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

Comments

  1. PS non-plain vanilla mindfulness that focuses on health (“what else is there?” and “which parts of my body feel alive and well? (NOT comfortably numb)?” are useful variations. I’m still working on putting together a general course to teach these variants – it’s easy working one-to-one because individual sensory patterns and responses are easy to adapt. Group classes not so easy to ensure that everyone is really hearing what is being taught – ecause there is such a wide range of quality and depth and focus of conscious somatic engagement.

  2. Nice review

    And also some really useful comments above. Mindfulness has been taken out of context as a therapeutic tool, and it is not without pitfalls. Particularly with pain, where a substantial amount of interoceptive skill is required to practice it properly. Expecting people unaccostomed to the concepts to just pick up plain vanilla mindfulness in an already difficult situation is rather optimistic. I’ve had a few conversations with very experienced meditators who have studied the original Pali texts in detail – the original instructions are “sense, move on”. When there are dense somatic sensations (e.g. pain), the mental effort and focus and clarity required to move on so that these dense sensations do not dominate all experience – is substantial. I am not surprised at the dropout rate.

  3. Seamus Barker says

    Thanks for that review, Fathima, and thanks for those articles, Tianna. I agree with your points about interoception, Tianna. I sometimes wonder whether mindfulness, when practised during bodily stillness, is a far more advanced and difficult activity than practising mindfulness while there is afferent input coming from movement to notice. I find mindfulness much, much, much easier to practise if doing something with built-in sensorimotor feedback mechanisms – shooting a basketball, doing highly proprioceptively demanding Yoga or Pilates, or, from what others tell me, knitting. I wonder if mindfulness might be better practised for novices when incorporated into movement (or movement incorporated into mindfulness)?

    EG Reply:

    Hi Seamus,

    Csíkszentmihályi (Mr Flow) said that it was highly advantageous to have “immediate and unambiguous feedback” in order to reach a flow state. That fits with what you’re saying. I agree about the difficulty of complete stillness with meditation (performed as ‘breath-watching’).

    Some teachers of meditation have advised vigorous cathartic exercises (yelling, jumping around) before attempting to breath-watch. I haven’t tried that, but can imagine it might help. I prefer sport or yoga. If I’m in the mood, I’ll have a go at meditation. Those who are very skilled at concentration meditation do actually get strong feedback to work with (apparently). It’s getting that skill that’s hard.

    EG.

  4. Sharon. Jacobson says

    Can you please give me the name of a chronic pain expert in Australia, preferably Sydney, who is trained & experienced to work with migrAINES sufferers? Thanks.

  5. It’s important to note that there are many different forms of mindfulness practice, and that siting in meditation is not the only way.

    I think that this is an important concept that you bring up. What are these studies really trying to demonstrate? When Kabat-Zinn began studying the effects of MBSR for pain in the 80’s, they were looking at the ability to “self-regulate.” To perhaps alter the pain experience. It is possible that in the studies of this meta analysis, the participants were not provided with explanations of why they were doing this–if they thought they were doing it to get rid of their pain, they may have been disappointed with results, leading to drop outs. I think this is what Neil was referring to.

    Mindfulness is really the practice of interoception. I like Bo Forbes description of it here, http://layoga.com/practice/yoga/interoception-mindfulness-in-the-body/. So perhaps we should be studying measures of interoception, like the Multimodal Assessment of Interoceptive Awareness, http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0048230 (Interesting to note, even this assessment was tested on mostly Caucasian, educated females—-how do we cross those socioeconomic lines to reach those that could greatly benefit?–perhaps offering training to the underserved vs those within an insurance based system?)

    Another recent study (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206164/) looked at health care utilization, among many other outcomes, post mindfulness training. Interestingly, self efficacy measures improved at the 8 week mark, but declined at 1 year. Again, how long is enough? I would venture to say, it’s a lifelong practice. But perhaps the education as to the how and why is missing–again as I believe Neil was alluding to. Might be interesting to see extended follow up comparing groups that went through the training initially and then breaking those into 2 groups: those that are provided continued training or “reminders” through several years and those that are left on their own.

    And I know from experience that my own daily Interoceptive/mindfulness practice does help improve outcomes in chronic pain. Knowledge, time and practice.

  6. *before or not.

  7. Some stuff which can make a difference to success or failure of meditation:

    – wide or narrow attention?
    – Focus on breath or body or external object?
    – If breath is used, how to handle the awkward feeling of controlling the breath
    – eyes open vs closed.
    – sweeping or focussed attention?
    – meditating with mental illness – yes or no?
    – exercise before or closed?
    – timing and dosage of painkillers.
    – degree of attentional effort used.
    – understanding the two broad types of distraction (desire/aversion).
    – subtle nuances of attention, eg. ‘thinking about the breath’ versus ‘direct experiencing of the physical sensation of the breath’.
    – Understanding that the aim of absorption-style meditation is actually peace, *powerful* positive affect and actual pain relief. This surprises a lot of people who tend to think it’s about learning to live with pain.
    -Understanding that this powerful positive affect probably won’t hapen without a LOT of work and skill development.
    – Understanding that most people won’t be able to develop the requisite skill to gain this powerful effect, even if they put the time in. It may take months of dedication.
    – Understanding that this powerful positive affect cannot be aimed at in the same way that ordinary goals are aimed at, and that goal directed efforts will fail.
    – Knowing what to do when a sudden positive affect emerges during practice.

    … and so on.

  8. Crane et al published recently on the effects of home practice during a Mindfulness Based Cognitive Therapy intervention on relapsing depression. In general 20 minutes practice per day 3 times per week or more sustained the effect and participants were around 50% less likely to relapse than those practicing less than this ‘optimum’. Levin et al have also reported a similar association in depression in MS patients.
    In general it is very difficult to persuade participants in MBSR courses to practice daily during the 9 week programs which run for 2 to 2.5 hours each week, plus an intensive 6 hour silent day after week 6, however as Kabat-Zinn has quoted many times ‘tuning in trumps tuning out every time’. It takes time and patience to cultivate mindful awareness, many preferring the path of attempting to avoid the pain rather than reducing its threat by getting to know and understand it.

  9. Thanks.

    The finding of ‘no benefit’ doesn’t surprise at all. However I’d suggest that meditation does work, and that it works far better than anything we have available to us. It’s just that this is a skill, not an intervention, and most people didn’t come close to mastering the skill in the research groups. Low retention rates will have a lot to do with this fact. If there’s no mastery, we can’t expect changes in pain levels.

    Typcially, meditation is very poorly taught. It’s also taught by people who can’t do it themselves. Imagine having golf lessons from someone who has never hit a ball themselves!?? If you interviewed the teachers of these research groups you’d probably find that none of them have achieved even the first level of absorption. In fact they would look at you askance if you mentioned absorption or jhana levels.

    Typical meditation instructions go like this: “sit comfortably, pay attention to the breath and whenever you notice the mind wandering, just gently let that go and return to the breath”. This is completely unsatisfactory! Because it’s so unsatisfactory, and because the teachers themseves can’t actually meditate, of course it will fail. Big time.

    Even with expert instruction, meditation is hard. Add strong pain into the mix and this is becomes an exercise in absolute futility. Adequate pain relief with bolus dosing before meditation would be a good start. It’s actually quite cruel the way sufferers have been rounded up and made to “pay attention to the breath” whilst in pain.

    EG

  10. Neil Pearson says

    Great review, though to those who don’t know mindfulness training, it might seem odd for the writer to continue studying something with apparently no useful outcomes.
    Important questions here – what was the dose of the mindfulness training? sure frequency of home practice is important, but do we have any idea of how many minutes of daily practice an average person needs before we expect changes? or how many days/weeks?
    These studies show that when people are involved in a certain dose of mindfulness training, that there are few changes related to pain, and that really should be made clear. maybe there is no dose that ‘works’, but for now we only know that this dose didn’t.
    Another key factor to consider when looking at whether mindfulness training leads to changes is that mindfulness training typically teaches people to stop trying to change. It sure would be interesting to compare results of mindfulness training when people are told that they are trying to change pain and function, versus being told to stop trying to change the outcome. And it would be interesting to see if the ‘stop trying to change’ perspective is a significant reason for drop-outs.
    And last, for now, a clinical observation of interest to at least me, is that many individuals who take part in mindfulness training do not transfer the skills they learn into other aspects of their life – unless they are guided in how to do so, or why (though processes such as Explain Pain).

  11. Thanks for doing this work – it is really useful to (have someone else) review the evidence and its quality as mindfulness becomes more of a staple within the delivery of care for people living with pain.

    I work in a small MDT ‘living with pain’ team and mindfulness has over the last five years crossed out of being a part of our ACT PMP into being a stand alone precursor for our ACT program.
    So in my PT sessions I am more often doing TNE and graded exercise with increasingly mindfully aware patients. I will use the idea of mindful movement in the imagined movement phase of the GMI or the Neuromatrix approach to behavioural experiments as it ties so into our team’s approach.

    For the patients that engage in the self-management of persitent pain it is my opinion that mindfulness practice is a foundation stone of effective self-management.

    Not that the pain is reduced but its distress is tuned down. It fosters acceptence and willingness to experience.

    Are we training out the amygdala sensitivity, are we tuning through the less threat outputing side of the insula, are we beefing up lost hippocampus or just creating a habit of observing without reacting which could arise from the rewiring that may be occuring. Who knows? Or even is the breath control that is a side effect of a lot of mindfulness just doing that vagal thing and downregulating cytokines? The jury is not even near sitting.

    As a PT of 15 years experience I have felt for the last two years that the most important work done in our team is by those doing the mindfulness training (not me by the way). For the first 13 years I thought it was all about me! Me doing the explaining – the Gifford, the Butler, the Moseley and working through graded exposure. Now my gut feels that the mindfulness works better than that TNE rehab alone. My gut feels that it works better than ACT and TNE rehab.

    That is why it is great to have someone who can root through the articles and show the current state of the evidence.

    Many thanks and kind thoughts,
    Steve