Mindfulness Meditation and Chronic Pain
Introduction
Chronic pain is a pervasive and devastating problem which affects the lives of nearly 85 million Americans (including the partial or total disability of 50 million Americans; Berman & Swyers, 1997). Traditional biomedical treatments for chronic pain have been largely unsuccessful in bringing pain relief to patients (Lanes et al., 1995). The biomedical approach (e.g., pain medications, nerve blocks, etc.) has been shown to be more appropriate for acute pain which is usually the result of trauma or medical procedures and is typically characterized as shorter in duration and greater in intensity (Patterson, 2004). Alternatively, chronic pain typically lasts at least 6 months and may be maintained in the absence of any specific tissue damage (Patterson & Jensen, 2004). In addition, chronic pain has also been shown to be perpetuated by other psychosocial factors such as emotional distress, heightened focus on physical complaints, believing the only cure is physical, and reward contingencies for not getting well (Patterson, 2004). Because chronic pain is such a unique phenomenon and includes complex interactions between physical, emotional, cognitive, and behavioral variables, it may be more appropriately conceptualized and addressed from the perspective of the biopsychosocial model.
The purpose of this paper is to review the use of mindfulness-based meditation interventions with chronic pain patients. First, the historical development of mindfulness meditation will be described. Second, the theoretical basis for using mindfulness meditation to treat chronic pain will be discussed. Third, initial studies exploring the use of mindfulness-based interventions to treat chronic pain patients will be reviewed. Fourth, the status of recent studies addressing mindfulness and chronic pain will be investigated. Finally, future directions for research will be discussed.
History of Mindfulness-Based Treatments
Jon Kabat-Zinn has been an influential figure in the integration and secularization of mindfulness meditation into the health care settings. Originally derived from Theravada Buddhism, Kabat-Zinn (1985) described his form of mindfulness meditation as what the Buddhists refer to as “bare attention” or “detached observation.” Mindfulness has been operationally defined as “an intentional focused awareness – a way of paying attention on purpose in the present moment, non-judgmentally” (Center for Mindfulness, 2006). Mindfulness meditation may be practiced either formally (i.e., traditional sitting meditation) or informally (i.e., attending to and bringing awareness to everyday activities such as eating, showering, etc.).
In 1979, Jon Kabat-Zinn established the Stress Reduction Clinic at the University of Massachusetts Medical School. At this site, mindfulness meditative practices were offered to treat patients for a variety of illnesses (e.g., chronic pain, cancer, heart disease, high blood pressure, etc.) referred sometimes as a last resort to traditional medical treatment. A group intervention program referred to as mindfulness-based stress reduction (MBSR) eventually arose from this clinic. MBSR is a structured 8-10 week group program, typically consisting of 10 to 40 participants with either a heterogeneous or homogeneous set of problems (Grossman et al., 2004). Each week, participants attend one session of approximately 2.5 hours (including a single day-long session), while also engaging in 45 minute homework assignments on the other six days of the week. The MBSR program includes training in mindfulness from the perspective of multiple modalities including sitting meditation, body scan meditation, walking meditation, and gentle Hatha yoga. The program also encourages participants to engage in mindfulness practice informally in their everyday lives (i.e., being mindful during eating, driving, etc.).
Mindfulness meditation differs from the more traditional stress reduction approaches (i.e., progressive muscle relaxation, deep breathing, hypnosis, and cognitive-behavioral strategies) because of its non-goal-directed nature. For example, while the more traditional stress reduction approaches may direct patients towards achieving states of relaxation, the mindfulness meditation approach would alternatively focus on cultivating present moment awareness and acceptance of the current situation regardless of emotional/physiological content. However, the paradox of the mindfulness meditation approach used for stress reduction is that by sustaining present moment attention and awareness to current bodily and emotional states, one may find that relaxation and stress reduction spontaneously occur without it being the primary directed goal (Kabat-Zinn, 1990).
Theoretical Basis
Given the potentially unconventional etiologic pathways for chronic pain, it is not surprising that approaches extending beyond the physical to the psychological aspects of the pain have been explored. Besides mindfulness meditation approaches, examples of other mind-body-based interventions used to treat chronic pain include hypnosis, biofeedback, progressive muscle relaxation, and cognitive-behavioral therapies (Byrne, 1996; Middaugh & Pawlick, 2002; Newton et al., 1995; & Strong, 1991). The theoretical basis for using mindfulness-based meditation interventions to treat chronic pain patients among the other more commonly used mind-body techniques has been supported in three important ways: 1) recognition of the attention regulation component in all of the mind-body techniques, 2) explanation of pain’s central role to the history of meditation practice, and 3) integration of the gate control theory of pain (Kabat-Zinn et al., 1985; Kabat-Zinn, 1990; & Melzack & Wall, 1965).
Kabat-Zinn and colleagues (1985) discussed the revelation that all of the commonly utilized mind-body approaches to treat chronic pain have some type of attention regulation component. For example, attention is utilized to regulate muscle tension in progressive muscle relaxation, to generate relaxation in biofeedback, to increase the expression of non-pain behaviors in operant conditioning, and to recognize maladaptive thought patterns in relation to pain symptoms in cognitive behavioral therapies (Kabat-Zinn et al., 1985). The authors suggested that the attention regulation component, which is fundamental to mindfulness meditation, may offer the most therapeutic value in the treatment of chronic pain patients. Furthermore, the authors explained that the objects of attention vary across the different mind-body approaches, but that the significance of attention to pain relief may be related to the actual intensity and regulation of attention rather than the object of focus. Thus, attention regulation may be a potential active ingredient by which these other mind-body approaches work to reduce chronic pain, which would support the use of the attention regulation-based technique of mindfulness meditation.
The theoretical argument for using mindfulness meditation to treat chronic pain is further supported by describing the role of meditation practice-based pain experiences. For the past 2,500 years, meditation practitioners engaged in intensive meditation training have likely encountered the physical pain associated with sitting still in cross-legged positions for hours at a time (Kabat-Zinn, 1990). Kabat-Zinn (1990) described the excruciating and intense physical pain associated with prolonged sitting meditations as an opportunity to practice mindfulness and bring awareness to the pain sensations. Through “detached observation” of the pain, it is explained that one begins to realize that the pain is not immutable but rather constantly changing in intensity from moment to moment. In this focused state of mindfulness during the experience of pain, one may learn that the physiological pain sensations are in fact separate from the psychological interpretations that we may commonly attribute to our pain. Mindfulness meditation may allow us to develop the ability to dwell in this state of heightened awareness to bodily sensations, without initiating the cascade of psychological interpretations that may lead to “suffering.” To summarize, using mindfulness meditation to cultivate the state of “detached observation” during the perception of pain occurs by attending to the pain from moment to moment, and then distinguishing the primary sensation of pain as separate from the thoughts that may occur about the pain (Kabat-Zinn et al., 1985).
Beyond pain’s role in the history of meditation, Kabat-Zinn (1982) suggested the gate control theory of pain as a potential mechanistic explanation for mindfulness meditation’s utility with chronic pain patients. Melzack and Wall (1970) expanded the conceptualization of pain from a primary focus on sensory pathways to include cognitive and motivation factors. Thus, the gate control theory provides a psychophysiological framework to conceptualize the potential modulating effects that cognitive and motivational factors may have on the sensory transmission of pain (Kabat-Zinn, 1982; Melzack & Casey, 1968; & Melzack & Wall, 1965). For example, the specific cognitive states of attention, commonly associated with mindfulness meditation practice, may not only alter the psychological experience of pain, but also the sensory transmission of pain signals in the nervous system.
Initial Studies
In a seminal study using mindfulness meditation to treat pain, Kabat-Zinn (1982) explored the efficacy of a 10-week stress reduction and relaxation program (later known as MBSR) to reduce pain among 51 chronic pain patients failing to respond to traditional medical care. The 10-week stress reduction and relaxation program consisted of sweeping (i.e., mindful body scan), mindfulness of breath and other perceptions, and Hatha Yoga postures. Results indicated that at the end of the 10-week intervention, 65% of the patients reported a ≥ 33% reduction in mean total McGill-Melzack Pain Rating Index and 50% reported a ≥ 50% pain reduction. Limitations include lack of a randomized control group and the extensive reliance on self-report data. Thus, while results were suggestive for the potential benefits of mindfulness meditation practices to reduce pain, they should be interpreted with caution.
Kabat-Zinn and colleagues (1985) conducted a similar study exploring the putative benefits of the same 10-week Stress Reduction and Relaxation Program on a different group of 91 chronic pain patients. However, this study updated the methodology from Kabat-Zinn (1982) and included a comparison group of 21 chronic pain patients. Statistically significant group improvements were reported between pre- and post- intervention periods for the 10-week intervention group in present-moment pain, negative body image, degree of inhibition of everyday activities by pain, medical symptoms, mood and affect, and psychological symptomatology (e.g., somatization, anxiety, depression, and self esteem). The comparison group did not show significant improvements in any of these areas after traditional medical care (e.g., nerve blocks, physical therapy, analgesics, and antidepressants) was applied. At a 15-month follow-up, all improvements in the meditation group remained significant except for present-moment pain. The authors discuss that although present-moment pain ratings returned to pre-intervention levels for the follow-up points, a change may have occurred in the way these participants were interpreting their present moment pain scores. For example, the meditation group maintained significant reductions in negative body image, which the authors interpret as indicative of the development of new coping skills which may help facilitate living with the pain and reinterpreting its meaning. It is important to note that this study is descriptive and reports only a within group comparison rather than a between groups analysis. Furthermore, since this is not a prospective randomized study, results need to be interpreted cautiously. Also noteworthy, both the intervention group and comparison group may have been exposed to significant demand effects (i.e., enthusiastic referral to the special program and high expectations of pain relief).
To examine the long-term effects of this intervention, Kabat-Zinn and colleagues (1986) conducted a four-year follow-up among 225 chronic pain patients undergoing the mindfulness-based meditation intervention as part of the University of Massachusetts Stress Reduction and Relaxation Training Program. Because many psychological interventions for chronic pain have only demonstrated short-term effects, this group sought to examine whether the positive effects of the mindfulness meditation program would be sustained four years later (Kabat-Zinn et al., 1986; Turner & Chapman, 1982). Two hundred twenty-five completers of the mindfulness-based meditation intervention showed significant sustained reductions in measures of negative body image, number of medical symptoms, and global psychology symptomatology over the course of the four-year follow-up period. However, McGill-Melzack Pain Rating Scale measures tended to return to pre-intervention levels at four years. Although pain relief was not sustained, a measure of overall improvement showed maintenance over the follow-up period: 72% of participants reported moderate to great improvements in pain status at 6 months, 1 year, and 3 years; 62% reached these levels at 2 years; and 60% reached moderate to great improvement status at 4 years.
Recent Studies
There is a large gap in the literature regarding the use of mindfulness meditation as a treatment approach to chronic pain from the time of publication of Kabat-Zinn and colleagues’ (1986) follow-up study to the late 1990’s. However, recent pilot studies exploring the potential benefits of mindfulness meditation as a treatment for chronic pain have made an attempt to improve upon previous methodology by using randomized controlled designs. For example, Plews-Ogan and colleagues (2005) conducted a randomized controlled study examining the effects of MBSR, massage, and standard care for the management of chronic pain. At the end of 8 weeks, the massage group reported significantly lower pain levels and better global mental health than the standard care condition. Alternatively, the MBSR group did not report significant pain reductions at the end of the 8-week intervention compared to the standard care condition. However, at 12 weeks, the MBSR group reported significantly better global mental health than the standard care group. Thus, results indicate that both MBSR and massage may be valid treatment modalities for chronic pain and both deserve further investigation. More specifically, MBSR may lead to longer-term changes in mental health compared to massage.
Another group has recently explored the potential feasibility for using an MBSR intervention with older adults. Morone and colleagues (2005) examined the effects of MBSR compared to a waitlist control condition in a randomized trial among 36 older adults (i.e., 65 or older) with chronic low back pain. The MBSR group reported reduced disability secondary to back pain, improvements on global and physical health, and improved pain levels compared to pre-intervention levels. However, when the MBSR group was compared to the waitlist control group there was a trend towards significance on all of the above measures, but none of the comparisons reached significance.
Future Studies
Future work should continue to explore the efficacy of mindfulness meditation in the treatment of chronic pain by means of more rigorous research methodology, increased focus on quality of life and functional ability outcome measures, and integration of measuring brain activity and utilizing neuroimaging technologies. Very limited work exists that explores mindfulness-based meditation interventions in the treatment of chronic pain with prospective randomized and controlled designs. The more rigorous methodology would help researchers to disentangle many of the common demand effects associated with mindfulness intervention programs and enhance understanding of how these interventions would fare in the general population of chronic pain sufferers. In addition, it may be helpful to supplement self-report pain outcome measures with more of a focus on quality of life and functionality outcomes. For example, there seems to be a discrepancy in previous work whereby mindfulness intervention completers reported overall improvement being sustained for years after the intervention but alternatively rated pain as returning to previous levels soon after the intervention (Kabat-Zinn et al., 1986). It would be helpful to explore the “real life” consequences of these mindfulness interventions in terms of the functional impact they may have for an individual, including measuring ability to return to work, activity level, and overall quality of life. Finally, with the advances in neuroimaging technologies, future work should aim to explain potential physiological mechanisms of mindfulness meditation applied to treatment of chronic pain. For example, this could include functional neuroimaging conducted by fMRI or even measures of brain electrical activity via EEG, which has been previously used to measure changes in brain function as the result of a mindfulness meditation study (Davidson et al., 2003).
References
Berman, B. & Swyers, J. (1997). Complementary and alternative therapies for chronic pain: establishing a research agenda for investigating alternative medial interventions for chronic pain. Primary Care: Clinical Office Practice, 24, 743-758.
Byrne, M. (1996). Hypnosis in the treatment of chronic back pain. Australian Journal of Clinical & Experimental Hypnosis, 24(1), 46-52.
Center for Mindfulness in Medicine, Health Care, and Society: History (n.d.). Retrieved September 18, 2006, from http://www.umassmed.edu/cfm/history.aspx
Davidson, R., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S., Urbanowski, R., Harrington, A., Bonus, K., & Sheridan, J. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564-570.
Grossman, P., Niemann, L., Schmidt, S., Walach, H. (2004). Mindfulness-based stress
reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research. 57(1), 35-43.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33-47.
Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (1990). New York, NY, US: Deltacore Press.
Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163-190.
Kabat-Zinn, J., Lipworth, L., Burnery, R., & Sellers, W. (1986). Four year follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance. Clinical Journal of Pain, 2, 159-173.
Lanes, T.C., Gauron, E.F., Spratt, F.F., Wernimont, T.J., Found, E.M., & Weinstein, J.N. (1995). Long-term follow-up of patients with chronic back pain treated in a multidisciplinary rehabilitation program. Spine, 20(7), 801-806.
Melzack, R. & Casey, K. (1968). Sensory, motivational and central control determinants of pain: A new conceptual model. In Kenshado, D. (Eds.), The Skin Senses (pp. 423-439). Springfield, IL: C. C. Thomas.
Melzack, R. & Wall, P. (1965). Pain mechanisms: A new theory. Science, 150, 971-979.
Melzack, R. & Wall, P. (1970). Psychophysiology of pain. International Anesthesiology Clinics, 8, 3-34.
Middaugh, S. & Pawlick, K. (2002). Biofeedback and behavioral treatment of persistent pain in the older adult: A review and a study. Applied Psychophysiology and Biofeedback, 27(3), 185-202.
Morone, N., Weiner, D., & Greco, C. (2005). Randomized trial of mindfulness meditation in older adults for the treatment of chronic low back pain. Journal of General Internal Medicine, 20(Supplement 1),58.
Newton, J., Spence, S., & Schotte, D. (1995). Cognitive-behavioral therapy versus EMG biofeedback in the treatment of chronic low back pain. Behaviour Research and Therapy, 33(6), 691-697.
Patterson, D. & Jenson, M. (2003). Hypnosis and clinical pain. Psychological Bulletin, 129(4), 495-521.
Patterson, D. (2004). Treating pain with hypnosis. Current Directions in Psychological Science, 13(6), 252-255.
Plews-Ogan, M., Owens, M., Goodman, M., Wolfe, P., & Schorling, J. (2005). Brief report: A pilot study evaluating mindfulness-based stress reduction and massage for the management of chronic pain. Journal of General Internal
Medicine, 20(12), 1136-1138.
Strong, J. (1991). Relaxation training and chronic pain. British Journal of Occupational Therapy, 54(6), 216-218.
Turner, J. & Chapman, C. (1982). Psychological interventions for chronic pain: a critical review. I. Relaxation training and biofeedback. Pain, 12, 1-21.
Introduction
Chronic pain is a pervasive and devastating problem which affects the lives of nearly 85 million Americans (including the partial or total disability of 50 million Americans; Berman & Swyers, 1997). Traditional biomedical treatments for chronic pain have been largely unsuccessful in bringing pain relief to patients (Lanes et al., 1995). The biomedical approach (e.g., pain medications, nerve blocks, etc.) has been shown to be more appropriate for acute pain which is usually the result of trauma or medical procedures and is typically characterized as shorter in duration and greater in intensity (Patterson, 2004). Alternatively, chronic pain typically lasts at least 6 months and may be maintained in the absence of any specific tissue damage (Patterson & Jensen, 2004). In addition, chronic pain has also been shown to be perpetuated by other psychosocial factors such as emotional distress, heightened focus on physical complaints, believing the only cure is physical, and reward contingencies for not getting well (Patterson, 2004). Because chronic pain is such a unique phenomenon and includes complex interactions between physical, emotional, cognitive, and behavioral variables, it may be more appropriately conceptualized and addressed from the perspective of the biopsychosocial model.
The purpose of this paper is to review the use of mindfulness-based meditation interventions with chronic pain patients. First, the historical development of mindfulness meditation will be described. Second, the theoretical basis for using mindfulness meditation to treat chronic pain will be discussed. Third, initial studies exploring the use of mindfulness-based interventions to treat chronic pain patients will be reviewed. Fourth, the status of recent studies addressing mindfulness and chronic pain will be investigated. Finally, future directions for research will be discussed.
History of Mindfulness-Based Treatments
Jon Kabat-Zinn has been an influential figure in the integration and secularization of mindfulness meditation into the health care settings. Originally derived from Theravada Buddhism, Kabat-Zinn (1985) described his form of mindfulness meditation as what the Buddhists refer to as “bare attention” or “detached observation.” Mindfulness has been operationally defined as “an intentional focused awareness – a way of paying attention on purpose in the present moment, non-judgmentally” (Center for Mindfulness, 2006). Mindfulness meditation may be practiced either formally (i.e., traditional sitting meditation) or informally (i.e., attending to and bringing awareness to everyday activities such as eating, showering, etc.).
In 1979, Jon Kabat-Zinn established the Stress Reduction Clinic at the University of Massachusetts Medical School. At this site, mindfulness meditative practices were offered to treat patients for a variety of illnesses (e.g., chronic pain, cancer, heart disease, high blood pressure, etc.) referred sometimes as a last resort to traditional medical treatment. A group intervention program referred to as mindfulness-based stress reduction (MBSR) eventually arose from this clinic. MBSR is a structured 8-10 week group program, typically consisting of 10 to 40 participants with either a heterogeneous or homogeneous set of problems (Grossman et al., 2004). Each week, participants attend one session of approximately 2.5 hours (including a single day-long session), while also engaging in 45 minute homework assignments on the other six days of the week. The MBSR program includes training in mindfulness from the perspective of multiple modalities including sitting meditation, body scan meditation, walking meditation, and gentle Hatha yoga. The program also encourages participants to engage in mindfulness practice informally in their everyday lives (i.e., being mindful during eating, driving, etc.).
Mindfulness meditation differs from the more traditional stress reduction approaches (i.e., progressive muscle relaxation, deep breathing, hypnosis, and cognitive-behavioral strategies) because of its non-goal-directed nature. For example, while the more traditional stress reduction approaches may direct patients towards achieving states of relaxation, the mindfulness meditation approach would alternatively focus on cultivating present moment awareness and acceptance of the current situation regardless of emotional/physiological content. However, the paradox of the mindfulness meditation approach used for stress reduction is that by sustaining present moment attention and awareness to current bodily and emotional states, one may find that relaxation and stress reduction spontaneously occur without it being the primary directed goal (Kabat-Zinn, 1990).
Theoretical Basis
Given the potentially unconventional etiologic pathways for chronic pain, it is not surprising that approaches extending beyond the physical to the psychological aspects of the pain have been explored. Besides mindfulness meditation approaches, examples of other mind-body-based interventions used to treat chronic pain include hypnosis, biofeedback, progressive muscle relaxation, and cognitive-behavioral therapies (Byrne, 1996; Middaugh & Pawlick, 2002; Newton et al., 1995; & Strong, 1991). The theoretical basis for using mindfulness-based meditation interventions to treat chronic pain patients among the other more commonly used mind-body techniques has been supported in three important ways: 1) recognition of the attention regulation component in all of the mind-body techniques, 2) explanation of pain’s central role to the history of meditation practice, and 3) integration of the gate control theory of pain (Kabat-Zinn et al., 1985; Kabat-Zinn, 1990; & Melzack & Wall, 1965).
Kabat-Zinn and colleagues (1985) discussed the revelation that all of the commonly utilized mind-body approaches to treat chronic pain have some type of attention regulation component. For example, attention is utilized to regulate muscle tension in progressive muscle relaxation, to generate relaxation in biofeedback, to increase the expression of non-pain behaviors in operant conditioning, and to recognize maladaptive thought patterns in relation to pain symptoms in cognitive behavioral therapies (Kabat-Zinn et al., 1985). The authors suggested that the attention regulation component, which is fundamental to mindfulness meditation, may offer the most therapeutic value in the treatment of chronic pain patients. Furthermore, the authors explained that the objects of attention vary across the different mind-body approaches, but that the significance of attention to pain relief may be related to the actual intensity and regulation of attention rather than the object of focus. Thus, attention regulation may be a potential active ingredient by which these other mind-body approaches work to reduce chronic pain, which would support the use of the attention regulation-based technique of mindfulness meditation.
The theoretical argument for using mindfulness meditation to treat chronic pain is further supported by describing the role of meditation practice-based pain experiences. For the past 2,500 years, meditation practitioners engaged in intensive meditation training have likely encountered the physical pain associated with sitting still in cross-legged positions for hours at a time (Kabat-Zinn, 1990). Kabat-Zinn (1990) described the excruciating and intense physical pain associated with prolonged sitting meditations as an opportunity to practice mindfulness and bring awareness to the pain sensations. Through “detached observation” of the pain, it is explained that one begins to realize that the pain is not immutable but rather constantly changing in intensity from moment to moment. In this focused state of mindfulness during the experience of pain, one may learn that the physiological pain sensations are in fact separate from the psychological interpretations that we may commonly attribute to our pain. Mindfulness meditation may allow us to develop the ability to dwell in this state of heightened awareness to bodily sensations, without initiating the cascade of psychological interpretations that may lead to “suffering.” To summarize, using mindfulness meditation to cultivate the state of “detached observation” during the perception of pain occurs by attending to the pain from moment to moment, and then distinguishing the primary sensation of pain as separate from the thoughts that may occur about the pain (Kabat-Zinn et al., 1985).
Beyond pain’s role in the history of meditation, Kabat-Zinn (1982) suggested the gate control theory of pain as a potential mechanistic explanation for mindfulness meditation’s utility with chronic pain patients. Melzack and Wall (1970) expanded the conceptualization of pain from a primary focus on sensory pathways to include cognitive and motivation factors. Thus, the gate control theory provides a psychophysiological framework to conceptualize the potential modulating effects that cognitive and motivational factors may have on the sensory transmission of pain (Kabat-Zinn, 1982; Melzack & Casey, 1968; & Melzack & Wall, 1965). For example, the specific cognitive states of attention, commonly associated with mindfulness meditation practice, may not only alter the psychological experience of pain, but also the sensory transmission of pain signals in the nervous system.
Initial Studies
In a seminal study using mindfulness meditation to treat pain, Kabat-Zinn (1982) explored the efficacy of a 10-week stress reduction and relaxation program (later known as MBSR) to reduce pain among 51 chronic pain patients failing to respond to traditional medical care. The 10-week stress reduction and relaxation program consisted of sweeping (i.e., mindful body scan), mindfulness of breath and other perceptions, and Hatha Yoga postures. Results indicated that at the end of the 10-week intervention, 65% of the patients reported a ≥ 33% reduction in mean total McGill-Melzack Pain Rating Index and 50% reported a ≥ 50% pain reduction. Limitations include lack of a randomized control group and the extensive reliance on self-report data. Thus, while results were suggestive for the potential benefits of mindfulness meditation practices to reduce pain, they should be interpreted with caution.
Kabat-Zinn and colleagues (1985) conducted a similar study exploring the putative benefits of the same 10-week Stress Reduction and Relaxation Program on a different group of 91 chronic pain patients. However, this study updated the methodology from Kabat-Zinn (1982) and included a comparison group of 21 chronic pain patients. Statistically significant group improvements were reported between pre- and post- intervention periods for the 10-week intervention group in present-moment pain, negative body image, degree of inhibition of everyday activities by pain, medical symptoms, mood and affect, and psychological symptomatology (e.g., somatization, anxiety, depression, and self esteem). The comparison group did not show significant improvements in any of these areas after traditional medical care (e.g., nerve blocks, physical therapy, analgesics, and antidepressants) was applied. At a 15-month follow-up, all improvements in the meditation group remained significant except for present-moment pain. The authors discuss that although present-moment pain ratings returned to pre-intervention levels for the follow-up points, a change may have occurred in the way these participants were interpreting their present moment pain scores. For example, the meditation group maintained significant reductions in negative body image, which the authors interpret as indicative of the development of new coping skills which may help facilitate living with the pain and reinterpreting its meaning. It is important to note that this study is descriptive and reports only a within group comparison rather than a between groups analysis. Furthermore, since this is not a prospective randomized study, results need to be interpreted cautiously. Also noteworthy, both the intervention group and comparison group may have been exposed to significant demand effects (i.e., enthusiastic referral to the special program and high expectations of pain relief).
To examine the long-term effects of this intervention, Kabat-Zinn and colleagues (1986) conducted a four-year follow-up among 225 chronic pain patients undergoing the mindfulness-based meditation intervention as part of the University of Massachusetts Stress Reduction and Relaxation Training Program. Because many psychological interventions for chronic pain have only demonstrated short-term effects, this group sought to examine whether the positive effects of the mindfulness meditation program would be sustained four years later (Kabat-Zinn et al., 1986; Turner & Chapman, 1982). Two hundred twenty-five completers of the mindfulness-based meditation intervention showed significant sustained reductions in measures of negative body image, number of medical symptoms, and global psychology symptomatology over the course of the four-year follow-up period. However, McGill-Melzack Pain Rating Scale measures tended to return to pre-intervention levels at four years. Although pain relief was not sustained, a measure of overall improvement showed maintenance over the follow-up period: 72% of participants reported moderate to great improvements in pain status at 6 months, 1 year, and 3 years; 62% reached these levels at 2 years; and 60% reached moderate to great improvement status at 4 years.
Recent Studies
There is a large gap in the literature regarding the use of mindfulness meditation as a treatment approach to chronic pain from the time of publication of Kabat-Zinn and colleagues’ (1986) follow-up study to the late 1990’s. However, recent pilot studies exploring the potential benefits of mindfulness meditation as a treatment for chronic pain have made an attempt to improve upon previous methodology by using randomized controlled designs. For example, Plews-Ogan and colleagues (2005) conducted a randomized controlled study examining the effects of MBSR, massage, and standard care for the management of chronic pain. At the end of 8 weeks, the massage group reported significantly lower pain levels and better global mental health than the standard care condition. Alternatively, the MBSR group did not report significant pain reductions at the end of the 8-week intervention compared to the standard care condition. However, at 12 weeks, the MBSR group reported significantly better global mental health than the standard care group. Thus, results indicate that both MBSR and massage may be valid treatment modalities for chronic pain and both deserve further investigation. More specifically, MBSR may lead to longer-term changes in mental health compared to massage.
Another group has recently explored the potential feasibility for using an MBSR intervention with older adults. Morone and colleagues (2005) examined the effects of MBSR compared to a waitlist control condition in a randomized trial among 36 older adults (i.e., 65 or older) with chronic low back pain. The MBSR group reported reduced disability secondary to back pain, improvements on global and physical health, and improved pain levels compared to pre-intervention levels. However, when the MBSR group was compared to the waitlist control group there was a trend towards significance on all of the above measures, but none of the comparisons reached significance.
Future Studies
Future work should continue to explore the efficacy of mindfulness meditation in the treatment of chronic pain by means of more rigorous research methodology, increased focus on quality of life and functional ability outcome measures, and integration of measuring brain activity and utilizing neuroimaging technologies. Very limited work exists that explores mindfulness-based meditation interventions in the treatment of chronic pain with prospective randomized and controlled designs. The more rigorous methodology would help researchers to disentangle many of the common demand effects associated with mindfulness intervention programs and enhance understanding of how these interventions would fare in the general population of chronic pain sufferers. In addition, it may be helpful to supplement self-report pain outcome measures with more of a focus on quality of life and functionality outcomes. For example, there seems to be a discrepancy in previous work whereby mindfulness intervention completers reported overall improvement being sustained for years after the intervention but alternatively rated pain as returning to previous levels soon after the intervention (Kabat-Zinn et al., 1986). It would be helpful to explore the “real life” consequences of these mindfulness interventions in terms of the functional impact they may have for an individual, including measuring ability to return to work, activity level, and overall quality of life. Finally, with the advances in neuroimaging technologies, future work should aim to explain potential physiological mechanisms of mindfulness meditation applied to treatment of chronic pain. For example, this could include functional neuroimaging conducted by fMRI or even measures of brain electrical activity via EEG, which has been previously used to measure changes in brain function as the result of a mindfulness meditation study (Davidson et al., 2003).
References
Berman, B. & Swyers, J. (1997). Complementary and alternative therapies for chronic pain: establishing a research agenda for investigating alternative medial interventions for chronic pain. Primary Care: Clinical Office Practice, 24, 743-758.
Byrne, M. (1996). Hypnosis in the treatment of chronic back pain. Australian Journal of Clinical & Experimental Hypnosis, 24(1), 46-52.
Center for Mindfulness in Medicine, Health Care, and Society: History (n.d.). Retrieved September 18, 2006, from http://www.umassmed.edu/cfm/history.aspx
Davidson, R., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S., Urbanowski, R., Harrington, A., Bonus, K., & Sheridan, J. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564-570.
Grossman, P., Niemann, L., Schmidt, S., Walach, H. (2004). Mindfulness-based stress
reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research. 57(1), 35-43.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33-47.
Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (1990). New York, NY, US: Deltacore Press.
Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163-190.
Kabat-Zinn, J., Lipworth, L., Burnery, R., & Sellers, W. (1986). Four year follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance. Clinical Journal of Pain, 2, 159-173.
Lanes, T.C., Gauron, E.F., Spratt, F.F., Wernimont, T.J., Found, E.M., & Weinstein, J.N. (1995). Long-term follow-up of patients with chronic back pain treated in a multidisciplinary rehabilitation program. Spine, 20(7), 801-806.
Melzack, R. & Casey, K. (1968). Sensory, motivational and central control determinants of pain: A new conceptual model. In Kenshado, D. (Eds.), The Skin Senses (pp. 423-439). Springfield, IL: C. C. Thomas.
Melzack, R. & Wall, P. (1965). Pain mechanisms: A new theory. Science, 150, 971-979.
Melzack, R. & Wall, P. (1970). Psychophysiology of pain. International Anesthesiology Clinics, 8, 3-34.
Middaugh, S. & Pawlick, K. (2002). Biofeedback and behavioral treatment of persistent pain in the older adult: A review and a study. Applied Psychophysiology and Biofeedback, 27(3), 185-202.
Morone, N., Weiner, D., & Greco, C. (2005). Randomized trial of mindfulness meditation in older adults for the treatment of chronic low back pain. Journal of General Internal Medicine, 20(Supplement 1),58.
Newton, J., Spence, S., & Schotte, D. (1995). Cognitive-behavioral therapy versus EMG biofeedback in the treatment of chronic low back pain. Behaviour Research and Therapy, 33(6), 691-697.
Patterson, D. & Jenson, M. (2003). Hypnosis and clinical pain. Psychological Bulletin, 129(4), 495-521.
Patterson, D. (2004). Treating pain with hypnosis. Current Directions in Psychological Science, 13(6), 252-255.
Plews-Ogan, M., Owens, M., Goodman, M., Wolfe, P., & Schorling, J. (2005). Brief report: A pilot study evaluating mindfulness-based stress reduction and massage for the management of chronic pain. Journal of General Internal
Medicine, 20(12), 1136-1138.
Strong, J. (1991). Relaxation training and chronic pain. British Journal of Occupational Therapy, 54(6), 216-218.
Turner, J. & Chapman, C. (1982). Psychological interventions for chronic pain: a critical review. I. Relaxation training and biofeedback. Pain, 12, 1-21.
