Mindfulness Meditation and Chronic Pain

By Yoon-Hang Kim, MD, MPH

Meditation can be defined as the intentional self-regulation of present awareness. There are two major classes of meditation practice: concentration meditation and mindfulness meditation.1 Concentration meditations, the most widely known and studied of which is transcendental meditation, focus the attention to a single aspect such as breathing, a visual object, or a sound and holding the attention for extended periods. Mindfulness meditation emphasizes the detached observation of oneself engaged in a practice such as breathing. In contrast to concentration meditation, the mindfulness meditation utilizes a detached observational state to experience all physical and mental events as they occur.

The historical roots of mindfulness meditation borrow from a variety of traditions including vipassana meditation, Soto Zen, and yoga. Jon Kabat-Zinn, PhD, is credited with developing a system of meditation both readily accessible and acceptable to the medical community and for creating educational programs to train health care professionals. Kabat-Zinn created the Mindfulness Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center in 1979.1 Kabat-Zinn’s MBSR program has since spawned more than 240 programs, including those at major university medical centers like Duke, Stanford, and the University of Wisconsin, as well as programs in Canada, England, Norway, Argentina, Germany, and Mexico.

Mechanism of Action

Mindfulness meditation appears to have broad applicability. It has been proven to be effective in a wide range of clinical problems including the treatment of psoriasis, anxiety disorder, and chronic pain.2-4 Pain relief is believed to occur as a result of uncoupling of the sensory dimension of the pain experience.4 A recent study also documented increased brain activity and enhanced immune modulation through the practice of mindfulness meditation.5

Clinical Research Evidence

A search of several clinical and medical research databases yielded many studies of the use of meditation for the treatment of chronic pain. Most of the studies utilized mindfulness meditation.

In 1982, Kabat-Zinn conducted a 10-week mindfulness meditation intervention trial on 51 chronic pain patients who had not improved with traditional medical care.6 At 10 weeks, 60% of the patients showed a reduction of at least 33% in the mean total Pain Rating Index (Melzack) and 50% showed a reduction of at least 50% in the mean total Pain Rating. The main limitation of the study was the lack of a control group. However, the significance of the study was that the study population had failed standard medical care for chronic pain.

Kabat-Zinn et al conducted another 10-week mindfulness meditation intervention program in 1985 on 90 chronic pain patients with a comparison group receiving more traditional methods employed at a pain clinic.4 The results showed statistically significant reductions in present-moment pain, inhibition of activity by pain, and pain-related drug utilization in the meditation group. In addition, reduction of mood disturbance, depression, and anxiety was shown. Although the use of the comparison group lends support to the conclusion of the previous study, the comparison group did not represent a true control group in that it consisted of a cohort of 21 consecutive patients who were being treated with traditional methods of the pain clinic. The authors state clearly that the quasi-experimental design of the study limits the interpretation to a descriptive comparison of the two functioning hospital clinics.

In 1987, Kabat-Zinn et al published the result on 225 chronic pain patients followed for up to four years. The results showed sustained benefits in pain relief up to four years.7

More recent chronic pain studies have utilized mindfulness meditation for the treatment of fibromyalgia. Kaplan et al conducted a 10-week mindfulness meditation intervention for 77 fibromyalgia patients.8 The results showed that 51% of the participants experienced moderate to marked improvements. Again one of the limitations of the study is the lack of a control group.

The most recent study conducted by Astin et al incorporated a randomized, controlled trial design for treating fibromyalgia with mindfulness meditation and qi gong.9 At trial’s end, participants in both the intervention and control groups experienced significant improvements; however, there were no statistically significant differences in outcomes between the two groups.

Procedure for Mindfulness Meditation

Physicians and other health care providers often refer patients to an eight-week course of mindfulness meditation. In the beginning, participants are invited to develop a detached observational state from one moment to the next while focusing on breathing. Once the detached observational state is stable, the focus can be widened to include body sensations, thoughts, memories, emotions, perceptions, and intuitions as they occur in time.6 Expansion of the field of attention is taught gradually over a number of sessions. After completing the course, participants are experienced in the daily practice of mindfulness meditation. Classes generally include 24-30 participants, and the recommended time to be set aside for daily meditation is 45 minutes.

Conclusion

Most existing clinical research data on mindfulness meditation are limited to quasi-experimental designs, but they show sustained physical and psychological benefits in chronic pain patients.

Despite the design limitations of the earlier studies, it is important to keep in mind that subjects often failed to achieve pain relief through conventional means of pain management.

Recommendation

Patients with chronic pain endure relentless suffering that impairs all aspects of quality of life. Patient self-empowerment is an integral part of any healing process, and interventions that support patient empowerment are potent therapeutic tools in the clinician’s armamentarium. Given the low risk and existing evidence supporting therapeutic benefits, mindfulness meditation should be strongly considered as a potentially useful option for patients experiencing chronic pain. v

Dr. Kim is a fellow in the Program in Integrative Medicine at the University of Arizona in Tucson.

References

1. Waring N. Mindfulness meditation. Hippocrates 2000;14(7).

2. Bernhard JD, et al. Effectiveness of relaxation and visualization techniques as a adjunct to phototherapy and photochemotherapy of psoriasis. J Am Dermatol 1988;19:572-573.

3. Miller JJ, et al. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry 1995;17:192-200.

4. Kabat-Zinn J, et al. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med 1985;8:163-190.

5. Davidson RJ, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med 2003;65:564-570.

6. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. Gen Hosp Psychiatry 1982;4:33-47.

7. Kabat-Zinn J, et al. Four year follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance. Clin J Pain 1986;2:159-173.

8. Kaplan KH, et al. The impact of a meditation-based stress reduction program on fibromyalgia. Gen Hosp Psychiatry 1993;15:284-289.

9. Astin JA, et al. The efficacy of mindfulness meditation plus qigong movement therapy in the treatment of fibromyalgia: A randomized controlled trial. J Rheumatol 2003;30:2257-2262.