longitudinal study by Raphael et al. (2001) found a complex relationship between childhood abuse and later development of one or more pain symptoms. People who self-reported any type of childhood victimization were significantly more likely to have unexplained pain symptoms later, than were victimized children whose medical records were followed by researchers over a period of up to 20 years. Strine et al. (2008) found an increased likelihood that adults would engage in health-risky behaviors if they suffered from depression and/or anxiety or had a history of depression. Anxiety had an additive effect when depression accompanied it.
A close relationship between the immune system and the nervous system has been described (e.g. Steinman, 2004), and the term “neuroimmune system” has entered the lexicon of medical science. He detailed how much of the anatomy and functioning of the brain overlaps with that of the endocrine system. He also described how much the endocrine system acted like the nervous system, describing “neural synapses” between glandular cells. Much of the work of Donald Pfaff and his colleagues has shown how the hormonal control of behavior is, in turn, controlled by the CNS, e.g. Nautiyal et al. (2008), who found that immune cells in the brain could modulate anxiety-like behavior in rats. Murrin & Thomas (2008) tracked the hormonal changes associated with the immune system, and their association with major depression and schizophrenia. Indeed, as Steinman (2004) demonstrated in his review, the immune system is completely represented in areas of the brain which act in the background, where we can be entirely unconscious of is action.
Emotions as Expression of Neural Program Satiety
Satiety is a safety measure in the brain. It is a standard method for computer programmers to use to test segments of a program for internal logic and production of satisfactory results. For instance, a programmer might want to generate a series of digits based upon a previous result. The programmer puts in a statement at the end of the subroutine which generates these digits to test the integrity of the code just written. A statement like, “The outcome is as expected” or some numerical statement, like “x= 32” would be put into the program to tell the operator that this subroutine satisfied the demands that called this subroutine. It results from some mathematical check written at the end of the program calling on this outcome, e.g. “if x=32, then write the end statement, else write the alarm statement”.
The brain operates in much the same way. If one center wants to find out if what it ordered another center to do was actually carried out, it can monitor metabolic results itself, or, being the master programmer, ask another center, a satiety center, to report every time a satisfactory result from the other center came out. Being the master programmer, it certainly doesn’t need to be bogged down in the minute-by-minute analysis that another satiety center could do. That way, the master programmer center could spend its time analyzing results from many other centers and made decisions much faster.
Memory has been addressed in detail elsewhere (Universe Review).
The discussion here is meant only to tie in general concepts of memory with the concepts of satiety and emotion. As one can see at this website (especially the table there), there are many aspects of memory that have evoked an enormous number of theories. I will zero in on certain parts of memory acquisition and processing that are considered to be unconscious. The first step is what some call sensory memory, or the signaling to the brain from sensory receptors. Most classifications only address memory as something that is consciously recalled, with little recognition of the big step in processing of sensory information. Universe Review recognizes that there the unconscious brain does operate in almost all aspects of memory acquisition, processing and storage.
There is a type of memory called “associative”, which applies to most of the types of memory people most often mean when they use the term “memory.” They use the term “non-associative” to refer to habituation and sensitization, processes involving the spinal cord, cerebellum, and basal ganglia, all non-conscious areas of the brain. I think that the term is inadequate when used this way because I suspect that the neuron mapping necessary in all memory, no matter what type, requires that neurons be physically associated with others involved in the storage and recall of any type of memory. In order for association to work at all, the brain must be “assigning” a role to every neuron present. Since the nervous system evolved as a “representative structure [The Social Brain, MRT 1.0: Using MRT (Muscle Reflex Testing)], it is a good idea to organize parts of it as associating with other parts. The plan may be to position representative cells with similar roles closer together. Synapses have been shown to be dynamic, with axon terminals moving closer to the cells with which they synapse during the learning process. I suggest that with many unmyelinated neurons, synapses and longer axons can form dynamically with cells that become associated with them, allowing rapid retrieval of memories, both conscious and unconscious.
I suspect that the association among cells in the brainstem (mesencephalon and medulla) is like the figure above, as a simple branched tree. However, it is limiting because, with growth and development of a complex behavioral repertoire, found in vertebrates, and especially mammals, this simple plan cannot accommodate the thousands of associations that will be needed. The neocortex is essentially a mammalian invention, with its columns of cells that can communicate across to other columns. This arrangement is fairly unique to the neocortex and may have evolved for the purpose of associating cells more efficiently than was found in the brainstem. However, the strength of association as being a necessity for memory retrieval is clearly important for the operation of ALL of the brain.
Clearly the developmental process in the brain during our earliest years is a critical time period, and the growth of major fiber tracts connecting the neocortex with the brainstem must explain some important facets of emotional representation in the brain. How many of us can remember anything from our first 3 years of life? We tend to “forget” what happened at that time because the infant brain changes so much during development that memory centers get disassociated from each other. Really bad memories are “walled off” from access by the conscious brain. However, the memories are still there and are called upon in some deeply unconscious circuits.
Memory and satiety go hand in hand. It is very likely that basic body functions like cellular metabolism, muscle contraction, production of immune cells, digestion, absorption, and processing of nutrients depend upon memory in some way. After all, remembering how the body handled a new food item, like the day the baby first started weaning from milk would be an important way to improve the efficiency of the nervous system in coordinating body responses to this food item. Not just the stomach is involved in handling this food item but the liver is really important for making the shift from storing the milk fats and generating the enzymes from milk proteins to converting sugars produced from the carbohydrates into glycogen for use by the rapidly growing brain. The heart, blood vascular system, lymphatics, muscle, endocrine system, as well as the subendothelial transport system, all have to make a shift in function with the new diet. That shift is not a one-time thing, since the baby goes through periods of only drinking milk, to having milk with other foods. But all of that memory is completely unconscious.
The brain depends upon circuits which tell other centers that certain conditions of the body and brain are satisfied, signaling the go-ahead for most neural programs. Whenever the body needs something done for survival, these ancient memories are triggered unconsciously to help guide the unconscious programs to the correct solutions. Because triggering the memories then signals dissatisfaction, the other neural programs connected to them never get the go-ahead signal, increasing the dissatisfaction component and spreading it to other parts of the brain. As the cascade of dissatisfaction spreads, the satiety center in the hypothalamus then signals the “bad” emotions, which get increasingly worse, going from anxiety to frustration, to sadness, to depression to anger, and finally, leading to rage. Sometimes the progression is very rapid, at other times it gets “hung up” mid-way. None of this process is “obvious” to us because we have never thought about the role of emotion in regulating physical processes.
Recent studies show a link between pregnant women suffering from anxiety, stress, or depression and their infants born after this pregnancy who suffer from asthma (Reyes 2011, Cookson 2009). News media report a cause and effect, but no such relationship has been shown because there have been no experimental study done that takes pregnant women who are not prone to anxiety or depression, caused to have one or both conditions as often as those who suffer from these emotional states to the point that they seek medical help, and their newborns then show asthma. However, the link should not be that surprising to us in the light of what I have just discussed. The anxiety or depression of pregnant women reflects dissatisfaction in the brain with some internal condition. No doubt that internal condition will also affect their growing fetuses. This study does not tell us what that internal condition is in the women suffering from anxiety or depression, but Muscle Reflex Testing (Applied Kinesiology) might have told us what to monitor in these women during their pregnancy [MRT 1.0: Using MRT (Muscle Reflex Testing)] for either for a better observational study or a controlled experiment.
Emotional satiety is strongly linked to any program stored in the brainstem. Because of this, any physiological event inside our bodies will trigger signals to emotion centers there. These centers in turn will send signals to the conscious centers of emotion in the prefrontal cortex and amygdala. Why? Because this allows our brains to become consciously aware that satiety from an operation in the medulla has been satisfactorily completed. Why should we be conscious that these processes have occurred successfully? It adds extra depth to our lives, helping us to have some conscious control over what we need to do to ensure our survival. All physiological processes are so affected, including the act of eat, digesting, absorbing, repairing, healing, growing, and maintaining equilibrium. Thus, when toxins enter our system, we are more likely to register dissatisfaction. Unless we use mindfulness to process this information, we will be unaware of why we are dissatisfied, or have some emotion along a continuum from anxiety or frustration to anger or rage (Mindfulness Techniques).
Emotional Links to Joints
I have found that there are usually emotional links to any joint pain. In order to understand this association, I have to explain some anatomy, embryology, and simple neuroanatomy. (What is the Hypodermis?). Tiger Woods is having a tough year (2011), trailing behind his former performance on the golf course, most apparent since his scandalous behavior became publicized. He also keeps injuring his joints (Injured Tiger Woods Won’t Play At U.S. Open, NPR’s Morning Edition for 16 June 2011). If we think about specific events in our past, we should realize that usually we are more likely to feel pain or injure joints when we are under emotional stress. Our posture and joint actions change in response to our emotional status, and injury becomes more likely when we are feeling sad, depressed, or angry.
All parts of a joint are innervated by pain nerves and stretch receptors. Cartilage also is innervated by pressure receptors. In addition to these nerves are tiny, unmyelinated neurons that belong to a class called visceroreceptors. Published definitions of these nerves imply that they supply information to the spinal cord about the chemical status of the tissues they innervate. I suspect that these are responsible for keeping track of the movement of molecules in the hypodermis, and thus have very strong roles to play in muscle and joint function, since both depend upon fast movement of calcium and phosphate within hypodermal fluids (see more discussion on the hypodermis and joints at What is the Hypodermis?).
The nervous system is also segmented (Segmentation in the Nervous System), although the segments in the brain have become greatly obscured by all the changes in that end of the neural tube. Each segment in the brain will carry an emotional center in it, emerging from a single one present in the very center of the brain, the mesencephalon, the gateway between conscious and unconscious processes in the brain. The emotional center in each of the segments of the brain is responsible for assigning destinations for information coming into the brain about the chemistry of the body (supplied by the visceroceptors mentioned above).
It may be a quirk of embryonic life, but the territory supplied by the 4th and 5th segments of the brain (future medulla) is larger than that covered by other brain segments. The mesenchyme from these segments migrates out over all the other segments of the body, carrying with it the innervation it was assigned from the future medulla. However, the nerves which eventually innervate the structures formed from the mesenchyme are going to be spinal nerves, not cranial nerves. The former innervation gets replaced by the spinal cord innervation as tissues undergo rapid development, but the physiological connection remains the same. Those old visceroceptors retract and form new connections within the brain (brain fiber tracts) with the incoming spinal nerves from the former territory controlled by the medulla. The tissues derived from this mesenchyme will thus continue to feed the emotional centers in the medulla information, but from ligaments and cartilage forming the spinal column.
Just as we can get “referred pain” from the arm when we have a heart attack, pain in the joints may be “referred” to parts of the medulla that handle emotional links, based upon their close association in the embryo. So when using MRT (Muscle Reflex Testing) and Mindfulness techniques to relieve back ache, it is always a good idea to include questions about your state of mind along with “body memory” of an event that is associated with your back ache. I describe one example more thoroughly in my blog post Finding Toxins and Repairing Tissue.
Stories in the News, Related to This Topic
Probiotics and Emotions
Comment on Confusion At The Yogurt Aisle? Time for Probiotics 101, reported on Morning Edition 09 July 2012, where I mention how this report supports the theory I presented earlier on this blog post. I also present a more careful analysis of the research presented in this report.
Reporter Allison Aubrey interviews a pediatric gastroenterologist, Dr. Athos Bousvaros (Harvard Medical School) who tells us how important gut microbes (probiotics) are helpful to us, but we don’t know which are and which are not. Aubrey discusses how little we know about how helpful yogurt is for us. Gastroenterologist Dr. Kirsten Tillisch (UCLA) tells us that we do not know which strains of probiotics are helpful, whether different people need different strains. We do know that a probiotic called Align has been shown to be helpful for people with irritable bowel syndrome. Most studies’ participants were eating yogurt two to three times per day, so it is unknown if eating less will do anything for us.
Aubrey says that two recent studies “found evidence that probiotics can reduce the risk of antibiotic-related diarrhea” (RAND Corporation, who also paid its staff to do this research) and that “people who eat fermented foods such as yogurt or take probiotic supplements were somewhat less vulnerable to upper respiratory illnesses, including the common cold” (Cochrane Collaboration Analysis).
Aubrey states that figuring out the specific benefits of probiotics “will take years and much more research”. However, some research has shown a “gut-mind” relationship. Dr. Tillisch mentions animal studies that show that “if you take an animal with inflamed gut, and give them a probiotic, they don’t act anxious anymore.” She decided to see if probiotics had a similar effect on women.
She and her colleagues did a small study with healthy women and brain scans, and presented the results at a conference recently. In a double-blind, controlled, parallel and preliminary study, 45 healthy women (aged 18-50 with no psychiatric or medical illness) were randomly assigned to one of three groups [1) control: received no treatment, 2) control: received non-fermented yogurt control, or 3) treatment: ate 125 g of probiotic yogurt with 4 species of Bacillus and Lactobacillus bacteria in it, twice a day over four-week period]..All women received a fMRI (functional MRI) brain scan measuring their emotional reactivity (measured with blood oxygen level) while they examined images of faces showing negative emotions (sadness or anger).
The probiotic group showed a muted blood oxygen level response in areas of the brain associated with gastrointestinal sensation processing and control when compared with the control groups. Interestingly it also showed no difference from the two control groups in areas of the brain associated with emotion and relationship processing, but did show a decreased connectivity between three areas that form an amygdala-centered network (meaning that strong, negative, emotional responses were reduced in the probiotic group.).
My Comments on NPR
This report is just one more piece of evidence supporting my theory that emotion centers (unconscious) exist in the medulla and they are strongly associated with unconscious metabolic and satiety centers. (There are centers regulating metabolism in the medulla, at the cellular, tissue and organ level. Thus, the gut is represented in the medulla physiologically, as well as mapped out anatomically (topographically) in the cortex of the temporal, frontal and parietal lobes. For further comments, see my blog post “Emotional Representation in the Brain”. https://marthalhyde.wordpress.com/2011/04/23/emotional-representation-in-the-brain/
Anxiety is an emotion with conscious representation in the prefrontal cortex, as well as in the amygdala. Probiotics probably promote healing, thus reduce inflammation, by providing protection of damaged cells from “bad” bacteria.. Once healed, damaged cells are not screaming for help anymore and the brain then registers satiety at a job that is finished. Satiety centers send that signal to the emotion center (conscious) in the prefrontal lobe, thus stopping the triggering of anxiety.
I can only guess that the paper that this report is citing as “a recent Cochrane Collaborative analysis”is one by Qiukui Hao et al 2011 that showed that probiotics helped to prevent upper respiratory tract infections since the provided URL is incorrect and bounces back to the NPR report I am reviewing here. I suspect the correct URL is http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006895.pub2/abstract.
My Extended Comments
I have to mention that interpretation of the studies reviewed on NPR needs clarification. Since the RAND study (Hempel et al. 2012) was a meta-analysis of many different kinds of studies, even though all studies were controlled studies where two parallel and concurrently treated groups were studied (both getting antibiotics, but only one also eating yogurt), the particulars of the studies differed. The differences are major, including amounts of yogurt eaten, different ages of participants, all who got antibiotics regardless of which kind and for which symptoms, 6 different types of bacteria involved, those treated for prevention included with those treated for presence of bacterial infection, all incidences of diarrhea were reported, regardless of cause (a toxin could have caused it but was still included).
Forty-two percent more people had few or no incidences of diarrhea in response to antibiotics in the group eating yogurt than those who were in the group who got no yogurt. Because the groups were made up of participants from many studies in a meta-analysis and thus composed of different populations, and neither the strain of bacteria, nor the antibiotic given was not the same in all studies, conclusions about the results must be guarded.
Hao et al. (2011) did a meta-analysis of several controlled studies on the effects of probiotics, but found that, due to the limitations of this analysis and the sample size, only a weak beneficial association between probiotics and a lower rate of upper respiratory tract infection incidences, and did not include older people.
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