Mindfulness for Chronic Pain: can we deliver mindfulness online? We think so, but more work needed!

Blog Post 21It has been estimated that 15 to 20 percent of people experience some form of chronic pain. Chronic pain is pain that persists for more than six months and can have a pervasive impact on the lives of those experiencing it. According to Breivik and colleagues 1 (2006), the most frequent causes of pain include arthritis/osteoarthritis (34 percent) followed by herniated/deteriorating discs (15 percent), traumatic injury (12 percent), rheumatoid arthritis (8 percent), and migraine (7 percent). The presence of pain sometimes results in people limiting their everyday activities, including work, leisure, social and household tasks in an attempt to either reduce the pain or prevent further harm. Ultimately, people may restrict their activity and constrain their lifestyles and become dominated by pain.

Chronic pain can also be difficult for others to understand and can thus impact on interpersonal relationships resulting, for example, in feelings of social isolation, being misunderstood and even helplessness. Associated with these physical and psychological losses are emotional problems such as frustration, anger, anxiety, and low mood. The overall level of disability resulting from chronic pain can thus be mediated by psychological variables rather than being directly linked to the pain.

There is a strong emerging body of evidence for the effectiveness of mindfulness and acceptance-based approaches for a range of difficulties, including chronic pain 2, 3, 4. A common definition of mindfulness describes it as a particular quality of consciousness, which involves “paying attention in a particular way: on purpose, in the present moment, and non-judgementally” 5 (Kabat-Zinn, 1990, p. 4). Others have distinguished mindfulness, in psychological terms, both as an outcome (i.e. mindful awareness) and a process (i.e. mindful practice) 6. Mindful awareness is defined as an abiding presence or awareness that manifests as freedom of mind, freedom from reflexive conditioning. Mindful practice is defined as the systematic practice of intentionally attending in an open, curious, and discerning way, which involves both knowing and shaping the mind7. Shapiro and Carlson 7 suggest a common definition that captures both of these aspects: “the awareness that arises through intentionally attending in an open, accepting, and discerning way to whatever is arising in the current moment” (p. 556).

Mindfulness is a subtle process that can be challenging to communicate and practice in therapeutic settings. It operates in a different way than does classic cognitive behavioral therapy, where the goal is to change behaviour by identifying, reality testing and changing maladaptive, dysfunctional beliefs 8. Building on the mindfulness concept, is the idea of acceptance. Rather than viewing cognitions as maladaptive or dysfunctional, acceptance models view cognitions as natural outcomes of learned experience 9. Building on mindfulness models, acceptance models suggest an alternative way of responding that focuses on the psychological and behavioural problems of avoidance 10.

The word acceptance derives from the Latin root ‘accipere’ which means to receive or take what is offered 9. Hayes and colleagues9 defined it as the “abandonment of dysfunctional change agendas and an active process of feeling feelings as feelings, thinking thoughts as thoughts, remembering memories as memories, and so on” (p.77). This perspective provides a new way to relate to distressing thoughts and emotions so they can be accepted as natural rather than avoided. In a similar way, patients are encouraged to re-engage in previously avoided valued activities10. Importantly, a therapeutic focus on strategies that reduce avoidance through increased acceptance have proved useful for people with chronic pain10. The evidence supporting the benefits of mindfulness and acceptance come from a variety of sources.

For example, Schutze, Rees, Preece, and Schutze11 carried out a cross-sectional study of 104 chronic pain patients attending a pain clinic with a view to assessing how mindfulness interacted with pain, fear, avoidance, and disability. They found that lower levels of mindfulness significantly predicted pain intensity, negative affect, pain catastrophising, pain related fear, pain hyper-vigilance, and functional disability, contributing 17 to 41 percent of the variance of each. The results also showed that mindfulness uniquely predicted pain catastrophising and moderated the relationship between pain intensity and pain catastrophising. The authors argued that the extent to which a person engages in negative ruminations and catastrophic thinking about their pain may depend on their ability to be mindful.

The seminal study establishing a stronger causal link between mindfulness and chronic pain experience and disability was published by Jon Kabat-Zinn in 198512. He implemented his newly developed mindfulness programme for 90 chronic pain patients. Statistically significant reductions were observed in measures of pain intensity, negative body image, pain interference, mood disturbance, and psychological symptomatology, including anxiety and depression. Pain-related drug utilization decreased and activity levels and feelings of self-esteem increased. A comparison group of pain patients did not show significant improvement on these measures after traditional treatment protocols. At 15-month follow-up, the improvements were maintained for all measures except pain intensity. Subsequent meta-analyses confirmed the potential effectiveness of mindfulness programmes13 reporting large effect sizes for improvements in mental and physical health in both controlled and uncontrolled studies (Cohen’s d > .5). Similarly, in treatment outcome studies acceptance-based methods are associated with improved emotional, psychosocial and physical functioning, and reduced healthcare use 14,15,16,17.

While these research findings point to the value of psychological interventions for chronic pain, access to effective pain management programmes is often limited, due to a scarcity of services. Other barriers to treatment include physical symptoms that limit mobility, distance from a clinic, transportation requirements and cost constraints. In response to these barriers to service delivery, internet-based interventions have emerged as a potential solution. The public demand for online health resources is increasing and many existing efficacious face-to-face interventions can be adapted for use on the internet with effect-sizes rivalling those of the original face-to-face interventions 18,19. However, we could not find any randomised controlled trial of an online mindfulness program for chronic pain compared with another active psychological treatment. Therefore, in a recent study, we evaluated the feasibility and effectiveness of a computerised and modified version of an existing mindfulness-based cognitive therapy program 20,21, which we called Mindfulness in Action (MIA) and compared it to an active comparator treatment, an online version of a pain management psychoeducation programme (PM) 22.

While online or distance education programmes for pain have produced small to moderate effect sizes (e.g., d = .2 – .4)23, mindfulness interventions have suggested potential for moderate to large effect sizes for primary outcomes (e.g., d = .48 – 1.1)13. Therefore, we predicted that the mindfulness programme would be superior to the education programme for primary outcomes of pain interference and distress, but also for other outcomes including self-reported pain, catastrophizing, pain acceptance, subjective wellbeing, and self-reported mindfulness.

Using an intention to treat (ITT) approach, 124 adult participants who reported experiencing pain that was unrelated to cancer and of at least six months duration were randomly assigned to computerized mindfulness-based cognitive therapy (“Mindfulness in Action” [MIA]) or pain management psychoeducation (PM) programmes. Week-by-week details of both programmes are presented in our paper, and all our mindfulness videos and meditations are available here.

We collected data on physical functioning and disability, psychological distress, pain intensity, participant ratings of improvement and satisfaction with treatment, catastrophic thinking, and adherence to the treatment regimen. These data were collected before and after the intervention and at six-month follow-up. Intervention effects were evaluated using multilevel modelling. We observed some very interesting findings.

Notably, participants in both MIA and PM groups showed equivalent change and significant improvements on measures of pain interference, pain acceptance and catastrophizing from pre-treatment to post-treatment and the improvements were maintained at six-month follow-up. Average pain intensity also reduced from baseline to post-treatment for both groups, but the reductions were not maintained at follow-up. Participants in both groups reported increases in subjective well-being, and these increases were more pronounced in the MIA when compared with the PM group. Participants in the MIA group also reported a greater reduction in pain ‘right now’, and increases in their ability to manage emotions, manage stress and enjoy pleasant events on completion of the intervention. The changes in ability to manage emotions and stressful events were maintained at follow-up.

The results of our study provide evidence that a computerized mindfulness-based programme brought about greater improvement on measures of life satisfaction, ability to manage emotions, and ‘pain right now’ than a computerized pain self-management psychoeducation program. However, the development of on-line interventions is still in its infancy. Although on-line interventions shows promise in making treatments widely accessible to the public, enthusiasm must be tempered by many questions concerning whether the delivery methods diminish impact. Discerning differences between treatments delivered in an on-line format may be especially difficult, as acceptability and efficacy expectations may be lowered to the point that the therapies are indistinguishable from one another in improving lives. In relation to feasibility, 30 percent of the population invited to participate in our study showed an interest in taking part and of those assigned to both programmes, 52 percent completed and 40 percent provided follow-up data six months later. Completion rates in the current study were low but similar to some other published studies of online interventions. However, the level of attrition raises questions about feasibility and how best to engage participants. Intervention studies that involve face-to-face therapeutic exchanges may benefit from greater commitment on the part of participants and the participants may thus be more likely to complete. At the same time, our study also had a number of strengths. Previous research has identified time and travel commitments as barriers to attendance at typical group programmes. The current study involved participants from across three continents and the format provided participants access to program materials at times that suited their own routine. Therefore, the flexibility of delivery and the low delivery cost of the online program in terms of therapist time suggests that such programmes may be of value even with lower uptake and completion rates than traditional programmes.

We continue working to innovate in this space and we welcome feedback, always!

Haulie Dowd (Mendeley), (ResearchGate) and Michael Hogan

Originally published Feb 20, 2015 in ‘In One Lifespan’ @ PsychologyToday.com

Some links contained within this post are external


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