Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

Importance

Mind-body therapies (MBTs) are emerging as potential tools for addressing the opioid crisis. Knowing whether mind-body therapies may benefit patients treated with opioids for acute, procedural, and chronic pain conditions may be useful for prescribers, payers, policy makers, and patients.

Objective

To evaluate the association of MBTs with pain and opioid dose reduction in a diverse adult population with clinical pain.

Data Sources

For this systematic review and meta-analysis, the MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Cochrane Library databases were searched for English-language randomized clinical trials and systematic reviews from date of inception to March 2018. Search logic included (pain OR analgesia OR opioids) AND mind-body therapies. The gray literature, ClinicalTrials.gov, and relevant bibliographies were also searched.

Study Selection

Randomized clinical trials that evaluated the use of MBTs for symptom management in adults also prescribed opioids for clinical pain.

Data Extraction and Synthesis

Independent reviewers screened citations, extracted data, and assessed risk of bias. Meta-analyses were conducted using standardized mean differences in pain and opioid dose to obtain aggregate estimates of effect size with 95% CIs.

Main Outcomes and Measures

The primary outcome was pain intensity. The secondary outcomes were opioid dose, opioid misuse, opioid craving, disability, or function.

Results

Of 4212 citations reviewed, 60 reports with 6404 participants were included in the meta-analysis. Overall, MBTs were associated with pain reduction (Cohen d = -0.51; 95% CI, -0.76 to -0.26) and reduced opioid dose (Cohen d = -0.26; 95% CI, -0.44 to -0.08). Studies tested meditation (n = 5), hypnosis (n = 25), relaxation (n = 14), guided imagery (n = 7), therapeutic suggestion (n = 6), and cognitive behavioral therapy (n = 7) interventions. Moderate to large effect size improvements in pain outcomes were found for meditation (Cohen d = -0.70), hypnosis (Cohen d = -0.54), suggestion (Cohen d = -0.68), and cognitive behavioral therapy (Cohen d = -0.43) but not for other MBTs. Although most meditation (n = 4 [80%]), cognitive-behavioral therapy (n = 4 [57%]), and hypnosis (n = 12 [63%]) studies found improved opioid-related outcomes, fewer studies of suggestion, guided imagery, and relaxation reported such improvements. Most MBT studies used active or placebo controls and were judged to be at low risk of bias.

Conclusions and Relevance

The findings suggest that MBTs are associated with moderate improvements in pain and small reductions in opioid dose and may be associated with therapeutic benefits for opioid-related problems, such as opioid craving and misuse. Future studies should carefully quantify opioid dosing variables to determine the association of mind-body therapies with opioid-related outcomes.

The Effectiveness of Group-Based Physiotherapy-Led Behavioral Psychological Interventions on Adults With Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Group-based physiotherapy-led behavioral psychological interventions (GPBPIs) are an emerging treatment for chronic low back pain, but the efficacy of these interventions is uncertain. A review of relevant randomized controlled trials and a meta-analysis was conducted to evaluate the effectiveness of GPBPIs on pain relief in adults with chronic low back pain. Literature databases, Google Scholar, bibliographies, and other relevant sources were searched. Thirteen intervention studies (13) published from 1998 to 2013 were included. The meta-analysis was conducted using RevMan software in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. In reviewing the short- (<6 mos), intermediate- (≥6 and <12 mos), and longer-term (≥12 mos) effects of GPBPIs, long-term follow-up evaluations showed large and significant effect sizes (standardized mean difference = -0.25, 95% confidence interval = -0.39 to -0.11, I2 = 38%, P < 0.01). Subgroup analysis indicated that patients from GPBPIs group had the greater short-, intermediate-, and long-term pain reduction than patients on waiting listing or usual care group. Compared with other active treatments, GPBPIs showed a small but significant long-term pain reduction in patients with chronic low back pain (standardized mean difference = -0.18, 95% confidence interval = -0.35 to -0.01, I2 = 32%, P = 0.04). In general, GPBPIs may be an acceptable intervention to relieve pain intensity.

Emotional Effects on Factors Associated with Chronic Low Back Pain

PURPOSE

Although chronic low back pain (CLBP) has profound effects on patients, society, and economy, its causes are difficult to identify. Psychogenic effects or social stress is known to affect CLBP; hence, investigation of its underlying causes requires a multifactorial approach. We determined the factors associated with CLBP by using an Internet-based survey. To prevent CLBP, we need to understand its cause and background.

PATIENTS AND METHODS

A total of 1000 participants either with (+) or without (-) CLBP answered the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), which assesses five domains of CLBP: low back pain, lumbar function, walking ability, social life function and mental health. We also administered a new questionnaire for participants, that comprised five different domains: Body, Lifestyle, Emotion, Diet, and Social. To evaluate psychogenic effects on CLBP, we added two original factors, namely outshout and HIE, which have not yet been studied. HIE is a traditional concept (sense) of "feeling cold" or "chilly." All participants completed both questionnaires.

RESULTS

Multivariate logistic regression analysis extracted four factors (sleep, room temperature, outshout, and HIE) that were associated with CLBP. The mental health domain was assessed using the JOABPEQ for each of these factors. The factors outshout and HIE differed between CLBP (+) and CLBP (-) patients. CLBP (-) participants also showed a difference in Sleep and HIE factors.

CONCLUSION

Among psychogenic effects, Emotion was common to all the four extracted factors. There was no common physical divisor. Therefore, we hypothesized that acute low back pain might develop into CLBP in the presence of psychological stress or other emotional factors such as outshout or HIE. Hence, we need to consider both physical and psychogenic effects in the prevention and treatment of CLBP. Furthermore, appropriate evaluation and treatment of psychological stress may be effective in reducing CLBP.

Effectiveness of a multidisciplinary BIOPSYCHOSOCIAL intervention for non-specific SUBACUTE low back pain in a working population: a cluster randomized clinical trial

BACKGROUND

Low back pain (LBP) is a multifactorial condition with individual and societal impact that affects populations globally. Current guidelines for the treatment of LBP recommend pharmacological and non-pharmacological strategies. The aim of this study was to compare usual clinical practice with the effectiveness of a biopsychosocial multidisciplinary intervention in reducing disability, severity of pain and improving quality of life in a working population of patients with subacute (2-12 weeks), non-specific LBP.

METHODS

Longitudinal cluster randomized clinical trial conducted in 39 Primary Health Care Centres (PHCC) of Barcelona, with patients aged 18-65 years (n = 501; control group = 239; 26 PHCC, intervention group = 262; 13 PHCC). The control group received usual clinical care. The intervention group received usual clinical care plus a biopsychosocial multidisciplinary intervention, which consisted of physiotherapy, cognitive-behavioural therapy and medication. The main outcomes were changes in the Roland Morris Disability Questionnaire (RMDQ), and the minimal clinically important differences. Secondary outcomes were changes in the McGill Pain (MGPQ) and Quality of Life (SF-12) questionnaires. Assessment was conducted at baseline, 3 and 12 months. Analysis was by intention-to-treat and analyst-blinded. Multiple imputations were used.

RESULTS

Of the 501 enrolled patients, 421 (84%) provided data at 3 months, and 387 (77.2%) at 12 months. Mean age was 46.8 years (SD: 11.5) and 64.7% were women. In the adjusted analysis of the RMDQ outcome, only the intervention group showed significant changes at 3 months (- 1.33 points, p = 0.005) and at 12 months (- 1.11 points, p = 0.027), but minimal clinically important difference were detected in both groups. In the adjusted analysis of the RMDQ outcome, the intervention group improvement more than the control group at 3 months (- 1.33 points, p = 0.005) and at 12 months (- 1.11 points, p = 0.027). The intervention group presented a significant difference. Both groups presented a minimal clinically important difference, but more difference in the intervention group. The intervention group presented significant differences in the MGPQ scales of current pain intensity and VAS scores at 3 months. No statistically significant differences were found in the physical and mental domains of the SF-12.

CONCLUSIONS

A multidisciplinary biopsychosocial intervention in a working population with non-specific subacute LBP has a small positive impact on disability, and on the level of pain, mainly at short-term, but no difference on quality of life.

TRIAL REGISTRATION

ISRCTN21392091 (17 oct 2018) (Prospectively registred).

Interactions between analgesic drug therapy and mindfulness-based interventions for chronic pain in adults: protocol for a systematic scoping review

INTRODUCTION

Most current chronic pain treatment strategies have limitations in effectiveness and tolerability, and accumulating evidence points to the added benefits of rational combinations of different therapies. However, most published clinical trials of treatment combinations have involved combinations of 2 drugs, whereas very little research has been performed to characterize interactions between drug and nondrug interventions. Mindfulness-based interventions (MBIs) have been emerging as a safe and potentially effective treatment option in the management of chronic pain, but it is unclear how MBIs can and should be integrated with various other pain treatment interventions. Thus, we seek to review available clinical trials of MBIs for chronic pain to evaluate available evidence on the interactions between MBIs and various pharmacological treatments.

METHODS

A detailed search of trials of MBIs for the treatment of chronic pain in adults will be conducted on the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO from their inception until the date the searches are run to identify relevant randomized controlled trials. Primary outcomes will include the following: (1) what concomitant analgesic drug therapies (CADTs) were allowed; (2) if and how trials controlled for CADTs and analyzed their interaction; and (3) results of available analyses of interactions between the MBI and CADT.

PERSPECTIVE

This review is expected to synthesize available evidence describing the interactions between MBIs and various studied drug therapies for chronic pain. Available evidence may help inform the rational integration of MBIs with drug therapy for chronic pain.

A Brief Mindfulness Intervention for Medically Hospitalized Patients with Acute Pain: A Pilot Randomized Clinical Trial

OBJECTIVE

Mindfulness interventions may be beneficial for patients with chronic pain; however, the effects for acute pain are not understood. The purpose of this study was to pilot test a brief mindfulness intervention for acute pain and stress for patients in an inpatient medical setting.

DESIGN

Pilot randomized clinical trial.

SETTING

An inpatient Acute Care Surgery service at an urban hospital.

SUBJECTS

Sixty patients with acute pain were randomly selected and agreed to participate.

METHODS

Interested patients consented to the study and were randomized to the 10-minute intervention (i.e., mindfulness strategy) or comparison group (i.e., education on the Gate Control Theory of Pain). Participants completed pre- and post-assessment measures on pain severity and stress.

RESULTS

Preliminary results showed that within the intervention and comparison groups, participants experienced decreases in pain from pre- to post-intervention (P = 0.002 and 0.005, respectively). Within the intervention group, there was a significant decrease in stress from pre- to post-intervention (P = 0.001). There were no significant changes for stress within the comparison group (P = 0.32). There were no significant differences between the intervention and comparison groups for pain (P = 0.44) or stress (P = 0.07) at post-intervention, although Cohen's d effect sizes were small to medium for pain and stress, respectively.

CONCLUSIONS

A brief mindfulness intervention for medically hospitalized patients with acute pain may decrease pain and stress. Future research should examine this intervention with a fully powered, larger sample to examine efficacy.

Cannabinoids, Pain, and Opioid Use Reduction: The Importance of Distilling and Disseminating Existing Data

The high prevalence of chronic pain conditions combined with an over-reliance on opioid prescriptions has resulted in an opioid epidemic and a desperate need for solutions. There is some debate about whether cannabis might play a role in addressing chronic pain conditions as well as the opioid epidemic. Recent surveys suggest that a large number of people are using cannabis as a treatment for pain and to reduce use of opioids, and cannabis-derived products demonstrate at least modest efficacy in the treatment of pain in randomized controlled trials. In addition, surveillance studies from countries that have approved the use of Sativex, which is a cannabis-based product, have demonstrated that a combination of Δ9-tetrahydrocannabinol and cannabidiol has low potential for harm, is well tolerated, and is helpful to patients. Given the number of people in the United States who are already using cannabis to manage pain and opioid use in state-regulated markets, it is imperative to conduct additional research in these areas, and to disseminate information on how to minimize harm and maximize any benefits of using cannabinoids to mitigate pain and reduce opioid use. The purpose of this article is to call attention to the fact that cannabis is being used in the management of chronic pain. Thus, this article also provides a set of guidelines on how to approach using cannabis to treat pain.

Promoting Spiritual Healing by Stress Reduction Through Meditation for Employees at a Veterans Hospital: A CDC Framework-Based Program Evaluation

Background: Employees in the Veterans Affairs (VA) hospital experience psychological stress from caring for vulnerable veteran populations. Evidence suggests that mindfulness meditation decreases stress in health care employees and military personnel. The purpose of this worksite program was to explore the acceptability of a mindfulness meditation program among VA workers. Methods: Chaplain residents developed the "Promoting Spiritual Healing by Stress Reduction Through Meditation" (Spiritual Meditation) program for employees in a VA hospital. To evaluate acceptability, a 13-multiple-choice-item survey with an open-ended question was administered after the intervention. Descriptive statistics and qualitative content analysis were performed. Findings: In 29 participants, 70% to 100% agreed with positive statements for the personal learning experience, program components, teacher quality, time to practice, and place to practice. Two categories emerged from qualitative responses: "positive practical experience of Spiritual Meditation" and "perceived values from Spiritual Meditation." Conclusion/Application to Practice: Occupational health nurses are uniquely positioned to lead and collaborate with chaplains to deliver Spiritual Meditation in their workplace setting.

Mapping the Affective Dimension of Embodiment With the Sensation Manikin: Validation Among Chronic Pain Patients and Modification by Mindfulness-Oriented Recovery Enhancement

OBJECTIVE

Mindfulness-based interventions target novel pain relief mechanisms not captured by legacy pain scales, including 1) cultivating awareness of pleasant and neutral sensations proximal to unpleasant sensations and 2) interoceptively mapping sensation location and spatial distribution.

METHODS

We created a digital sensation manikin (SM) by overlaying a human figure silhouette with a grid of 469 "sensation" pixels. A series of five research questions examined the SM's discriminant validity, construct validity, incremental validity, convergence with an objective measure of pain attentional bias, and sensitivity to a mindfulness-based psychological treatment, Mindfulness-Oriented Recovery Enhancement (MORE). A sample of opioid treated chronic pain patients (n = 108; age, 53.79 (12.94) years; female, 65%) was recruited to answer research questions 1 to 5, and a sample of healthy controls (n = 91; age, 36.47 (13.50) years; female, 55%) was recruited as the comparison group for research question 1.

RESULTS

Chronic pain patients reported significantly more unpleasant sensations than did healthy controls (p < .001, d = 1.23) and significantly fewer pleasant sensations (p = .001, d = 0.50). The SM also evidenced expected relationships with multiple measures of pain (r = 0.26-0.29) and well-being (r = -0.21 to 0.28), uniquely predicted pain interference (β = -0.18), and exhibited a significant association with pain attentional bias (r = 0.25). Finally, mindfulness-based intervention via MORE significantly increased the ratio of pleasant to unpleasant sensations reported by chronic pain patients relative to an active control condition (p = .036, d = 0.51).

CONCLUSIONS

This study supports the SM's validity and indicates that assessing both pleasant and unpleasant sensations broadens the scope of pain measurement. Although the SM would benefit from further optimization, its continued use is likely to contribute to improved assessment and treatment options for chronic pain patients.

The Chinese Association for the Study of Pain (CASP): Consensus on the Assessment and Management of Chronic Nonspecific Low Back Pain

Chronic nonspecific low back pain (CNLBP) is defined as pain or discomfort originating from the waist, which lasts for at least 12 weeks, but no radiculopathy or specific spinal diseases. CNLBP is a complicated medical problem and places a huge burden on healthcare systems. Clinical manifestation of CNLBP includes discogenic LBP, zygapophyseal joint pain, sacroiliac joint pain, and lumbar muscle strain. Further evaluation should be completed to confirm the diagnosis including auxiliary examination, functional assessment, and clinical assessment. The principle of the management is to relieve pain, restore function, and avoid recurrence. Treatment includes conservative treatment, minimally invasive treatment, and rehabilitation. Pharmacologic therapy is the first-line treatment of nonspecific LBP, and it is most widely used in clinical practice. Interventional therapy should be considered only after failure of medication and physical therapy. Multidisciplinary rehabilitation can improve physical function and alleviate short-term and long-term pain. The emphasis should be put on the prevention of NLBP and reducing relevant risk factors.

Mindfulness interventions and pain management in a patient with encephalomyelitis

Chronic pain is considered a common disabling disease, frequently related to a high comorbidity with anxiety and depression. Several psychological techniques have demonstrated to be effective in the treatment of chronic pain, in particular, mindfulness-based interventions (MBIs) seem to reduce pain acting on self-regulatory individual's ability. In addition, this approach could develop cognitive strategies to decrease impulsivity. We selected a case of a patient with encephalomyelitis and spastic tetraparesis to assess the application and effectiveness of MBIs to reduce pain perception, improve anxiety and depressive symptoms. Our treatment showed a reduction in pain perception, and an improvement in anxious and depressive symptoms. In conclusion, MBIs could be useful to relieve disorders related to pain in neurological patients.

The neural mechanisms of mindfulness-based pain relief: a functional magnetic resonance imaging-based review and primer

The advent of neuroimaging methodologies, such as functional magnetic resonance imaging (fMRI), has significantly advanced our understanding of the neurophysiological processes supporting a wide spectrum of mind–body approaches to treat pain. A promising self-regulatory practice, mindfulness meditation, reliably alleviates experimentally induced and clinical pain. Yet, the neural mechanisms supporting mindfulness-based pain relief remain poorly characterized. The present review delineates evidence from a spectrum of fMRI studies showing that the neural mechanisms supporting mindfulness-induced pain attenuation differ across varying levels of meditative experience. After brief mindfulness-based mental training (ie, less than 10 hours of practice), mindfulness-based pain relief is associated with higher order (orbitofrontal cortex and rostral anterior cingulate cortex) regulation of low-level nociceptive neural targets (thalamus and primary somatosensory cortex), suggesting an engagement of unique, reappraisal mechanisms. By contrast, mindfulness-based pain relief after extensive training (greater than 1000 hours of practice) is associated with deactivation of prefrontal and greater activation of somatosensory cortical regions, demonstrating an ability to reduce appraisals of arising sensory events. We also describe recent findings showing that higher levels of dispositional mindfulness, in meditation-naïve individuals, are associated with lower pain and greater deactivation of the posterior cingulate cortex, a neural mechanism implicated in self-referential processes. A brief fMRI primer is presented describing appropriate steps and considerations to conduct studies combining mindfulness, pain, and fMRI. We postulate that the identification of the active analgesic neural substrates involved in mindfulness can be used to inform the development and optimization of behavioral therapies to specifically target pain, an important consideration for the ongoing opioid and chronic pain epidemic.

Enhancing Motivation for Change in the Management of Chronic Painful Conditions: a Review of Recent Literature

PURPOSE OF REVIEW

The purpose of this review is to evaluate and summarize recent empirical research investigating motivational factors for management of chronic pain and headache disorders.

RECENT FINDINGS

Research on motivation for non-pharmacological treatment of chronic pain and headache disorders has identified factors that influence initiation of and adherence to treatment. To address common factors that inhibit initiation of treatment (i.e., cost, time commitment), several electronic treatments have been developed. Self-efficacy is the most commonly studied psychosocial influence on treatment adherence, with evidence that it is positively correlated with adherence. Other studies have sought to improve adherence to treatment using motivational interviewing interventions. There is currently limited research on how to enhance motivation for initial adherence to non-pharmacological treatment for chronic pain and headache disorders. Instead of enhancing motivation, researchers have looked to reduce barriers to treatment with electronic health treatments; however, many of these studies have focused on intervention feasibility, rather than efficacy or effectiveness. Numerous studies have identified a relationship between self-efficacy and treatment adherence. Although motivational interviewing interventions have been shown to improve adherence to treatment, there is little evidence that they improve treatment outcomes. Recommendations for further investigation include improving interventions to enhance accessibility and adherence to treatment with the goal of improving outcomes, as well as identifying ways to improve treatment initiation and adherence in patients who are currently engaged in long-term opioid therapy.

The Role of Heart Rate Variability in Mindfulness-Based Pain Relief

Mindfulness meditation is a self-regulatory practice premised on sustaining nonreactive awareness of arising sensory events that reliably reduces pain. Yet, the specific analgesic mechanisms supporting mindfulness have not been comprehensively disentangled from the potential nonspecific factors supporting this technique. Increased parasympathetic nervous system (PNS) activity is associated with pain relief corresponding to a number of cognitive manipulations. However, the relationship between the PNS and mindfulness-based pain attenuation remains unknown. The primary objective of the present study was to determine the role of high-frequency heart rate variability (HF HRV), a marker of PNS activity, during mindfulness-based pain relief as compared to a validated, sham-mindfulness meditation technique that served as a breathing-based control. Sixty-two healthy volunteers (31 females; 31 males) were randomized to a 4-session (25 min/session) mindfulness or sham-mindfulness training regimen. Before and after each group's respective training, participants were administered noxious (49°C) and innocuous (35°C) heat to the right calf. HF HRV and respiration rate were recorded during thermal stimulation and pain intensity and unpleasantness ratings were collected after each stimulation series. The primary analysis revealed that during mindfulness meditation, higher HF HRV was more strongly associated with lower pain unpleasantness ratings when compared to sham-mindfulness meditation (B = -.82, P = .04). This finding is in line with the prediction that mindfulness-based meditation engages distinct mechanisms from sham-mindfulness meditation to reduce pain. However, the same prediction was not confirmed for pain intensity ratings (B = -.41). Secondary analyses determined that mindfulness and sham-mindfulness meditation similarly reduced pain ratings, decreased respiration rate, and increased HF HRV (between group ps < .05). More mechanistic work is needed to reliably determine the role of parasympathetic activation in mindfulness-based pain relief as compared to other meditative techniques. Perspective: Mindfulness has been shown to engage multiple mechanisms to reduce pain. The present study extends on this work to show that higher HRV is associated with mindfulness-induced reductions in pain unpleasantness, but not pain intensity ratings, when compared to sham-mindfulness meditation. These findings warrant further investigation into the mechanisms engaged by mindfulness as compared to placebo.

Differential sensitivity of mindfulness questionnaires to change with treatment: A systematic review and meta-analysis

[Correction Notice: An Erratum for this article was reported in Vol 31(10) of Psychological Assessment (see record 2019-58643-005). The article should have been published under the terms of the Creative Commons Attribution License (CC BY 3.0). Therefore, the article was amended to list the authors as copyright holders, and information about the terms of the CC BY 3.0 was added to the author note. In addition, the article is now open access. All versions of this article have been corrected.] In support of the construct validity of mindfulness questionnaires, meta-analytic reviews have reported that scores increase in mindfulness-based interventions (MBIs). However, several studies have also found increased mindfulness scores in interventions with no explicit mindfulness training, raising a question about differential sensitivity to change with treatment. We conducted a systematic review and meta-analysis of 37 randomized controlled trials in which mindfulness questionnaires were administered before and after an evidence-based MBI and a nonmindfulness-based active control condition. The central question was whether increases in mindfulness scores would be greater in the MBI than in the comparison group. On average, participants in MBIs showed significantly greater pre-post changes in mindfulness scores than were seen in active control conditions with no explicit mindfulness elements, with a small overall effect size. This effect was moderated by which mindfulness questionnaire was used, by the type of active control condition, and by whether the MBI and control were matched for amount of session time. When mindfulness facet scores were analyzed separately, MBIs showed significantly greater pre-post increases than active controls in observing, nonjudging, and nonreactivity but not in describing or acting with awareness. Although findings provide partial support for the differential sensitivity of mindfulness questionnaires to change with treatment, the nonsignificant difference in pre-post change when the MBI and control were matched for session time highlights the need to clarify how mindfulness skills are acquired in MBIs and in other interventions and whether revisions to mindfulness questionnaires would increase their specificity to changes in mindfulness skills. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Best Evidence Rehabilitation for Chronic Pain Part 3: Low Back Pain

Chronic Low Back Pain (CLBP) is a major and highly prevalent health problem. Given the high number of papers available, clinicians might be overwhelmed by the evidence on CLBP management. Taking into account the scale and costs of CLBP, it is imperative that healthcare professionals have access to up-to-date, evidence-based information to assist them in treatment decision-making. Therefore, this paper provides a state-of-the-art overview of the best evidence non-invasive rehabilitation for CLBP. Taking together up-to-date evidence from systematic reviews, meta-analysis and available treatment guidelines, most physically inactive therapies should not be considered for CLBP management, except for pain neuroscience education and spinal manipulative therapy if combined with exercise therapy, with or without psychological therapy. Regarding active therapy, back schools, sensory discrimination training, proprioceptive exercises, and sling exercises should not be considered due to low-quality and/or conflicting evidence. Exercise interventions on the other hand are recommended, but while all exercise modalities appear effective compared to minimal/passive/conservative/no intervention, there is no evidence that some specific types of exercises are superior to others. Therefore, we recommend choosing exercises in line with the patient's preferences and abilities. When exercise interventions are combined with a psychological component, effects are better and maintain longer over time.

Complementary and Integrated Health Approaches: What Do Veterans Use and Want

OBJECTIVES

Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches.

METHODS

Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n = 3346, 37% response rate) in July 2017.

RESULTS

In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA.

CONCLUSIONS

Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.

The Many Roads to Mindfulness: A Review of Nonmindfulness-Based Interventions that Increase Mindfulness

Objectives: Mindfulness-based interventions (MBIs) have become increasingly popular for treating various physical and mental disorders. An increase in mindfulness levels through the teaching of mindfulness meditation is the most well-studied mechanism of MBIs. Recent studies, however, suggest that an increase in mindfulness is also observed in physical or psychosocial interventions not explicitly labeled as MBIs, or what the authors call non-MBIs. The authors aimed to review what non-MBIs can increase mindfulness levels despite not explicitly teaching mindfulness meditation. Design: The authors conducted a literature search for studies that included a non-MBI study arm measuring pre- and postintervention mindfulness levels using one of the following eight validated self-reported mindfulness questionnaires: Five-Faceted Mindfulness Questionnaire, Mindful Awareness and Attention Scale, Freiburg Mindfulness Inventory, Toronto Mindfulness Scale, Philadelphia Mindfulness Scale, Kentucky Inventory of Mindfulness Skills, Child and Adolescent Mindfulness Measure, and Cognitive and Affective Mindfulness Scale-Revised. The authors identified 69 non-MBI study arms from 51 independent studies of the non-MBI itself or as active controls of an MBI under investigation. The authors documented or calculated, if not provided, effect sizes (ES) for changes in mindfulness levels following these interventions. Results: Among the 69 non-MBI arms, 36 showed no effect for change in mindfulness (ES <0.20), 3 were indeterminate (no ES available or unable to calculate), 13 had small effects (0.20 < ES <0.5), 13 had medium effects (0.50 < ES <0.80), 3 had large effects (0.80 < ES <1.3), and 1 had a very large effect (ES >1.3) for change in mindfulness. Conclusions: Analysis of the characteristics of non-MBIs with significant increases in mindfulness levels suggested some commonalities between MBIs and non-MBIs, shedding light on a spectrum of mindfulness-related interventions and the possibility that there are many roads to developing mindfulness.

Acceptability and Feasibility of a Mindfulness-Based Intervention for Pain Catastrophizing among Persons with Sickle Cell Disease

BACKGROUND

Few investigators have developed and tested nonpharmacological interventions for helping persons with sickle cell disease (SCD) manage persistent pain.

AIMS

The purpose of this pilot study was to examine the feasibility and acceptability of a mindfulness-based intervention (MBI) in adults with SCD and chronic pain and to gather preliminary data on its efficacy.

DESIGN

Data on feasibility and acceptability, including recruitment, retention, and attendance rates, were collected during a single-site, randomized control trial. Participants were randomly assigned to either a 6-session group telephonic MBI or a wait-listed control. Pain catastrophizing was assessed at baseline and at weeks 1, 3, and 6.

SETTING

Outpatient, comprehensive, interdisciplinary sickle cell disease center in the Southeast.

PARTICIPANTS/SUBJECTS

Adults at least 18 years of age with a self-reported diagnosis of sickle cell disease who self-identified as having chronic, non-cancer pain that persisted on most days for at least 6 months and adversely affected function and/or well-being.

METHODS

Seventy-eight adults were recruited; 18 (23%) declined to participate; 60 were randomly assigned to either the MBI (N = 40) or control (N = 20). Of those, 14 (35%) from the MBI and 12 (60%) from the control group withdrew immediately after random allocation, resulting in 34 evaluable cases (MBI: N = 26; control: N = 8).

RESULTS

Among the 26 assigned to MBI, the median number of sessions attended per person was 4; 7 (27%) attended all six sessions. Qualitative findings indicated that MBI participants viewed the program as acceptable and liked the telephonic format, community, and content. Reductions in pain catastrophizing outcomes were identified after intervention.

CONCLUSIONS

An MBI is feasible and acceptable for persons with SCD experiencing chronic pain. A larger randomized controlled trial to establish MBI efficacy on pain and related outcomes for SCD will provide nonpharmacologic, behavioral pain management options for nurses and other clinicians caring for persons with SCD and chronic pain.

Conducting a pilot randomized controlled trial of community-based mindfulness-based stress reduction versus usual care for moderate-to-severe migraine: protocol for the Mindfulness and Migraine Study (M&M)

BACKGROUND

Migraine is one of the most common neurological disorders in clinical practice and is a substantial cause of disability worldwide. Current approaches to therapy are primarily based on medication but are often limited by inadequate effectiveness and common side effects. Newer, more effective medications are expensive. Mindfulness-based stress reduction (MBSR), an 8-week classroom-based meditation intervention, is inexpensive, has no known side effects, and has demonstrated clinically meaningful effectiveness for several chronic-pain syndromes. In addition, MBSR has shown promising results for migraine therapy in a few small case studies and pilot studies. We present here the protocol for a two-arm randomized controlled pilot trial of MBSR for moderate-to-severe episodic migraine, which, if successful, will form the basis for a fully powered clinical trial.

METHODS/DESIGN

This study, set in Northern California, is a two-arm parallel-comparison single-blinded randomized controlled pilot trial with the goal of recruiting approximately 60 participants with moderate-to-severe episodic migraine. The feasibility outcomes include ability and time required to recruit, adherence to the MBSR treatment, and ability to measure outcomes using 31-day headache diaries and patient-reported questionnaire data. The active treatment arm consists of an 8-week community-based MBSR class plus usual care, and the wait-list control group is usual care. Recruitment is underway and expected to be complete by the end of 2018.

DISCUSSION

To our knowledge, this is the first pragmatic trial in the U.S. of MBSR for migraine using community-based classes, and if it proves viable, we plan to conduct a fully powered trial to determine the effectiveness of the intervention for reducing headache days for moderate-to-severe episodic migraineurs.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02824250 . Registered on 6 July 2016.

Care for low back pain: can health systems deliver?

Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients’ self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.

Mindfulness Training and Physical Health: Mechanisms and Outcomes

OBJECTIVE

There has been substantial research and public interest in mindfulness interventions, biological pathways, and health for the past two decades. This article reviews recent developments in understanding relationships between mindfulness interventions and physical health.

METHODS

A selective review was conducted with the goal of synthesizing conceptual and empirical relationships between mindfulness interventions and physical health outcomes.

RESULTS

Initial randomized controlled trials in this area suggest that mindfulness interventions can improve pain management outcomes among chronic pain populations, and there is preliminary evidence for mindfulness interventions improving specific stress-related disease outcomes in some patient populations (i.e., clinical colds, psoriasis, irritable bowel syndrome, posttraumatic stress disorder, diabetes, HIV). We offer a stress-buffering framework for the observed beneficial effects of mindfulness interventions and summarize supporting biobehavioral and neuroimaging studies that provide plausible mechanistic pathways linking mindfulness interventions with positive physical health outcomes.

CONCLUSIONS

We conclude with new opportunities for research and clinical implementations to consider in the next two decades.

Predictors of Mindfulness Meditation and Exercise Practice, from MEPARI-2, a randomized controlled trial

Objectives

Health-supporting behaviors can be challenging to initiate and maintain. Data from the MEPARI-2 randomized trial were used to assess predictors of sustained exercise and meditation practice.

Methods

Adults aged 30 to 69 years not exercising regularly and without prior meditation training were randomized to 8-week trainings in mindfulness meditation, moderate intensity exercise, or observational control, and monitored for 8 months. Exercise participants reported day-to-day minutes of moderate and vigorous activity; mindfulness meditation participants reported minutes of informal and formal practice. Demographic characteristics and psychosocial factors were assessed as predictors of practice. Growth mixture modeling was used to identify higher and lower practice subgroups.

Results

413 participants (75.8% female; mean (SD) age 49.7 (11.6) years) were randomized to exercise (137), mindfulness meditation (138), or control (138), with 390 (95%) completing the study. Seventy-nine percent of exercisers and 62% of meditators reported ≥150 minutes/week practice for at least half of the 37 weeks monitored. Self-reported minutes of mindfulness meditation and/or exercise practice were significantly (p<0.01) predicted by baseline levels of: general mental health, self-efficacy, perceived stress, depressive symptoms, openness, neuroticism, physical activity, smoking status, and number of social contacts. Growth mixture modeling identified subsets of people with moderate (100-200 min/week) and high (300-450 min/week) levels of self-reported practice for both mindfulness meditation (62% moderate; 38% high) and exercise (71% moderate; 29% high).

Conclusions

In this sample, participants randomized to behavioral trainings reported high levels of practice sustained over 37 weeks. Baseline psychosocial measures predicted practice levels in expected directions.

Discogenic Back Pain: Literature Review of Definition, Diagnosis, and Treatment

Discogenic back pain is multifactorial; hence, physicians often struggle to identify the underlying source of the pain. As a result, discogenic back pain is often hard to treat—even more so when clinical treatment strategies are of questionable efficacy. Based on a broad literature review, our aim was to define discogenic back pain into a series of more specific and interacting pathologies, and to highlight the need to develop novel approaches and treatment strategies for this challenging and unmet clinical need. Discogenic pain involves degenerative changes of the intervertebral disc, including structural defects that result in biomechanical instability and inflammation. These degenerative changes in intervertebral discs closely intersect with the peripheral and central nervous systems to cause nerve sensitization and ingrowth; eventually central sensitization results in a chronic pain condition. Existing imaging modalities are nonspecific to pain symptoms, whereas discography methods that are more specific have known comorbidities based on intervertebral disc puncture and injection. As a result, alternative noninvasive and specific diagnostic methods are needed to better diagnose and identify specific conditions and sources of pain that can be more directly treated. Currently, there are many treatments/interventions for discogenic back pain. Nevertheless, many surgical approaches for discogenic pain have limited efficacy, thus accentuating the need for the development of novel treatments. Regenerative therapies, such as biologics, cell‐based therapy, intervertebral disc repair, and gene‐based therapy, offer the most promise and have many advantages over current therapies. © 2019 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research

Brief Mindfulness-Based Interventions for Acute and Chronic Pain: A Systematic Review

OBJECTIVES

Nonpharmacologic approaches have been characterized as the preferred means to treat chronic noncancer pain by the Centers for Disease Control and Prevention. There is evidence that mindfulness-based interventions (MBIs) are effective for pain management, yet the typical MBI may not be feasible across many clinical settings due to resource and time constraints. Brief MBIs (BMBIs) could prove to be more feasible and pragmatic for safe treatment of pain. The aim of the present article is to systematically review evidence of BMBI's effects on acute and chronic pain outcomes in humans.

METHODS

A literature search was conducted using PubMed, PsycINFO, and Google Scholar and by examining the references of retrieved articles. Articles written in English, published up to August 16, 2017, and reporting on the effects of a BMBI (i.e., total contact time <1.5 h, with mindfulness as the primary therapeutic technique) on a pain-related outcome (i.e., pain outcome, pain affect, pain-related function/quality of life, or medication-related outcome) were eligible for inclusion. Two authors independently extracted the data and assessed risk of bias.

RESULTS

Twenty studies meeting eligibility criteria were identified. Studies used qualitative (n = 1), within-group (n = 3), or randomized controlled trial (n = 16) designs and were conducted with clinical (n = 6) or nonclinical (i.e., experimentally-induced pain; n = 14) samples. Of the 25 BMBIs tested across the 20 studies, 13 were delivered with audio/video recording only, and 12 were delivered by a provider (participant-provider contact ranged from 3 to 80 min). Existing evidence was limited and inconclusive overall. Nevertheless, BMBIs delivered in a particular format-by a provider and lasting more than 5 min-showed some promise in the management of acute pain.

CONCLUSIONS

More rigorous large scale studies conducted with pain populations are needed before unequivocally recommending BMBI as a first-line treatment for acute or chronic pain.

Cost-Effectiveness of a Team-Based Integrative Medicine Approach to the Treatment of Back Pain

OBJECTIVES

To report the results of health economic analyses comparing two treatment approaches for chronic low back pain (CLBP).

DESIGN

Observational prospective cohort study comparing effectiveness and cost-effectiveness of CLBP care provided at an integrative care clinic with that provided in other clinics within the same hospital. CLBP-related medical utilization, function, quality of life, and days of work incapacity were self-reported at baseline, 3, 6, and 12 months.

SETTINGS/LOCATION

Osher Clinical Center (OCC) based at a tertiary academic hospital (Brigham and Women's Hospital [BWH]) and other clinics at BWH.

SUBJECTS

CLBP patients seeking care at OCC or non-OCC BWH clinics.

INTERVENTIONS

Integrative or conventional care for CLBP as prescribed by the treating clinician(s).

OUTCOME MEASURES

Quality-adjusted life years (QALYs) were estimated per treatment approach based on the SF-12. Cost per QALY gained was evaluated using an incremental cost-effectiveness ratio (ICER). ICERs based on CLBP-specific effectiveness measures (Roland Disability Questionnaire [RDQ] and bothersomeness of pain [BOP]) were exploratory outcomes.

RESULTS

Total adjusted annual CLBP-related costs per patient were greater in the OCC versus non-OCC group ($11,526.73 vs. $6,810.63). Between group differences in QALYs were small and ICER estimate of cost per QALY gained was high ($436,676). However, unadjusted mean direct costs per patient decreased over time in the OCC group. Savings in direct costs of $391 (95% confidence interval: -1,078 to 1,861) were observed in the OCC group for the 6- to 12-month period, driven primarily by reduced medication usage. ICERs based on adjusted RDQ and BOP group differences showed cost of $2,073 and $4,203 for a one-point reduction per respective scale.

CONCLUSIONS

When adjusted for baseline differences, self-reported costs were higher in the OCC group with only small effects on QALYs. However, trends toward decreased direct expenditures and medication usage over time warrant further investigation. Future studies evaluating potential benefits of integrative care models for the management of CLBP should employ randomized designs, longer observational periods, and explore multiple metrics of cost-effectiveness.

Update and future perspective of behavioral medicine in the treatment for chronic pain

Chronic pain is a biopsychosocial condition, and behavioral medicine has made significant contributions to the understanding of the phenomenon and optimization of therapeutic outcomes. The objective of this article is to provide future perspectives of behavioral medicine in pain management based upon recent development in the field. We will briefly review the mainstream approach of cognitive-behavioral therapy, its variations and new and innovative approaches that are on the horizon. We also review strategies that address potential barriers to pain management. Behavioral medicine is a promising field in pain medicine. The future growth is likely to come from addressing how we incorporate the patient heterogeneity into our treatment approaches and a better understanding of its role in a multimodal treatment.

Psychotherapeutic interventions for chronic pain: Evidence, rationale, and advantages

BACKGROUND

Long-term use of opioids to treat chronic pain incurs serious risks for the individual-including misuse, abuse, addiction, overdose and death-as well as creating economic, social, and cultural impacts on society as a whole. Chronic pain and substance use disorders are often co-morbid with other medical problems and at the present time, primary care clinicians serve most of this population. Primary care clinicians would benefit from having alternatives to opioids to employ in treating such patients.

METHOD

We electronically searched different medical databases for studies evaluating the effect of nonpharmacological treatments for chronic pain. We describe alternative approaches for the treatment of chronic pain and cite studies that provide substantial evidence in favor of the use of these treatments.

RESULTS

Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based programs have well-documented effectiveness for the treatment of chronic nonmalignant pain. Integration of such behavioral health therapies into primary care settings may optimize health resources and improve treatment outcomes.

CONCLUSION

Evidence-based psychotherapy for chronic pain has established efficacy and safety and improves quality of life and physical and emotional functioning. Such interventions may be used as an alternative or adjunct to pharmacological management. Chronic opioid use should be reserved for individuals undergoing active cancer treatment, palliative care, or end-of-life care.

The impact of yoga in medically underserved populations: A mixed-methods study

OBJECTIVES

We evaluated the acceptability, access, and impact of yoga among participants in yoga classes co-located in community health centers.

DESIGN

Participants were invited to complete a mixed-methods program evaluation consisting of a pre/post survey at their first class and structured interviews at 4 months.

SETTING

The study took place at two community health centers on the South Side of Chicago, IL, USA.

INTERVENTIONS

Four weekly 1-1.5 hour yoga classes were provided by four certified yoga instructors trained to teach to all ability levels.

MEASURES

Our primary outcome measures were pain and stress before and after the first class, and at 4-months. We gathered data about participant demographics, their health problems, how they accessed the classes, and motivations and barriers to attending. We also extracted themes from participants' qualitative feedback about their experiences.

RESULTS

Overall, 70 participants completed the initial surveys; 44 completed the 4-month interviews. A racially and ethnically diverse group of middle- and low-income adult patients and community members attended, with flyers and word of mouth the major routes to the class. A single yoga class provided statistically significant decreases in pain and stress, but these benefits were not demonstrated at the 4-month follow-up. The primary motivators for yoga class attendance were stress relief, exercise, and overall health improvement. Primary barriers included family issues, schedule, illness, and work conflicts. Primary benefits included physical benefits, relaxation, emotional benefits, and community connectedness.

CONCLUSIONS

Co-locating yoga classes in community health centers provides a variety of benefits and is a viable pathway to addressing disparities in yoga access.

Reporting of Treatment Fidelity in Mindfulness-Based Intervention Trials: A Review and New Tool using NIH Behavior Change Consortium Guidelines

Mindfulness-based interventions (MBIs) are in the fourth decade of adaptation and testing, yet little is known about their level of treatment fidelity. Treatment fidelity is a methodological strategy used to monitor and enhance the reliability and validity of behavioral interventions. The Treatment Fidelity Workgroup of the National Institutes of Health Behavior Change Consortium (BCC) put forth recommendations covering five components of treatment fidelity: design, training, delivery, receipt, and enactment. We conducted a literature review to describe how these five components of treatment fidelity are reported in published main outcomes articles of MBI efficacy trials among adult participants. Our search yielded 202 articles and we identified 25 (12%) described study treatment fidelity. All 25 studies reported on design, n=24 (96%) reported on training, n=23 (92%) reported on delivery, n=23 (92%) reported on receipt, and n=16 (64%) reported on enactment. Eleven (44%) articles analyzed measures of receipt and enactment with a participant outcome. Fourteen (56%) articles reported on all five fidelity components. There was high variation in the way each component was conducted and/or reported, making comparisons across articles difficult. To address the prevailing limitation that the majority of MBI efficacy studies did not detail treatment fidelity, we offer the Treatment Fidelity Tool for MBIs adapted from the BCC guidelines to help researchers monitor and report these methods and measures in a simple and standardized format. By using this tool, researchers have the opportunity to improve the transparency and interpretability of the MBI evidence base.

Gender Differences in Prevalence, Patterns, Purposes, and Perceived Benefits of Meditation Practices in the United States

INTRODUCTION

Meditation is a common type of complementary and alternative medicine (CAM), and the evidence for its usefulness for health promotion is growing. Women have higher rates of overall CAM use than men do, but little is known about gender differences in meditation practices, reasons for use, or perceived benefits.

METHODS

Data from the 2012 National Health Interview Survey (NHIS) were used. The NHIS design is a multistage probability sample representative of US adults aged ≥18 (n = 34,342). Design-based F-test and logistic regression were used; all analyses were weighted and were performed in 2017-2018.

RESULTS

Overall, 10.3% of women and 5.2% of men reported using some type of meditation in the past year (p < 0.001). Among meditators, a higher percentage of women used meditation with yoga, tai chi, or qi gong, but men were more likely to use specific types of stand-alone practices (e.g., mindfulness) than women (p < 0.001 for each type). The most common reason reported for using meditation was to reduce stress (35%). Although women and men reported similar reasons for meditating, there were gender differences in the prevalence of some reasons. Both men and women perceived meditation to be helpful (90% and 94%, respectively).

CONCLUSIONS

There are gender differences in prevalence, purpose, and perceived benefits of using meditation. US adults aged ≥18 use meditation and find it helpful. Although currently less prevalent among men, providers can consider meditation as a tool for health promotion in both men and women.

Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: A systematic review and network meta-analysis

QUESTION

This review compares mindfulness-based stress reduction (MBSR) to cognitive-behavioural therapy (CBT) in its ability to improve physical functioning and reduce pain intensity and distress in patients with chronic pain (CP), when evaluated against control conditions.

STUDY SELECTION AND ANALYSIS

Ovid MEDLINE, EmbaseClassic+Embase, PsycINFO and the Cochrane Library were searched to identify randomised controlled trials. The primary outcome measure was physical functioning. Secondary outcomes were pain intensity and depression symptoms. We used random and fixed effects (RE and FE) network meta-analyses (NMA) to compare MBSR, CBT and control interventions on the standardised mean difference scale.

FINDINGS

Twenty-one studies were included: 13 CBT vs control (n=1095), 7 MBSR vs control (n=545) and 1 MBSR vs CBT vs control (n=341). Of the 21 articles, 12 were determined to be of fair or good quality. Findings from RE NMA for change in physical functioning, pain intensity and depression revealed clinically important advantages relative to control for MBSR and CBT, but no evidence of an important difference between MBSR and CBT was found.

CONCLUSIONS

This review suggests that MBSR offers another potentially helpful intervention for CP management. Additional research using consistent measures is required to guide decisions about providing CBT or MBSR.

A Pilot Randomized Controlled Trial Comparing Mindfulness Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain

Objective

This pilot trial compared the feasibility, tolerability, acceptability, and effects of group-delivered mindfulness meditation (MM), cognitive therapy (CT), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP).

Setting

University of Queensland Psychology Clinic.

Subjects

Participants were N = 69 (intent-to-treat [ITT] sample) adults with CLBP.

Design

A pilot, assessor-blinded randomized controlled trial.

Methods

Participants were randomized to treatments. The primary outcome was pain interference; secondary outcomes were pain intensity, physical function, depression, and opioid medication use. The primary study end point was post-treatment; maintenance of gains was evaluated at three- and six-month follow-up.

Results

Ratings of acceptability, and ratios of dropout and attendance showed that MBCT was acceptable, feasible, and well tolerated, with similar results found across conditions. For the ITT sample, large improvements in post-treatment scores for pain interference, pain intensity, physical function, and depression were found (P < 0.001), with no significant between-group differences. Analysis of the follow-up data (N = 43), however, revealed that MBCT participants improved significantly more than MM participants on pain interference, physical function, and depression. The CT group improved more than MM in physical function. The MBCT and CT groups did not differ significantly on any measures.

Conclusions

This is the first study to examine MBCT for CLBP management. The findings show that MBCT is a feasible, tolerable, acceptable, and potentially efficacious treatment option for CLBP. Further, MBCT, and possibly CT, could have sustained benefits that exceed MM on some important CLBP outcomes. A future definitive randomized controlled trial is needed to evaluate these treatments and their differences.

Physical functioning and mindfulness skills training in chronic pain: a systematic review

PURPOSE

The importance of improved physical function as a primary outcome in the treatment of chronic pain is widely accepted. There have been limited attempts to assess the effects mindfulness skills training (MST) has on objective outcomes in chronic pain care.

METHODS

This systematic review evaluated published reports of original randomized controlled trials that described physical function outcomes after MST in the chronic pain population and met methodological quality according to a list of predefined criteria. PRISMA criteria were used to identify and select studies, and assess their eligibility for inclusion. The established guidelines for best practice of systematic reviews were followed to report the results.

RESULTS

Of the 2,818 articles identified from the original search of four electronic databases, inclusionary criteria were met by 15 studies published as of August 10, 2015, totaling 1,199 patients. All included studies used self-report measures of physical function, and only two studies also employed performance-based measures of function. There were wide variations in how physical function was conceptualized and measured. Although the quality of the studies was rated as high, there was inconclusive evidence for improvement in physical function assessed by self-report due to contradiction in individual study findings and the measures used to assess function. Strong evidence for lack of improvement in physical function assessed via performance-based measures was found.

CONCLUSION

This review draws attention to the importance of having a unified approach to how physical function is conceptualized and assessed, as well as the importance of using quality performance-based measures in addition to subjective self-reports that appropriately assess the physical function construct within MSTs for chronic pain.

Putting Integrative Oncology Into Practice: Concepts and Approaches

Unmet symptom needs and a desire for holistic health approaches or even cure are among the motivations patients have for seeking out complementary and alternative medicine. Using complementary and alternative medicine instead of conventional cancer treatment can have a negative impact on clinical outcomes and survival. Integrative oncology is a patient-centered, evidence-informed field of comprehensive cancer care that uses mind-body practices, natural products, and lifestyle modifications from different traditions alongside conventional cancer treatments. It prioritizes safety and best available evidence to offer appropriate therapeutic interventions along with conventional care. This review summarizes the underlying principles of integrative oncology and how it is distinct from alternative medicine, and it provides a practical guide for the effective application of evidence-based complementary and alternative medicine interventions in patient-centered care. In addition, we recommend resources for patients and clinicians and provide algorithms for appropriate integrative medicine referrals. Finally, we offer suggestions on developing and implementing an integrative oncology program and addressing current challenges in the field.

Central mechanisms of real and sham electroacupuncture in the treatment of chronic low back pain: study protocol for a randomized, placebo-controlled clinical trial

BACKGROUND

Chronic low back pain (CLBP) is the most common chronic pain condition and is often resistant to conventional treatments. Acupuncture is a popular alternative for treating CLBP but its mechanisms of action remain poorly understood. Evidence suggests that pain regulatory mechanisms (particularly the ascending and secondarily the descending pain modulatory pathways) and psychological mechanisms (e.g., expectations, pain catastrophizing and self-efficacy) may be involved in the pathogenesis of CLBP and its response to treatments. We will examine these mechanisms in the treatment of CLBP by electroacupuncture (EA).

METHODS

We present the aims and methods of a placebo-controlled, participant-blinded and assessor-blinded mechanistic study. Adult patients with CLBP will be randomized to receiving 16 sessions of real (active) or sham (placebo) EA over the course of 8 weeks. The primary pain regulatory measure for which the study was powered is temporal summation (TS), which approximates ascending pain facilitation. Conditioned pain modulation (CPM), representing a descending pain modulatory pathway, will be our secondary pain regulatory measure. The primary psychological measure is expectations of benefit, and the secondary psychological measures are pain catastrophizing and self-efficacy in managing pain. Main clinical outcomes are back pain bothersomeness on a 0-100 visual analog scale (primary), Roland Morris Disability Questionnaire (secondary), and relevant items from the National Institutes of Health (NIH) Patient-Reported Outcome Measures Information System (secondary). We hypothesize that compared to sham, real EA will lead to greater reduction in TS after 8 treatment sessions (4 weeks); and that reduction in TS (and secondarily, increase in CPM) after 8 treatment sessions will mediate reduction in back pain bothersomeness from baseline to week 10 (clinical response) to EA. We also hypothesize that the three psychological factors are moderators of clinical response. With 100 treatment completers, the study is designed to have 80% power to detect a medium-sized between-group effect (d = 0.5) on temporal summation.

DISCUSSION

To the best of our knowledge, this is the first appropriately powered, placebo-controlled clinical trial evaluating mechanisms of EA in the treatment of CLBP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02503475 . Registered on 15 July 15 2015. Retrospectively registered.

Pediatric Integrative Medicine in Academia: Stanford Children's Experience

Pediatric integrative medicine is an emerging field which, to date, has not been described in detail in academic medical centers in the United States. Early research of pediatric integrative medicine modalities shows promise for the treatment of common pediatric conditions such as irritable bowel syndrome, acute and chronic pain, headache, and allergy, among others. In light of the growing prevalence of pediatric illnesses and patient complexity, it is crucial to emphasize the patient's overall well-being. As academic centers around the world start to develop pediatric integrative medicine programs, the aim of this manuscript is to briefly highlight evidence of effective integrative treatments in pediatric subspecialties, to describe the establishment of our integrative medicine program, to summarize its early efforts, and to discuss potential barriers and keys to success.

Brain systems at the intersection of chronic pain and self-regulation

Chronic pain is a multidimensional experience with cognitive, affective, and somatosensory components that can be modified by expectations and learning. Individual differences in cognitive and affective processing, as well as contextual aspects of the pain experience, render chronic pain an inherently personal experience. Such individual differences are supported by the heterogeneity of brain representations within and across chronic pain pathologies. In this review, we discuss the complexity of brain representations of pain, and, with respect to this complexity, identify common elements of network-level disruptions in chronic pain. Specifically, we identify prefrontal-limbic circuitry and the default mode network as key elements of functional disruption. We then discuss how these disrupted circuits can be targeted through self-regulation and related cognitive strategies to alleviate chronic pain. We conclude with a proposal for how to develop personalized multivariate models of pain representation in the brain and target them with real-time neurofeedback, so that patients can explore and practice self-regulatory techniques with maximal efficiency.

Perceptions and experiences of MediYoga among patients with paroxysmal atrial fibrillation-An interview study

OBJECTIVES

We investigated the perceptions and experiences of a therapeutic yoga form, MediYoga, which is evolved from Kundaliniyoga among patients with symptomatic paroxysmal atrial fibrillation (PAF).

DESIGN AND SETTING

an inductive exploratory design was chosen with individual semi-structured interviews. The study was conducted with 12 participants (7 men and 5 women, average age 63.5) at a university hospital, Sweden. Informed consent was obtained from all participants. The data were analyzed using a qualitative content analysis with an inductive method and a manifest approach.

RESULTS

Three categories were found in the analysis. In the category "A time for a sense of existence and presence", the patients described an increased thoughtfulness and experiences of gaining access to an inner self. The category "A way of gaining well-being and increased consciousness" describes patients` feelings of relaxation and feeling of comfort, with components of mental and physical well-being. Furthermore, "Access to a tool to gain willpower and relieve symptoms" describes the perceptions from patients to obtained access to a tool for handling the emotions, such as fear and anxiety, as well as symptoms that they could struggling with between, and during, their episodes of atrial fibrillation. No adverse events were reported by the yoga group, during the study.

CONCLUSIONS

Patients with PAF described MediYoga as an accessible tool to manage emotions and symptoms related to episodes of AF. MediYoga may also assist in enhancing body awareness, whereby physical, mental and spiritual components are integrated. MediYoga may strengthen self-management among patients with PAF.