Blowing Off Steam: Mindfulness and COPD
Abstract & Commentary
By Russell H. Greenfield, MD, Editor
Synopsis: This well-done trial compared a combination of mindfulness-based breathing therapy (MBBT) and training in the relaxation response with participation in group support for elderly subjects, almost all men, with moderate to severe COPD. The results did not suggest any benefit of MBBT over group support, and in rare instances suggested superiority of group support. The dropout rate was high, but related data provide valuable insight into potential barriers to participation by patients in mind-body therapies.
Source: Mularski R, et al. Randomized controlled trial of mindfulness-based therapy for dyspnea in chronic obstructive lung disease. J Altern Complement Med 2009;10:1083-1090.
The authors of this randomized controlled trial sought to test the efficacy of a mindfulness-based breathing therapy (MBBT) on improving dyspnea, other symptoms, and health-related quality of life in people with chronic obstructive pulmonary disease (COPD) as compared to participation in a support group. A total of 545 people recruited by clinician referral or posted advertisement from a single academic-affiliated veterans health care center were evaluated for eligibility, of which 86 were ultimately randomized (85 men; average age, 67 years; 50% Caucasian; 47% having completed at least some college; most of whom were ex-smokers). The study was billed as a "mind-body trial of shortness of breath in COPD." Those who did not participate were either excluded (n = 193) or refused (n = 266) based on a variety of factors (lack of interest, problems with transportation, other commitments). All participants had advanced and symptomatic COPD at enrollment.
The intervention group attended weekly group MBBT sessions for 8 weeks and were to practice MBBT daily on their own time. During the first 2 weeks they also received supplemental relaxation response training. The weekly sessions included practice in mindfulness meditation (body scan, seated and walking meditation, and mindful movement), the relaxation response, and group discussion. Sessions were scripted and protocolized. Tapes were provided for subjects to use in their home practice of both MBBT and the relaxation response, the times of which were to be recorded by participants in their personal diaries.
Instructors had specific training in mind-body therapies and a significant degree of clinical experience using them in practice. Additionally, all three instructors had completed an 8-week mindfulness-based stress reduction course together just prior to study initiation to "align intent and approach."
Support group participation was designed to parallel the personal attention and time commitment of those in the MBBT group, meeting weekly for 8 weeks for the same amount of time as the MBBT group. Subjects experienced group-facilitated discussions about various aspects of having COPD, had open time for group interaction, and submitted a matched collection of daily diary entries ("homework" was defined as time spent contemplating or discussing issues raised within the group that specifically dealt with COPD-related issues).
Medical records were reviewed to determine severity of COPD, and a combination of personal report and clinical database findings were monitored regarding exacerbations during the trial. Primary outcome measure of interest was the difference between pre- and post-trial 6-minute walking test (6MWT) Borg dyspnea assessment scores, essentially a self-rated score of dyspnea severity. Secondary outcome measures included 6MWT distance, symptoms scores, exacerbation rates, and a variety of measures of health-related quality of life. Stress levels were determined using the Perceived Stress Scale, mindfulness was assessed using the 5-Factor Mindfulness Questionnaire, and subject expectations were evaluated using adapted questions from the complementary and alternative medicine literature. A phone interview was conducted at trial's end to better understand the subjects' unique experiences during the study period.
At baseline the groups were different in two respects: Support group members were on average about 7 years younger than MBBT group subjects, and had a significantly higher body mass index. Across both groups nearly all participants had little or no knowledge of mindfulness-based therapy, with about 60% believing it would be helpful, while 57% believed that support group therapy would be of benefit.
A significant number of people dropped out of the study (23 in the active group, 13 in group support), most before they had experienced even a single session.
Analyses, whether by intention-to-treat or on the subset of subjects who attended at least 75% of all sessions (n = 36), failed to reveal any benefit of MBBT over group support across all outcome measures. In fact, a few outcomes favored the support group over MBBT. Results of post-study telephone surveys suggested feasibility issues of interest that include difficulty with transportation and feeling too ill to participate. While less than 5% reported the sessions to be "weird or silly," 15% reported they did not believe the mind-body work they experienced during the trial was going to help them.
The researchers concluded that mindfulness meditation offers no measurable clinical benefit in patients with moderate-to-severe COPD over support group attendance.
While the study suffers from small sample size, lack of generalizability (only one female subject and the source of patients being a single VA medical center), not to mention the drastic dropout rate, it is nonetheless very well done. The results point not only to an apparent lack of clinical effectiveness of the MBBT intervention for those with symptomatic COPD, but also underscore the realistic challenges of trying to offer mindfulness-based interventions to groups whose maladies (chronic pain comes to mind) the research shows mindfulness to be effective against. Even though participants were given $10 per session attended with the potential to collect $80 over the course of the study, compliance was poor. It is true that most of the dropouts did so without having experienced MBBT or a group support session, but the dropout rate among those who did was still relatively high at 19%.
Relaxation therapies have been touted as being potentially effective in select respiratory disorders, such as asthma and dyspnea, but the underlying problem in COPD, whether chronic bronchitis or emphysema, is damage to the pulmonary tissues, most often from smoking. One would think that relaxation strategies like mindfulness would help at least relieve anxiety related to a sense of dyspnea, since that sense is clearly impacted not only by the physical difficulty of breathing but also by mental distress. In that regard the findings of the trial are puzzling.
Might is be possible that mindfulness-based therapies are beneficial in those with mild COPD, or among women? Yes, but the results of this study, however hampered by the realities of providing such an intervention, suggest that efforts be directed elsewhere.