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Integrative Medicine Epidemiologist, Cary, NC
Dr. Fahey reports no financial relationships relevant to this field of study.
SYNOPSIS: Chronic pain is a multifactorial public health issue and the treatment plan needs to address all biopsychosocial aspects of this disease.
Chronic pain usually is defined as pain lasting more than three months. It can be devastating to patients and their families, with more than half of these patients ending up disabled.1 Chronic pain is a worldwide public health crisis affecting more than 1.5 billion people, with the total costs in the United States reaching $635 billion, including lost work and medical expenses.2,3 As a result of the growing public health concern and the prescription opioid crisis, the overall treatment plan for pain management is evolving into an integrative model that includes acupuncture, massage, and mind-body techniques to encourage patients to engage in multiple forms of self-care to promote long-lasting health.4 The biopsychosocial approach to chronic pain includes all aspects of an individual’s response to chronic pain.5 A new approach incorporates the physical, social, psychological, and cultural aspects of a human being’s perception of pain.6
In his book, Quantum Healing, Deepak Chopra, MD, described the conceptual analysis for understanding this phenomenon and provided the pathway from materialism, or focusing only on the body, into a real-life model focusing on the holistic perception of pain.7 The issue with the materialistic viewpoint is that it considers the vast influence that a person’s daily life has on his or her understanding and perception of chronic pain. Chopra illustrated that DNA encodes all of the biological processes in the body, defining it as the connection between the body and the mind, including the perception of pain, and that it governs the mechanisms of healing.7 Mind-body techniques, such as meditation and mindfulness, directly affect the genes because the mind-body connection is completely spawned in the genes.7 This idea reinforces the research examined in Quantum Healing that mind-body therapies are able to influence gene expression, that genes are alive, and that they may upregulate or downregulate in response to every patient experience.7
According to the theory of Quantum Healing, the starting point in the management of an integrative approach to healing begins with an examination of the patient’s self-awareness regarding his or her perception of pain. Next, the approach to chronic pain management should be multifactorial to focus on addressing the messages from multiple sources, including genes. In effect, every signal of pain and the perception of pain originate within the DNA, as per this hypothesis. Then, with respect to treatment, mind-body therapies fortify the signals from the mind to the body, creating a situation in which wellness and happiness are possible. In this way, mind-body therapies give the patient many different ways to address and manage the stress in his or her life, and the pain signals alluded to above.8 (See Table 1.)
Researchers have established that a patient’s ability to handle stress affects how he or she deals with chronic pain. The research reflects many benefits of mindfulness-based stress reduction (MBSR) on improving a broad range of natural processes. Yet, current understanding of the effects of MBSR on the immune system and the neural networks within the brain is limited. Some researchers have begun to examine these effects at the cellular level. In a study by Kaliman et al, after a day of intense meditation, a group of expert meditators vs. controls showed swift changes in their expression of histone deacetylase genes (HDAC 2, 3, and 9; regulate transcription), global histone modifications, and proinflammatory genes (RIPK2 and COX-2). Individuals with lower levels of some of these genes (HDAC 2, -0.137; 95% confidence interval [CI], -0.250 to -0.025; P < 0.05; and RIPK2, -0.25; 95% CI, - 0.39 to -0.11; P < 0.01) showed better recovery from stressful social situations.9
More research is needed to examine whether these changes in gene expression produce a physical reduction in the proteins. Every process in the body, including the mind, comes from the genes and is governed by genetic activity. In essence, the brain is thought to be plastic, meaning that every interaction in the world (what we eat, our thoughts, choices, feelings, and self-awareness) also affects the way the genes are expressed.
It is within this dynamic model that meditation and other mind-body therapies begin to allow the patient to quiet the mind. In this state, the patient can listen to his or her inner voice or pain to heal. Chopra and his colleagues call this phenomenon Self-Directed Biological Transformation. A quasi-randomized trial was performed on 69 healthy women and men who participated in a six-day Ayurvedic intervention program (meditation, yoga, healthy diet and herbs, massage, presentations, and journaling) or a six-day vacation (control group) at the same setting. The Ayurvedic group showed improvements across the surveys (spirituality, P < 0.01; gratitude, P < 0.05; self-compassion, P < 0.01) and had a decrease in anxiety after the one-month follow-up (P < 0.05), while the vacation group showed no improvements.10
The Self-Directed Biological Transformation Initiative, conducted at the Chopra Center, Harvard, Duke, and other top U.S. universities, was a controlled trial that examined the effects (changes in plasma metabolites) of Ayurveda (Panchakarma) and meditation vs. relaxation on the genes, the microbiome, telomeres, and cardiovascular physiology in 65 healthy participants and controls. The results indicated that 12 metabolites classified as phosphatidylcholines significantly decreased (Bonferroni adjusted P < 0.01) in 75-90% of Panchakarma program participants. These studies have begun to map the effects of integrated mind-body programs, their effects on the human genome, and the subsequent link to body processes.11
Blankfield’s physiological explanation of the mind-body connection centers on the underlying effects that inflammation and diet have on serotonergic pathways.12 Tryptophan is a precursor of serotonin. Serotonin (body) has been proven as a marker for an individual's psychological responses (mind) to life stimuli.12 Now that a possible pathway has been found for the connection between the mind and the body, mind-body therapies may be explored from a new perspective. This new treatment strategy focuses on the patient’s perception of the psychological, social, cultural, and physical aspects of chronic pain to direct the mind to heal the body. With this approach, clinicians may implement these therapies by focusing on the patients’ strengths.
Mind-body treatments comprise an extensive assortment of tactics, including a focus on reducing or eliminating the need for opiates in the treatment plan. These treatments collectively concentrate on the influence of the mind on the body and the body’s response to thoughts, feelings, and emotions.13 Mind-body therapies include various techniques, such as yoga, meditation/mindfulness, electromyography biofeedback, progressive relaxation practices, cognitive behavioral therapy, and operant therapy. These therapies and others are defined in Table 1. In addition to the P value, these references use the effect size, which is the difference in magnitude between two groups and gives a value to the difference between groups. See Table 2 for the description of small, medium, and large effect sizes.
Yoga is a group of physical (asanas), mental (pranayama), and spiritual (dhyana) practices created more than 4,000 years ago in India.14,15,16 Yoga combines this group of practices into a flowing series of postures and stretches controlled by the breath. There are many different types of yoga practiced around the world, but all the variations hold true to these three practices. Holtzman et al performed a meta-analysis on yoga for the treatment of chronic low back pain and disability using eight randomized, controlled trials involving 743 patients.14 After treating participants with various types and durations of yoga, the effect size (medium to large) for functional disability was d = 0.645 (95% CI, 0.496 to 0.795), and it decreased (degree of heterogeneity was significant, x2 = 15.86; df = 4; P = 0.003) after follow-up to d = 0.486 (95% CI, 0.226 to 0.746). The effect size (medium to large) for pain after yoga treatment was d = 0.632 (95% CI, 0.377 to 0.868), and it also decreased but remained significant (degree of heterogeneity was significant, x2 = 15.86; df = 4; P = 0.003) after follow-up at d = 0.397 (95% CI, 0.053 to 0.848).
Cramer et al performed a systematic review and meta-analysis of 10 randomized, controlled trials involving 967 patients; their review corroborates the efficacy of yoga as an adjunct treatment for chronic low back pain.17 There was strong support for yoga’s short-term (standardized mean difference [SMD], -0.48; 95% CI, -0.65 to -0.31; P < 0.01) and long-term effects (SMD, -0.33; 95% CI, -0.59 to -0.07; P = 0.01) on pain. Strong support was shown for short-term effects (SMD, -0.59; 95% CI, -0.87 to -0.30; P < 0.01) and moderate support was shown for long-term effects (SMD = -0.35; 95% CI, -0.55 to -0.15; P < 0.01) on disability.17 Crow et al performed another systematic review of six studies and 670 patients, and confirmed yoga’s effectiveness in the treatment of back and neck pain.18
Meditation is the practice of observing one’s thoughts and developing or beginning to accept the thoughts by practicing disassociation from the thoughts without judgment. Patients may be able to separate themselves enough from their thoughts to reduce stress and even change their vital signs.19 On the other hand, mindfulness is the practice of being present in the moment. Mindfulness is a form of meditation that is employed in everyday life; it is a way to observe life without judgment, with an accepting attitude toward the present.19 An example of mindfulness is to pay attention to the sensation created while brushing one’s teeth, how the brush feels on the teeth and gums, the responses/feelings that this may invoke (such as pleasure or even pain), and any thoughts that may arise while practicing mindfulness.
The evidence supporting meditation and mindfulness for the treatment of chronic pain management is mixed. In two of the high-quality studies, meditation practice did not last beyond six months. In a review of 11 studies involving 1,209 participants, three of the five high-quality studies reported favorable effects on pain outcomes.8 One study reporting unfavorable results was a single-blind, randomized, controlled trial that compared a mind-body program to a health education program for chronic low back pain. The authors concluded that the mind-body program increased function on the Roland Morris Disability Questionnaire (RMDQ, a higher number means less disability) at eight weeks (RMDQ = 1.1 points; mean, 12.1 vs. 13.1 points in the control) and six months (RMDQ = -0.04 points, with a decrease in function compared to control; mean, 12.2 vs. 12.6 points; d = -0.23 and -0.08), and provided relief for acute pain (RMDQ = -1.8 points; 95% CI, -3.1 to -0.05 points; d = -0.33) and chronic pain (-1.0 points; 95% CI, -2.1 to 0.2 points; d = -0.19), but did not provide lasting relief.1
In a 2017 meta-analysis of mindfulness-based interventions for chronic pain, 11 studies included the following chronic pain disorders: fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, failed back surgery syndrome, and mixed complaints.20 The studies were of varied methodological value and the outcomes reported were depression, sleep quality, mindfulness, and pain acceptance. Meta-analysis effect sizes (d) for clinical outcomes ranged from d = 0.12 (95% CI, -0.05 to 0.30) for depression, d = 1.32 (95% CI, -1.19 to 3.82) for sleep quality and for humanistic outcomes, d = 0.03 (95% CI, -0.66 to 0.72) for mindfulness, and d = 1.58 (95% CI, -0.57 to 3.74) for pain acceptance.20 As a reminder, effect sizes of the Hartung-Knapp-Sidik-Jonkman effect model are used in meta-analyses when the number of studies is small. Cohen’s d also is used to measure effect sizes in meta-analyses. Effect sizes can range in sizes from small (0.2), medium (0.5), and large (0.8), which are considered positive/effective, while smaller effect sizes are deemed less beneficial.
In 2013, Reiner et al concluded that MBSR was effective in addressing stress and disability in the population.21 In a medium-quality randomized, controlled trial, patients with chronic back pain were treated with MBSR and traditional therapy (d = 1.02 effect size; P < 0.05) and still showed pain reductions at 10 months (d = 0.10).22
Acceptance and commitment therapy (ACT) uses mindfulness to work on values, behavior change, and commitment, and is offered for chronic pain patients. ACT is not a formal meditation method; it illustrates that there are multiple ways to be mindful. In a 2007 study, Vowles et al found that ACT is effective for chronic pain patients (P < 0.01), and the pain reduction continued for three months (d = 0.48).2
Many mind-body studies are of low methodological quality, because of incorrect study designs, short duration, inadequate sample size, no control group, mistaken outcomes, and inappropriate interventions.23 Chou et al assessed 32 trials on psychological therapies for chronic low back pain.23 A systematic review included 28 studies (n = 3,090; range of participant number, 18 to 409), and the authors included four RCTs not included in the systematic review (n = 976; range of participant number, 54 to 701).24 The researchers found that progressive relaxation (three trials: mean difference, -19.77 on a 0 to 100-point VAS; 95% CI, -34 to -5.20), electromyography biofeedback (three trials: SMD, -0.80; 95% CI, -1.32 to -0.28), operant therapy (three trials: SMD, -0.43; 95% CI, -0.75 to -0.1), and cognitive behavioral therapy (five trials: SMD, -0.60; 95% CI, -0.97 to -0.22) resulted in lower post-treatment pain intensity compared to controls. Progressive relaxation was the only therapy to improve function (three trials: SMD, -0.88; 95% CI, -1.36 to -0.39).24
As the pathophysiology of the typical chronic pain patient has evolved into one involving a various biopsychosocial factors, the management of chronic pain has morphed to match these aspects. Experts such as Chopra recommend that people make time each day to meditate, eat a healthy diet, engage in some form of exercise, get a good night’s rest, release emotional toxins, fortify loving relationships, and enjoy a good laugh.7 Today’s physician should move away from the materialistic approach, focusing only on the physical, to an understanding that the body registers every thought. The evidence supports the integration of mind-body therapies into an allopathic model to encourage patient self-care and personal responsibility for healing.
Barriers remain for the implementation of these mind-body practices. Many insurance plans do not cover these mind-body treatments, although some will cover a portion of the cost if the practitioner can provide the ICD-10 code. However, mediation and yoga classes routinely are offered at a low cost, $10 to 20 a class. Some MBSR courses can be reimbursed by insurance if recommended by a physician. There are even some games that have been created to help patients practice biofeedback and meditation that begin around $30.
Financial Disclosure: Integrative Medicine Alert’s Executive Editor David Kiefer, MD; Peer Reviewer Suhani Bora, MD; AHC Media Executive Editor Leslie Coplin; Editor Jonathan Springston; and Editorial Group Manager Terrey L Hatcher report no financial relationships relevant to this field of study.