Effectiveness of MBSR on Chronic Pain
Literature Review: Effectiveness of Mindfulness Based Stress Reduction on Chronic Pain
John Hai Tran
Saint James School of Medicine
Anguilla Campus
Preceptor: Dr. Zahidur Rahman
Jackson Park Hosptial
November 2016
Abstract
BACKGROUND:One of the most common issues encountered today in medicine is pain. Conventional treatments often involve pharmaceuticals that have harmful side effects with the potential for addiction. Mindfulness Based Stress Reduction (MBSR) offers an alternative management to those suffering from chronic pain. The goal of this study is to review randomized controlled studiesexamining the effectiveness of MBSR in the reduction of pain intensity in those suffering from chronic pain.
METHOD: A review of the literature was undertaken using GoogleScholar and PubMed. Key words were effectiveness, MBSR and chronic pain. Search parameters included studies done from January 1, 1996 to November 16, 2016 and studies published in English. A comparison was made between populations, outcomes, and conclusion of the various studies.
RESULTS: 147 articles were reviewed with 9 articles meeting the necessary parameters. Out of the 9 studies, 8 showed improvement of pain intensity as measured by self-reported pain questionnaires. All patients had undergone an 8-week MBSR intervention.
DISCUSSION: It was found that MBSR improved the pain intensity in those exposed to the 8-week intervention. It is believed that perceptual changes caused by mindfulness meditation lead to reduced perceived impairment and greater acceptance of pain. Major limitations of the study included variations in participants cause of chronic pain, differences in the structure of MBSR, variations in pain assessment scales used, differences in control groups employed, and social factors.
CONCLUSION:The systematic review of the literature demonstrated significant evidence for the effectives of MBSR in those with chronic pain
Key words: Mindfulness Based Stress Reduction, MBSR, Effectiveness, Chronic Pain
Introduction
Chronic pain is one of the most common problems encountered in medicine today. It has become such a huge issue that there are now dedicated medical specialties focused on its management. Managing pain is extremely complicated due to the physical and psychological components attached to it. Traditionally, pain has been managed pharmaceutically with analgesic and opioid drugs.
Alternative medicine offers another therapeutic avenue that avoids the detrimental side effects of medication. Recent studies have shown that the most potent drugs only reduce pain symptoms by 30%-40% and only in 50% of patients (Morone, Greco, & Weiner, 2008). The side effects of these medications are severe and dosing often must be increased during treatment. This leads to greater side effects and the potential for abuse.
MBSR is an interventional technique designed to combat the negative effects of stress and has been shown to have potential in diminishing the intensity of pain (Kabat-Zinn, 2015). The MBSR is a program designed by Kabat-Zinn and colleagues. The intervention lasts about 8-weeks. Participants are trained in a variety of meditations such as sitting meditation where they are asked to sit down, relax, and focus on their breathing. Yoga is also taught to improve participant’s sense of awareness and balance. Many of the MBSR programs assign homework to the participants. Each individual is given a journal to record their meditational experience. The journals are used by the researchers to measure compliance to MBSR program.
Central to the MBSR intervention is achieving a state of mindfulness. This is a state where the individual releases all of their thoughts and distraction so that they can solely focus on the present moment (Rosenzweig, Greeson, Reibel, Green, Jasser, & Beasley, 2010). When individuals have finished their meditation,they will be in a mindful state. This will help individualsbe more relax and aware of their body’s needs.
Several studies looking at MBSR’s effect on chronic pain utilized pre-intervention and post-intervention pain scales. Typical duration of intervention is approximately 8 weeks with homework for each participant ranging from 40-50 minutes a day. A pilot project by Moronea et al (2008) involved 37 participants aged 65 and over with chronic lower back pain defined as moderate intense pain occurring almost daily. The program appeared to have a beneficial effect on pain acceptance and physical function as measured by the CPAQ and SF-36’s physical function. A more expansive study was done by Cramer, Haller, Lauche, & Dobos(2013)that reviewed controlled studies investigating the efficacy of MBSR for the reduction of chronic lower back pain. Cramer et al (2013) searched MEDLINE, the Cochrane Library, EMBASE, CAMBASE, and PsycInfo yielded 117 relevant studies. Only three randomized clinical trials comparing MBSR to control groups were selected out of the 117. The review found inconclusive evidence for effectiveness of MBSR in improving pain intensity in chronic low back pain patients. However, they did find limited evidence that MBSR can improve pain acceptance.
Significant studies on MBSR have examined its effectiveness in helping individuals with fibromyalgia.Kaplan, Goldenberg, & Galvin-Nadeau, (1993)examined 77 patients with fibromyalgia that took part in a 10-week group outpatient program. All participants showed improvement on pain scales taken after the intervention. The researchers suggested that a MBSR is effective for patient with fibromyalgia. The study's results were limited as there were no control groups. Schmidt, Grossman, Schwarzer, Jena, Naumann, & Walach, (2011)examined the effectiveness MBSR on the well-being of fibromyalgia patients by randomizing 177 female patients into one of the following: (1) MBSR, (2) active control procedure for nonspecific effects of MBSR such as relaxation, (3) wait list. Major outcome was health-related quality of life (HRQoL). Secondary outcomes included pain, depression, anxiety, and quality of life. Results showed significant post intervention improvement on HRQoL and modest benefits on secondary measures. The researchers concluded that patients in the MBSR arm of the study benefited the most.
Other studies have also try to examine a heterogeneous group of patients with chronic pain. These pains include migraines and headaches, arthritis, facial pain, abdominal pain, multiple sclerosis pain, chronic chest pain and neuropathies. Gardner et al. (2008) found that a MBSR course significantly improved the physical and mental component sores of the SF-36 including pain levels. The results of this study supported the use of mind-body intervention.
The purpose of this review is to determine how effective MBSR is in reducing the pain intensity of chronic pain sufferers. If MBSR can be used as an adjunct or successful alternative to the current therapeutic dogma, we can avoid many of the common side effects of medications as well as the potential for abuse. MBSR is also a cheaper choice. It teaches individuals a life skill that may continue long after intervention sessions are completed.
Methods
Literature Search
PubMed and Google Scholar were the two main electronic databases used in the literature review. The search included original published articles. Unpublished data and abstracts were not used in this review. The literature search focused on articles in the English language and those involving human subjects. The time parameters were January 1, 1996 through November 16, 2016. The main search terms were mindfulness-based stress reduction, MBSR, chronic pain, and effectiveness.
FIGURE 1. Search strategy textbox for PubMed.
FIGURE 2. Search strategy textbox for Google Scholar.
Selection of Trials
Studies included in the review were studies that showed the effectiveness of MBSR using pre-interventional and post-interventional pain questionnaires including Pain Catastrophizing Scale, Chronic Pain Acceptance Questionnaire Total Score and Activities Engagement subscale,McGill Pain Questionnaire Short Form, and Short-Form 36 Health Survey and Symptom Checklist-90-Revised. Participants included those 18years of age and order of both genders that had chronic pain. Chronic pain was defined as pain that occurred almost daily for 1 or more months and included musculoskeletal pain, headaches, and pain from various medical disorders such as fibromyalgia, multiple sclerosis or neuropathies. Selected interventional studies had a control group that could either be a waiting list group or a group receiving standard treatment of care. Exclusion criteria included theabsence of control group, review articles, comparative studies, qualitative reports and feasibility reports.
Results
The original literature review yielded 147 articles. One hundred-thirty-seven articles were excluded for not meeting the inclusion criteria. Forty articles were comparison studies with other alternative treatments such as massage therapy. Fifty articles were non-interventional studies that discussed issues such as thefeasibility of MBSR. Twenty articles were qualitative studies that analyze patients’ feelings and experiences with MBSR. Twenty-two studies were review articles. Three studies included a pediatric population aging 5-8 years old. A flow chart of the selection process can be seen in figure 3.
FIGURE 3. Flow diagram of the review process.
Nine randomized controlled trials (RCT) were included in the review. The studies included a geographically diverse population that included Iran, Canada, Europe and the United States. The sample sized ranged from 37 to as high as 282. Three of the nine studies had a retention rate of less than 60%. Eight of the nine studies predominately had women as study subjects (greater than 70%) with Esmer, Blum, Rulf, & Pier (2010)the only exception (44% females).
Participants varied in the etiology of their chronic pain. Two studies focused on headache type pain. One study studied focused on thechronic pain in fibromyalgia patients. Three studies focused on lower back pain while another 3 focused on nonspecific chronic pains. The minimal duration of pain for participants ranged from 1 to 3 months that occurred daily. Participants conditions were confirmed by outpatient clinic assessments, committees such as the International Headache Classification Subcommittee, and utilization of scales such as Roland and Morris Disability Questionnaire with points equal to or greater than 11 as a threshold for chronic pain.
The RCTs included in the review all utilized the MBSR intervention. Four of the studies also used MBSR plus normal treatment of care. The MBSR utilized was based on the Stress Reduction and Relaxation program developed by Kabat-Zinn and colleagues. The typical intervention lasted about 8-weeks and consisted of 8 sessions, each lasting about 2.5 hours for a total of 17.5 hours. Participants were trained to meditate and were involved in exercises that increase empathy and listening skills.Participants were trained in a variety of meditations. Sitting meditation wasa key component of every MBSR. Yoga lessonswere also taught in a few of the studies to improve participant's balance and sense of awareness. Other meditations included amongst studies were body scan, walking meditation and guided audio tapes. The key component employed in MBSR was a focus on breathing to increase awareness. Many of the MBSR present in the studies assigned homework to the participants. This included a requirement to participate in meditational exercises for about 45 minutes each day and to complete a journal. In the journals, participants would recordthe length of their meditation and experiences associated with the meditation.
Five out of nine studies utilize a wait-list control where applicants were crossed over into the meditation program immediately after the intervention group finished the 8-week program. Four studies included controls that received standard medical treatment. Typical standard medical treatment included analgesics and opioid medications.
All nine studies used various forms of numerical pain assessments scales that included the short-form 36 questionnaires(SF-36), McGill Pain Questionnaire, Chronic Pain Assessment Questionnaire(CPAQ), Roland-Morris Disability Questionnaire, Summary Visual Analog Scale for Pain, Pain catastrophizing scale, and Brief Pain Inventory. Five studies utilized theSF-36 or a shorter version of it the short-form 12 questionnaires (SF-12). The SF-36 assesses the perception of the quality of life in 8 subscales include: physical functioning (PF), role limitations due to physical health (RP), bodily pain (PB), general health (GH), energy and vitality (VT), social functioning (SF), role limitations due to emotional problems (RE) and affect health (AH). Three studies utilized the Roland-Morris Disability Questionnaire while two studies utilized the CPAQ and the McGill Pain Questionnaire. Scores for the various scales were taken at baseline, right after intervention and 3-6 month follow-up depending on the study.
Eight studies demonstrated statistically significant improvement of pain after intervention and that the effects continued several months after follow-up. The exception was Schmidt et al (2011) that did not find any significant changes in pain between the intervention group and the control group. Other findings include improvement in several secondary outcomes measured by the global scales. The SF-36 showed strongest improvements in physical health, quality of life and energy and vitality. All three studies utilizing the Roland-Morris Disability Questionnaire showed astatistically significant decrease in functional limitation. Esmer et al (2010) also found improvement in sleep quality post intervention while Gardner et al (2008) found improvement in acceptance of pain and mindfulness scales after the 8 weeks of MBSR. With the exception of Schmidtel al (2011)’s study, all reviewed articles found MBSR effective in reducing pain intensity in patients suffering from various chronic pain conditions.
Table I: Population, Intervention, Control, Outcomes, Conclusions
Reference / Population / Intervention / Control / Outcomes/Results / ConclusionBakhshani et al / Zahedan-Iran, n = 40 (37 finished), with chronic headache, mean age 30.6, 70% female / MBSR + usual drug, 8-session MBSR, 1.5 to 2h/week / Usual drug only / Intensity of pain:intervention (Mean = 53.89) vs. control group (Mean = 71.94)
Other:SF-36: statistically significant differencein physical health (RP), bodily pain (BP), general health (GH), energy and vitality (VT), Affect health (AH) and sum of physical health dimensions (PCS) and mental health (MCS) / MBSR effective on perceived pain intensity and quality of life of patients with chronic headache
Banth et al / Ardebil-Iran, n = 88 (48 finished), with nonspecific chronic LBP, mean age 40.3, females only / MBSR + usual medical care, 8 weeks, each session lasted for 90 min / Usual medical care only / McGill Pain questionnaire: Intervention (Baseline = 26.08, After intervention = 16.37,4 Weeks after = 13.58) vs Control (Baseline = 26.70, After intervention = 24.25, 4 Weeks after = 23.60), subject factor group (F [1, 45] =110.4,P< 0.001) and (F [1, 45] =115.8,P< 0.001).
Other: increasing physical quality of life scores, SF-12 / Highlighted the effectiveness of complementary and alternative treatment for patients with chronic LBP
Esmer et al / Greater Portland, Maine, n = 46 (25 finished), with failed back surgery syndrome, mean age 55.0, 44% female / MBSR + traditional therapy, 8-week period, engaged in classroom learning 1.5 to 2.5 h/week, other 6 days meditate 45 minutes/day / Traditional therapy alone / Chronic Pain Assessment Questionnaire: 7.0-point (on a 108-point [corrected] scale) increase in pain acceptance and quality of life
Roland-Morris Disability Questionnaire: mean 3.6-point [corrected] decrease (on a 24-point scale) in functional limitation
Summary Visual Analog Scale for Pain: mean 6.9-point [corrected] reduction (on a 30-point scale) in pain level
Abridged Pittsburgh Sleep Quality Inventory: mean 2.0-point [corrected] increase (on a 5-point scale) / MBSR can be a useful clinical intervention for patients with FBSS
Gardner-Nix et al / Ontario-Canada, n = 278 (157 finished), with chronic pain (50% were back pain sufferers, other pain conditions included
migraines and headaches, arthritis, facial pain,
fibromyalgia, abdominal pain), mean age 50–55, 81% female / Mindfulness-Based Chronic Pain Management coursetwo hours per week for 10 weeks / Wait list control / Pain catastrophizing scale: Week 10 = catastrophized an
average of 15% less than those in the Control group,
Pain rating scale: Intervention (1-week = 5.9, 10-week = 5.2, Control (1-week = 6.2, 10-week = 6.2)
Quality of life (SF-36): significant difference in PCS scores (F ¼ 5.7,
P, 0.05), significantly higher than those of the Control group at Week 10 (q ¼ 5.46, P, 0.01), / Mindfulness course and may represent a new way of helping chronic pain patients
Cour et al / Rigshospitalet- Copenhagen,
N = 109 (90 finished), with nonspecific chronic pain mean age 48.84, 87% female / MSBR,8-week course period, 45minutes every day in meditation / Wait list control, wait list period lasted between 2 and 2.5 months before exposure to MBSR / Pain Measures:
1) Brief Pain Inventory, Intervention (after = 18.8, at 6 months = 18.0), Control = 17.9
2) SF36 pain scale, Intervention (after = 28.5, at 6 months 30.1), Control = 25.1
3) Control over pain,
Intervention (after = 2.9, at 6 months 2.8), Control = 2.4
4) Pain acceptance, total score, Intervention (after = 56.0, at 6 months 2.8), Control = 47.2
SF36, vitality dimension: Intervention (after= 36.8, at 6 months = 34.8), Control = 27.8
At 6 months after the intervention, none of the scores were significantly different from the scores measured just after treatment ended in a paired samplet-test. After 6 months positive direction: pain measures, the depression scale, and all pain acceptance measures / MSBR significant effects on the lives of patients with long-term chronic pain compared with a wait list group. Significant effect sizes in areas other than vitality, especially in the areas of pain acceptance, being in control of pain, and in general anxiety in the treatment group compared with the wait list group. Lasting significant changes were found for vitality, better coping with pain, better pain acceptance, and better mental health quality of life.
Morone et al (2008) / Pittsburgh-PA, n = 37 (30 completed), with chronic lower back pain, mean age 74.9, 89% female / MBSR group format once a week for
90 minutes for eight weeks, homework recommendation of daily
meditation (six of seven days/week) lasting 50 minutes (45 minutes of meditation, 5 minutes
to complete a diary) / Wait list control, controls were crossed over into the meditation program immediately after the
intervention group finished the 8-week program / Chronic Pain Acceptance: significantly improved for the meditation group, control group worsened over the 8-
week period (P =.008), Activities Engagement subscale of the CPAQ was also significantly
improved (P = .004).
McGill Pain Questionnaire and SF-36 Pain Scale:
Mean pain scores changed in the expected direction for the meditation group as compared to
the control group at 8-week follow-up
Physical Function Scale of the SF-36: significant improvement for the meditation group (P =.03)
Roland Disability Questionnaire: changed in the expected direction for the meditation group as
compared to the control group but this change did not reach statistical significance / 8-week mindfulness meditation program is feasible among community
dwelling older adults with CLBP. Three-month follow-up suggested sustained benefit from
the program as measured by continued meditation by program participants and sustained
improvement in physical function and pain acceptance. MBSR
program a promising non-pharmacologic adjunct to current pain treatment for older adults.
Morone et al (2016) / Pittsburgh metropolitan area, n = 282, with chronic LBP (≥11 points on the Roland and Morris Disability Questionnaire) and chronic pain (duration ≥3 month, mean age 74.5, 66.3% female / 8-week group program followed by 6 monthly sessions, modeled on the Mindfulness-Based Stress Reduction program / Wait list control / Roland and Morris Disability Questionnaire: intervention participants improved an additional -1.1 (mean, 12.1 vs 13.1) points at 8 weeks and -0.04 (mean, 12.2 vs 12.6) points at 6 months (effect sizes, -0.23 and -0.08, respectively)
Numeric Pain Rating Scale: intervention participants improvedan additional -1.8 points (95% CI, -3.1 to -0.05 points; effect size, -0.33), mean pain measure after the intervention were not significant (-0.1 [95% CI, -1.1 to 1.0] at 8 weeks and -1.1 [95% CI, -2.2 to -0.01] at 6 months; effect size, -0.01 and -0.22, respectively)
-functional improvement was not sustained / Mind-body program for chronic LBP improved short-term function and long-term current and most severe pain
Omidi et al / Kashan City-Iran, n = 66 (60 finished), with a tension-type headache according to the International Headache Classification Subcommittee, mean age 34.5, 80% female / MBSR + Treat as usual. The MBSR group received eight weekly treatments. Any session lasted 120 minutes. The sessions were based on MBSR protocol. / Treat as theusual group was treated by antidepressant medication and clinical management. / Pain Scales (International Headache Classification Subcommittee Diary Scale for Headache): mean of pain severity was 7.36 ± 1.25 before intervention, significantly reduced to 5.62 ± 1.74 and 6.07 ± 1.08 after the intervention and follow-up (P < 0.001)
Mindful Attention Awareness Scale: mean of mindful awareness before intervention was 34.9 ± 10.5 and changed to 53.8 ± 15.5 and 40.7 ± 10.9 after the intervention and follow-up sessions (P < 0.001) / BSR could reduce pain and improve mindfulness skills in patients with tension headache.
Schmidt et al / Breisgau-Germany, n = 177, with fibromyalgia, mean age 52.5 years, 100% female / MBSR, an 8-week structured program
with groups of up to 12 patients, taught by a single instructor, one 2.5-h session every week, and an additional
7-h all-day session on a weekend day, daily
homework assignments of 45–60 min. / Wait-list control group / Pain Measures (Quality of Life Profile for the Chronically Ill (PLC): There were no significant differences between groups on primary
outcome,
Other: MBSR patients rated themselves higher on the mind-fulness scale than active control patient, / On the basis of the resultsof this trial, MBSR cannot be recommended as an effective treatment for women with fibromyalgia.
Discussion