Does mindfulness improve outcomes in chronic pain patients?

Chronic pain is a common condition[1], often involving frequent use of health care services[2]. The chronic pain experience, involving a combination of biological, psychological and social factors, can be amplified by emotions and thoughts about the pain.[3]

Mindfulness meditation has become increasingly popular as a self-management technique practiced both within and outside healthcare settings. Mindfulness courses, typically delivered as weekly group sessions over eight weeks, teach specific practices including noticing thoughts and emotions as passing phenomena, while placing attention on the breath or another aspect of present-moment experience. An attitude of curiosity, openness and acceptance towards one’s experience is developed.[4]

Previous reviews on mindfulness-based interventions (MBIs) for patients with chronic pain have focused on clinical outcomes[5, 6] such as pain and depression symptoms, however we considered that it is also important to measure humanistic outcomes. Humanistic outcomes are the aspects of one’s life that are affected by the condition (such as physical functioning), or factors that moderate the way a condition affects life (such as pain acceptance).[7] So, with colleagues from Universities of Aberdeen, Glasgow, and NHS Highland and Tayside, I conducted a systematic review and meta-analysis looking at the effects of MBIs for chronic pain patients, on humanistic as well as clinical outcomes[8]. We systematically searched electronic databases for Randomised Controlled Trials (RCTs) involving chronic pain patients taking part in a group MBI of at least six weeks.

Each included study was assessed for quality using the Yates Quality Rating Scale[9] , a scale specific for assessing quality of RCTs of psychological trials for pain. The effect of mindfulness on outcomes was compared between intervention and control groups. Results from individual studies were combined in a meta-analysis. We also looked at whether the control group being active (such as an educational control) or inactive (such as standard care) made a difference.

We found eleven studies to be included. Participants were most commonly female and Caucasian, aged 47 to 52 years on average, except two studies with older adults. The majority of participants had completed secondary education and/or had a college qualification, and were either employed or retired. Chronic pain conditions included fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, failed back surgery syndrome, and mixed aetiology. Study population sizes were often small, with several being pilot studies or failing to recruit target numbers.

The quality of included studies was variable. Drop-out rates from studies ranged up to 50% and were generally higher from intervention than from control group programmes. Studies reported that drop-outs had a lower level of education[10], were older[11], had more severe symptoms[11,12] and poorer physical functioning[12,13].

Pain intensity and depression symptoms were the most frequently reported clinical outcomes. When combined in meta-analysis, results did not show significant improvement in any clinical outcomes. The most frequently reported humanistic outcomes were physical functioning, health-related quality of life and mindfulness. Perceived pain control was measured in two studies and, when combined in meta-analysis, showed significant improvement. Other humanistic outcomes did not show significant improvement when combined. Studies involving inactive rather than active control groups showed significant improvement in physical functioning and the mental health component of health related quality of life.

So what does all this mean? Clearly, there is currently limited evidence for effectiveness of mindfulness for patients with chronic pain. However, a number of interesting issues are raised. Where there was a significant improvement, it was in humanistic rather than clinical outcomes. The most commonly reported outcomes were clinical, however, it is questionable whether these are the most appropriate outcomes to measure, given that the goal of MBIs is not necessarily to alter the symptom experienced, but rather to increase self-management and coping. Where studies had active comparators, effects were weaker. It is likely that benefits of attending the mindfulness group included factors other than mindfulness meditation alone, that may also be present in active comparators, such as the effects of being in a group.

There were many limitations in included studies. Frequency of home meditation practice was not measured although it may be an important factor affecting outcomes.[14]
Most of the studies measuring mindfulness used the Mindful Attention and Awareness Scale (MAAS) as their measure of mindfulness. The MAAS is less sensitive to change in novice meditators[15], and so a suggestion for future research would be to use a multidimensional scale appropriate for novice meditators, such as the Kentucky Inventory of Mindfulness Skills (KIMS) or the Five Facet Mindfulness Questionnaire (FFMQ).[16]
Low participation rates will have resulted in samples being self-selected. High drop-out rates and inclusion of drop-outs in analyses may have resulted in effects of the intervention being diluted.

I have begun exploring the issues of recruitment and retention in the next stage of my research, a study exploring the barriers and facilitators to engagement with mindfulness interventions for chronic pain patients.

About Fathima Leila Marikar Bawa

Leila BawaLeila is currently conducting a part-time PhD with University of Aberdeen, while working as a General Practitioner. She has been living for the last 7 years in Fort William area whilst completing academic GP training and beginning work as a locum GP and Academic Fellow. She was born in Cambridge and went to University in Nottingham, where she discovered mindfulness meditation and began a regular meditation practice. Her research work, focused on engagement in mindfulness for people with chronic pain, has enabled her to bring her interests in spirituality and psychology into her working life.

References

[1] Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999; 354: 1248¬1252.

[2] Von Korff M, Wagner EH, Dworkin SF, Saunders KW. Chronic pain and the use of ambulatory healthcare. Psychosom Med 1991; 53(1): 61–79.

[3] Gatchel RJ, Bo Peng Y, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychol Bull 2007;133;4:581–624.

[4] Bishop S, Lau M, Shapiro S, Anderson ND et al. Mindfulness: A proposed operational definition. Clin Psychol Sci Prac 2004; Autumn; 11,3: Health Module pg. 230.

[5] Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: A systematic review of the evidence. J Altern Complem Med 2011; 17(1): 83¬93.

[6] Veehof M, Oskam M, Schreurs K, Bohlmeijer E. Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis. Pain 2011; March; 152(3): 533¬542.

[7] Gunter M. The role of the ECHO model in outcomes research and clinical practice improvement. Am J Manag Care 1999; Apr; 5(4 Suppl): S217¬24.

[8] Bawa FL, Mercer SW, Atherton RJ, Clague F, Keen A, Scott NW, Bond CM. Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis. Br J Gen Pract. 2015 Jun;65(635):e387-400

[9] Yates SL, Morley S, Eccleston C, de C Williams AC. A scale for rating the quality of psychological trials for pain. Pain 2007; 117: 314–325.

[10] Morone NE, Greco CM, Weiner DK. Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study. Pain 2008; 134(3): 310¬319.

[11] Morone NE, Rollman BL, Moore CG, Li Q, Weiner DK. A mind-body program for older adults with chronic low back pain: Results of a pilot study. Pain Med 2009; 10(8): 1395¬1407.

[12] Sephton SE, Salmon P, Weissbecker I et al. Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: Results of a randomized clinical trial. Arthritis Rheum 2007; 57(1): 77¬85.

[13] Weissbecker I, Salmon P, Studts JL, Floyd AR, Dedert EA, Septon SE. Mindfulness-based stress reduction and sense of coherence among women with fibromyalgia. J Clin Psych Med S 2002; 9(4): 297¬307.

[14] Pradhan EK, Baumgarten M, Langenberg P et al. Effect of mindfulness-based stress reduction in rheumatoid arthritis patients. Arthritis Rheum 2007; 57(7): 1134¬1142.

[15] MacKillop J, Anderson EJ. Further Psychometric Validation of the Mindful Attention Awareness Scale (MAAS). J Psychopathol Behav Assess 2007; 29: 289–293.

[16] Baer RA. Measuring Mindfulness. Contemporary Buddhism, 2011; 12:01, 241-261