mindfulness meditation for chronic pain: systematic review ... · [9], tobacco cessation [10],...
TRANSCRIPT
ORIGINAL ARTICLE
Mindfulness Meditation for Chronic Pain: SystematicReview and Meta-analysis
Lara Hilton, MPH1& Susanne Hempel, PhD1
& Brett A. Ewing, MS1&
Eric Apaydin, MPP1& Lea Xenakis, MPA1
& Sydne Newberry, PhD1&
Ben Colaiaco, MA1& Alicia Ruelaz Maher, MD1
& Roberta M. Shanman, MS1&
Melony E. Sorbero, PhD1& Margaret A. Maglione, MPP1
Published online: 22 September 2016# The Author(s) 2016. This article is published with open access at Springerlink.com
AbstractBackground Chronic pain patients increasingly seek treat-ment through mindfulness meditation.Purpose This study aims to synthesize evidence on efficacyand safety of mindfulness meditation interventions for thetreatment of chronic pain in adults.Method We conducted a systematic review on randomizedcontrolled trials (RCTs) with meta-analyses using theHartung-Knapp-Sidik-Jonkman method for random-effectsmodels. Quality of evidence was assessed using the GRADEapproach. Outcomes included pain, depression, quality of life,and analgesic use.Results Thirty-eight RCTs met inclusion criteria; seven re-ported on safety. We found low-quality evidence that mind-fulness meditation is associated with a small decrease in paincompared with all types of controls in 30 RCTs. Statisticallysignificant effects were also found for depression symptomsand quality of life.Conclusions While mindfulness meditation improves painand depression symptoms and quality of life, additionalwell-designed, rigorous, and large-scale RCTs are needed todecisively provide estimates of the efficacy of mindfulnessmeditation for chronic pain.
Keywords Chronic pain .Mindfulness .Meditation .
Systematic review
Introduction
Chronic pain, often defined as pain lasting longer than3 months or past the normal time for tissue healing [1], canlead to significant medical, social, and economic conse-quences, relationship issues, lost productivity, and largerhealth care costs. The Institute of Medicine recognizes painas a significant public health problem that costs our nation atleast $560–635 billion annually, including costs of health careand lost productivity [2]. Further, chronic pain is frequentlyaccompanied by psychiatric disorders such as pain medicationaddiction and depression that make treatment complicated [3].The high prevalence and refractory nature of chronic pain, inconjunction with the negative consequences of pain medica-tion dependence, has led to increased interest in treatmentplans that include adjunctive therapy or alternatives to medi-cation [4]. One such modality that pain patients are using ismindfulness meditation. Based on ancient Eastern meditationpractices, mindfulness facilitates an attentional stance of de-tached observation. It is characterized by paying attention tothe present moment with openness, curiosity, and acceptance[5, 6]. Mindfulness meditation is thought to work byrefocusing the mind on the present and increasing awarenessof one’s external surroundings and inner sensations, allowingthe individual to step back and reframe experiences. Currentresearch using neuroimaging to elucidate neurological mech-anisms underlying effects of mindfulness has focused on brainstructures such as the posterior cingulate cortex, which appearto be involved in self-referential processing [7, 8]. Clinicaluses of mindfulness include applications in substance abuse
Electronic supplementary material The online version of this article(doi:10.1007/s12160-016-9844-2) contains supplementary material,which is available to authorized users.
* Lara [email protected]
1 RAND Corporation, 1776 Main Street, PO Box 2138, SantaMonica, CA 90407-2138, USA
ann. behav. med. (2017) 51:199–213DOI 10.1007/s12160-016-9844-2
[9], tobacco cessation [10], stress reduction [11], and treat-ment of chronic pain [12–14].
Early mindfulness studies in pain patients showed promis-ing outcomes on pain symptoms, mood disturbance, anxiety,and depression, as well as pain-related drug utilization [5].Numerous systematic reviews on the effects of mindfulnessmeditation have been published in recent years. Of those thatreport pain outcomes, several have focused on specific typesof pain such as low back pain [13], fibromyalgia [15], orsomatization disorder [16]. Others were not limited to RCTs[14, 17]. There have been several comprehensive reviews fo-cused on controlled trials of mindfulness interventions forchronic pain including a review [4] that showed improve-ments in depressive symptoms and coping, another review[18] on mindfulness for chronic back pain, fibromyalgia,and musculoskeletal pain that showed small positive effectsfor pain, and the most recent review [19] on various painconditions which found improvements in pain, pain accep-tance, quality of life, and functional status. Authors of thesereviews echoed concerns that there is limited evidence forefficacy of mindfulness-based interventions for patients withchronic pain because of methodological issues. They haveconcluded that additional high-quality research was neededbefore a recommendation for the use of mindfulness medita-tion for chronic pain symptoms could be made.
The purpose of this study was to conduct a systematic re-view and meta-analysis of the effects and safety of mindfulnessmeditation, as an adjunctive or monotherapy to treat individ-uals with chronic pain due to migraine, headache, back pain,osteoarthritis, or neuralgic pain compared with treatment asusual, waitlists, no treatment, or other active treatments. Painwas the primary outcome, and secondary outcomes includeddepression, quality of life, and analgesic use. The systematicreview protocol is registered in an international registry forsystematic reviews (PROSPERO 2015:CRD42015025052).
Methods
Search Strategy
We searched the electronic databases PubMed, CumulativeIndex to Nursing and Allied Health Literature (CINAHL),PsycINFO, and Cochrane Central Register of ControlledTrials (CENTRAL) for English-language-randomized con-trolled trials from inception through June 2016. We combinedpain conditions and design terms with the following mindful-ness search terms: “Mindfulness” [Mesh]) or “Meditation”[Mesh] or mindfulness* or mindfulness-based or MBSR orMBCT or M-BCT or meditation or meditat* or Vipassana orsatipaṭṭhāna or anapanasati or Zen or Pranayama or Sudarshanor Kriya or zazen or shambhala or buddhis*.” In addition tothis search and the reference mining of all included studies
identified through it, we reference mined prior systematic re-views and retrieved all studies included therein.
Eligibility Criteria
Parallel group, individual or cluster RCTs of adults who reportchronic pain were included. Studies where the author definedchronic pain and studies in patients reporting pain for a min-imum of 3 months were included. Studies were required toinvolve mindfulness meditation, either as an adjunctive ormonotherapy; studies testing other meditation interventionssuch as yoga, tai chi, qigong, and transcendental meditationtechniques without reference to mindfulness were excluded.Mindfulness interventions that did not require formal medita-tion, such as acceptance and commitment therapy (ACT) werealso excluded. Only studies that reported pain measures orchange in analgesic use were included. Dissertations and con-ference abstracts were excluded.
Procedures
Two independent reviewers screened titles and abstracts ofretrieved citations—following a pilot session to ensure similarinterpretation of the inclusion and exclusion criteria. Citationsjudged as potentially eligible by one or both reviewers wereobtained as full text. The full text publications were then du-ally screened against the specified inclusion criteria. The flowof citations throughout this process was documented in anelectronic database, and reasons for exclusion of full-text pub-lications were recorded. Data abstraction was also conductedin dual. Risk of bias was assessed using the Cochrane Risk ofBias tool [20]. Other biases related to the US PreventiveServices Task Force’s (USPSTF) criteria for internal validityof included studies were assessed [21, 22]. These criteria wereused to rate the quality of evidence as good, fair, or poor foreach included study.
Meta-analytic Techniques
When sufficient data were available and statistical heteroge-neity was below agreed thresholds [20], we performed meta-analysis to pool efficacy results across included studies for theoutcomes of interest and present a forest plot for the mainmeta-analysis. We used the Hartung-Knapp-Sidik-Jonkmanmethod for random effects meta-analysis using unadjustedmeans and measures of dispersion [23–25]. For studiesreporting multiple pain outcomes, we used specific pain mea-sures, such as the McGill Pain Questionnaire (MPQ) for themain meta-analysis rather than the pain subscale of the SF-36,and average or general pain measures rather than situationalmeasures such as pain at the time of assessment. Due to thesmall number of adverse events reported, quantitative analysiswas not conducted. We conducted subgroup analyses and
200 ann. behav. med. (2017) 51:199–213
meta-regressions to address whether there were differences ineffect sizes between different interventions types, populations,or when used as monotherapy versus an adjunctive therapy.The quality of the body of evidence was assessed using theGRADE approach [22, 26] by which a determination of high,moderate, low, or very low was made for each major outcome[27].
Results
Description of Included Studies
We identified 744 citations through searches of electronic da-tabases and 11 additional records identified through othersources (see Fig. 1). Full texts were obtained for 125 citationsidentified as potentially eligible by two independent re-viewers; 38 RCTs met inclusion criteria. Details of study char-acteristics are displayed in Table 1 and effects for individualstudies are displayed in Table 2.
In total, studies assigned 3536 participants; sample sizesranged from 19 to 342. Fifteen studies reported an a priori
power calculation with targeted sample size achieved, tenstudies did not report information about a power calculation,and three studies were unclear in the reporting of a powercalculation. Ten studies noted there was insufficient power;the authors considered these pilot studies. The majority ofthe studies were conducted in North America or Europe.The mean age of participants ranged from 30 (SD, 9.08) to78 years (SD, 7.1. Eight studies included only femaleparticipants.
Medical conditions reported included fibromyalgia in eightstudies and back pain in eight studies. (Categories are notmutually exclusive; some studies included patients with dif-ferent conditions.) Osteoarthritis was reported in two studiesand rheumatoid arthritis in three. Migraine headache was re-ported in three studies and another type of headache in fivestudies. Three studies reported irritable bowel syndrome(IBS). Eight studies reported other causes of pain and threestudies did not specify a medical condition or source of chron-ic pain.
The total length of the interventions ranged from 3 to12 weeks; the majority of interventions (29 studies) were8 weeks in length. Twenty-one studies were conducted onmindfulness-based stress reduction (MBSR) and six onmindfulness-based cognitive therapy (MBCT). Eleven addi-tional studies reported results on other types of mindfulnesstraining. Thirteen RCTs provided the mindfulness interven-tion as monotherapy, and eighteen utilized a mindfulness in-tervention as adjunctive therapy, specifying that all partici-pants received this in addition to other treatment such as med-ication. Seven of the studies were unclear as to whether themindfulness intervention was monotherapy or adjunctive ther-apy. Nineteen RCTs used treatment as usual as comparators,thirteen used passive comparators, and ten used education/support groups as comparators. Beyond these common com-parators, one study each used stress management, massage, amultidisciplinary pain intervention, relaxation/stretching, andnutritional information/food diaries as comparators; two stud-ies used cognitive-behavioral therapy. Several studies had twocomparison arms.
Study Quality and Risk of Bias
The study quality for each included study is displayed inTable 1. Eleven studies obtained a “good” quality rating[28–38]. Fourteen studies were judged to be of fair quality,primarily due to being unclear in some aspects of the methods[39–52]. Thirteen studies were judged to be poor; ten primar-ily due to issues with completeness of reporting outcome datasuch as inadequate or missing intention to treat (ITT) analysisand/or less than 80 % follow-up [53–62] and three due tounclear methods [63–65]. Details of the quality ratings andrisk of bias for each included study is displayed inElectronic Supplementary Material 1.Fig. 1 Literature flow diagram
ann. behav. med. (2017) 51:199–213 201
Tab
le1
Characteristicsof
included
studies
Study
Samplesize
Location
Source
ofpain
%male
Age
(M(SD))
Interventio
nCom
parators
Quality
ratin
g
Astin
etal.[53]
128
USA
Fibromyalgia
0.7
48(10.6)
MBSR
andQigongfor8weeks
Educatio
nsupportg
roup
Poor
Bakhshani
etal.[61]
40MiddleEast
Migraine,headache
35.1
Interventio
n,30
(9.08);
control,31
(9.57)
MBSRfor8weeks
with
TAU
TAU
Poor
Banth
andArdebil[60]
88MiddleEast
Backpain
040.3(8.2)
MBSRfor8weeks
with
TAU
TAU
Poor
BrownandJones[54]
40Europe
Fibrom
yalgia,
rheumatoid
arthritis,other
musculoskeletal
26Interventio
n,48
(10);
control,45
(12)
Mindfulness-based
pain
managem
entp
rogram
:breath
awareness,body
awareness,
gentlemovem
ent,pain
managem
ent,compassion
training
for8weeks
TAU
Poor
Cashetal.[39]
91USA
Fibromyalgia
0Not
reported
MBSR
for8weeks
Waitlistcontrolg
roup
Fair
Cathcartetal.[40]
58Australia
Headache
37Interventio
n,46
(13.10);
control,45
(14.2)
Brief
mindfulness-based
therapy,
basedon
MBSRand
MBCTfor3weeks
Waitlistcontrolg
roup
Fair
Cherkin
etal.[38]
342
USA
Backpain
34.3
49(12.3)
MBSRfor8weeks
with
TAU
CBTwith
TAUor
TAU
alone
Good
DavisandZautra[42]
79USA
Fibrom
yalgia
246;range
=22–81
Mindful
socialem
otional
regulatio
ninternetinterventio
nin
12modules
for6weeks
Health
ylifestyletip
sviainternet
Fair
Day
etal.[41]
36USA
Migraine,headache
1142
(12.0)
MBCTfor8weeks
adaptedfor
headache
pain
with
TAU
Waitlistcontrolg
roup
Fair
Dow
detal.[43]
124
Europe
Headache,back
pain,
osteoarthritis,
fibrom
yalgia,
nervepain,neuropathy
1045
(12.25)
MBCTcomputerized:
included
audio-recorded
meditatio
n,psychoeducation,mindfulness,
andacognitive
andbehavioral
change
for6weeks
Psychoeducation
Fair
Esm
eretal.[55]
40USA
Backpain,leg
pain
56Interventio
n,55
(11.2);
control,58
(9.5)
MBSRfor8weeks
with
TAU
TAU
Poor
Fjorback
etal.[32]
120
Europe
Bodily
distress
syndrome
20Interventio
n,38
(9);
control,40
(8)
MBSR
for8weeks
with
TAU
EnhancedTA
Uof
2-h
specialistm
edical
care
andbriefCBT
Good
Fogartyetal.[30]
51New
Zealand
Rheum
atoidarthritis
12Interventio
n,52
(12);
control,55
(13)
MBSRfor8weeks
andTA
UTA
UGood
Garland
etal.[44]
115
USA
Osteoarthritis,
fibrom
yalgia
3248
(14)
MORE:m
ultim
odalinterventio
nof
mindfulness,C
BT,
positiv
epsychology
for8weeks
with
TAU
Supportg
roup
with
TAU
Fair
Gaylord
etal.[45]
75USA
Irritablebowel
syndrome
0Interventio
n,45
(12.55);
control,41
(14.68)
Mindfulness
training
tailo
redfor
IBSpopulatio
nfor8weeks
with
TAU
TAUandsupport
group
Fair
Jayetal.[50]
112
Europe
Musculoskeletalpain
0Interventio
n,45.5
(9.0);
control,47.6(8.2)
Mindfulness
pain
andstress
workplace
program
for10
weeks
TAU
Fair
202 ann. behav. med. (2017) 51:199–213
Tab
le1
(contin
ued)
Study
Samplesize
Location
Source
ofpain
%male
Age
(M(SD))
Interventio
nCom
parators
Quality
ratin
g
Johnsetal.[37]
71USA
Cancer
9.9
Interventio
n,56
(9.9);
control,56
(12.7)
MBSR
for8weeks
Psychoeducation
supportg
roup
Good
Kanteretal.[62]
20USA
Interstitialcystitis,bladder
pain
syndrome
0Interventio
n,46
(15.2);
control,44
(13.9)
MBSRfor8weeks
with
TAU
TAU
Poor
Kearney
etal.[51]
55USA
GulfWar
illness
85.5
Interventio
n,51
(6.8);
control,48
(7.4)
MBSRfor8weeks
with
TAU
TAU
Fair
laCourandPetersen[46]
109
Europe
Varied,non-specificpain
15Interventio
n,47
(12.42);
control,49
(12.20)
MBSR
:Standardprogram
modified
forchronicpain
patientsfor8
weeks
with
co-interventionTA
U
Waitlist,T
AU
Fair
Lengacher
etal.[52]
322
USA
Cancer
056.6
(9.7)
MBSR
modifiedforbreastcancer
patientsfor6weeks
with
TAU
TAU
Fair
Ljotssonetal.[33]
85Europe
Irritablebowelsyndrome
1535
(9.4)
MBCTprotocol
viaInternetforIBS
grouptreatm
entfor
10weeks
Onlinediscussion
forum
Good
Ljotssonetal.[34]
195
Europe
Irritablebowelsyndrome
2139
(11.1)
MBCTprotocol
viainternetforIBS
grouptreatm
entfor
10weeks
Onlinestress
managem
ent
program
Good
Meize-G
rochow
ski
etal.[56]
31USA
Postherpetic
neuralgia
44Overall,
72(9.6)
MBSR:1
hinstructionfocusing
breathingwhileseated
comfortably,
daily
meditatio
nusingCD,phone
callreminders,daily
journal,for6
weeks
with
TAU
TAU
Poor
Moroneetal.[47]
37USA
Backpain
43Interventio
n,74
(6.1);
controls,76(5.0)
ModifiedMBSR
:(1)
thebody
scan;
(2)sitting
practice;(3)walking
meditatio
nfor8weeks
Waitlistcontrols
Fair
Moroneetal.[57]
40USA
Backpain
37Interventio
n,78(7.1);
control,73(6.2)
ModifiedMBSR
:(1)
thebody
scan;
(2)sitting
practice;(3)walking
meditatio
nfor8weeks;O
verthe
counterandprescribed
medications
Overthecounterand
prescribed
medications
Poor
Moroneetal.[36]
282
USA
Backpain
33.7
74.5
(6.6)
MBSR
for8weeks
Health
educationprogram
Good
Omidiand
Zargar[58]
66MiddleEast
Headache
20Interventio
n,35
(2.41);
control,32
(3.2)
MBSRfor8weeks
TAU
Poor
Parra-D
elgado
and
Latorre-Postig
o[31]
33Europe
Fibrom
yalgia
053
(10.08)
MBCTfor12
weeks
with
TAU
TAU
Good
Plews-Oganetal.[59]
30USA
Musculoskeletalpain
2347
(NR)
MBSRfor8weeks
TAU(thisgroupused
inanalysis)or
massage
Poor
Rahmaniand
Talepasand
[63]
24MiddleEast
Cancer
0Interventio
n,43
(3.07);
control,45
(3.28)
MBSR
andgroupconsciousyoga
for8weeks
Notreatm
ent
Poor
Schmidtetal.[48]
177
Europe
Fibrom
yalgia
053
(9.6)
ModifiedMBSR
:mindfulness,
yoga,and
socialinteraction
topics
for8weeks
Waitlist(thisgroupused
inanalysis),relaxatio
nandstretching
support
group
Fair
Teixeira
[64]
22USA
Diabetic
peripheral
neuropathy
2575
(10.8)
ModifiedMBSR
:mindfulness
meditatio
ninstructionand
compact
Nutritio
nalinformation
andfood
diary
Poor
ann. behav. med. (2017) 51:199–213 203
Measures
Studies reported patient pain measures such as the VisualAnalog Scale, the SF-36 pain subscale, and McGill PainQuestionnaire. Secondary outcomemeasures included depres-sion symptoms (e.g., Beck Depression Inventory, PatientHealth Questionnaire), physical and mental health-relatedquality of life (e.g., SF-36 mental and physical components),and functional impairment/disability (e.g., Roland-MorrisDisability Questionnaire, Sheehan Disability Scale).
Chronic Pain Treatment Response
Thirty RCTs reported continuous outcome data on scalesassessing chronic pain [29, 31–33, 36, 39–49, 51–60, 62–64,66].
Eight studies met screening inclusion criteria but did notcontribute to the meta-analysis because they did not reportpoolable data [28, 30, 34, 35, 38, 50, 61, 65]. Their studycharacteristics are displayed in Table 1, and study level effectsalong with the reasons they were not in pooled analyses aredisplayed in Table 2.
Pain scales and comparators varied from study to study.The median follow-up time was 12 weeks, with a range of4 to 60 weeks. Figure 2 displays the results of meta-analysis using data at the longest follow-up for each study.The pooled analysis indicates a statistically significant ef-fect of mindfulness meditation compared with treatment asusual, passive controls, and education/support groups(SMD, 0.32; 95 % CI, 0.09, 0.54; 30 RCTs). Substantialheterogeneity was detected (I2 = 77.6 %). There was noevidence of publication bias (Begg’s p = 0.26; Egger’s testp = 0.09). To investigate whether the treatment estimate isrobust when excluding poor-quality studies and to explorethe possible source of the substantial heterogeneity, we con-ducted a sensitivity analysis including only fair or goodquality studies. The improvement remained significant, theeffect size was smaller (SMD, 0.19; 95 % CI, 0.03, 0.34;19 RCTs), and there was less heterogeneity (I2 = 50.5 %).Meta-regressions showed that changes in pain outcomes ingood- (p = 0.42) and fair-quality (p = 0.13) studies werenot significantly different from changes in poor-qualitystudies.
In subgroup analyses, the effect was not statistically sig-nificant at 12 weeks or less (SMD, 0.25; 95 % CI, −0.13,0.63; 15 RCTs; I2 = 82.6 %) but was significant for follow-up periods beyond 12 weeks (SMD, 0.31; 95 % CI, 0.04,0.59; 14 RCTs, I2 = 69.0 %). Begg’s test was not statisti-cally significant (p = 0.16) but Egger’s test showed evi-dence of publication bias (p = 0.04). The quality of evi-dence that mindfulness meditation is associated with a de-crease in chronic pain compared with control is low overalland for both short- and long-term follow-up due toT
able1
(contin
ued)
Study
Samplesize
Location
Source
ofpain
%male
Age
(M(SD))
Interventio
nCom
parators
Quality
ratin
g
disk
5days/weekover
a4-week
period
for4weeks
Wellsetal.[49]
19USA
Migraine
11Interventio
n,46
(17);
control,45
(12)
MBSRfor8weeks
TAU
Fair
Wong[65]
100
Asia
Unspecified
NR
NR
MBSRfor8weeks
Multid
isciplinary
educationprogram
Poor
Wong[28]
100
Asia
Unspecified
NR
48(7.84)
MBSR
for8weeks
Multid
isciplinarypain
interventio
nGood
Zautraetal.[29]
144
USA
Rheum
atoidarthritis
32Men,62(N
R);
wom
en,51(N
R)
Mindfulness
meditatio
nbasedon
MBSR
andem
otionregulatio
ntherapyofferedin
sessions
and
homepracticefor8weeks
Educatio
ngroup(this
groupused
inanalysis),
cognitive
behavioral
therapy
Good
Zgierskaetal.[35]
35USA
Backpain
2051.8
(9.7)
MBCT-manualized
program
6days/
weekfor8weeks
with
TAU
TAUandopioid
therapy
Good
Note.Age
(M(SD))agemean(standarddeviation,range,ornotreported),C
BTcognitive
behavioraltherapy,IBSirritablebowelsyndrome,MBCTmindfulness-based
cognitive
therapy,MBSR
mindfulness-
basedstress
reduction,MOREmindfulness-orientedrecovery
enhancem
ent,NRnotreported,TA
Utreatm
entasusual
204 ann. behav. med. (2017) 51:199–213
Tab
le2
Effectsforindividualstudies
Study
Outcome
Measure
%pain
change
TxGrp
%pain
change
CtrlG
rpSMD(95%
CI)
Follow-up
(week)
Astin
etal.[53]
Pain
SF-36pain
score
−31.58
%−3
4.39
%0.02
(−0.47,0.5)
14
−28.79
%−3
5.03
%−0
.04(−0.52,0.45)
24
−23.22
%−2
9.94
%−0
.05(−0.54,0.43)
8
Depression
BDI
––
0.15
(−0.35,0.64)
24
Bakhshani
etal.[61]
Pain
Significantimprovem
entin
pain,qualityof
life;
samplesize
ofgroups
atfollo
w-upnotreported
Qualityof
life
Banth
andArdebil[60]
Pain
MPQ
−47.92
%−1
1.62
%2.5(1.94,3.07)
12
Qualityof
life
SF-12mentalh
ealth
––
1.11
(0.65,1.56)
8
––
1.49
(1.01,1.97)
12
SF-12physicalhealth
––
1.34
(0.88,1.81)
8
––
1.86
(1.36,2.37)
12
BrownandJones[54]
Pain
Laser
pain
unpleasantness
9.26
%6.78
%0.24
(−0.51,0.98)
24
Qualityof
life,mental
SF-36mentalcom
posite
––
1.16
(0.36,1.96)
24
Qualityof
life,physical
SF-36physicalcomposite
––
−0.42(−1.17,0.33)
24
Cashetal.[39]
Pain
VAS
−4.26%
−5.92%
0(−0.42,0.41)
16
−11.31
%−1
.01%
0.32
(−0.1,0.74)
8
Cathcartetal.[40]
Pain
Headacheintensity
−4.42%
−11.16
%0.08
(−0.52,0.69)
8
Cherkin
etal.[38]
Pain
Significantreductio
nsin
pain
anddisability;
Reportedonly
adjusted
data
Disability
DavisandZautra[42]
Pain
Pain
−0.93%
−1.52%
−0.24(−0.69,0.2)
6
Day
etal.[41]
Pain
BPI
intensity
−11.98
%−6
.53%
−0.01(−0.66,0.65)
8
Dow
detal.[43]
Pain
Average
pain
1.26
%−1
1.77
%0(−0.36,0.35)
6
7.18
%1.71
%−0
.19(−0.54,0.17)
30
Esm
eretal.[55]
Pain
VAS
−29.74
%−0
.82%
0.3(−0.5,1.1)
12
Disability
Roland-Morrisdisability
––
0.90
(0.06
,1.74)
12
Fjorback
etal.[32]
Pain
SF-36bodily
pain
−31.25
%−7
.38%
0.15
(−0.23,0.53)
12
−44.12
%−1
2.08
%0.23
(−0.18,0.63)
36
−34.93
%−3
1.54
%−0
.1(−0.51,0.31)
60
Qualityof
life,mental
SF-36mentalcom
posite
––
−0.04(−0.42,0.34)
60
Qualityof
life,physical
SF-36physicalcomposite
––
0.22
(−0.16,0.61)
60
ann. behav. med. (2017) 51:199–213 205
Tab
le2
(contin
ued)
Study
Outcome
Measure
%pain
change
TxGrp
%pain
change
CtrlG
rpSMD(95%
CI)
Follow-up
(week)
Fogartyetal.[30]
Pain
Significantreductio
nreported;
nousabledataas
only
reported
change
with
ingroup
Garland
etal.[44]
Pain
BPI
−12.32
%11.11%
0.76
(0.38,1.14)
20
−10.66
%4.01
%0.57
(0.19,0.94)
8
Gaylord
etal.[45]
Pain
Pain
severity
−42.96
%−1
4.73
%0.53
(0.06,0.99)
20
−35.83
%−5
.36%
0.54
(0.08,1)
8
Depression
BSI-18depression
––
0.03
(−0.42,0.49)
20
Qualityof
life,general
IBSquality
oflife
––
0.25
(−0.21,0.7)
20
Jayetal.[50]
Pain
Significantreductio
nreported;
nousabledataas
only
reported
differences
Johnsetal.[37]
Pain
BPI
−35.19
%−3
0.90
%−0
.07(−0.54,0.41)
24
Kanteretal.[62]
Pain
VAS
−16.95
%−1
9.30
%−0
.14(−1.05,0.77)
8
Qualityof
life
SF-12MCS
0.7(−0.24,1.64)
8
SF-12PCS
−0.02(−0.93,0.89)
8
Kearney
etal.[51]
Pain
MPQ
−23.87
%−5
.67%
0.41
(−0.13,0.94)
24
Depression
PHQ
––
0.34
(−0.2,0.87)
8
––
0.47
(−0.07,1)
24
laCourandPetersen[46]
Pain
BPI
−1.05%
−6.77%
−0.16(−0.53,0.22)
8
Depression
HADS
––
0.37
(−0.01,0.75)
8
Qualityof
life,mental
SF-36mentalcom
posite
––
0.53
(0.15,0.91)
8
Qualityof
life,physical
SF-36physicalcomposite
––
0.00
(−0.38,0.38)
8
Lengacher
etal.[52]
Pain
BPI
−25.92
%−1
0.63
%0.02
(−0.2,0.25)
12
Depression
CES-Dscore
––
0.12
(−0.11,0.35)
6
––
0.04
(−0.18,0.27)
12
Qualityof
life
QoL
MOSSF
-36
––
−0.05(−0.28,0.17)
6
––
0.01
(−0.21,0.24)
12
Ljotssonetal.[33]
Pain
Totalp
ain
−46.15
%0.00
%0.64
(0.19,1.08)
10
Depression
MADRS-S
––
0.43
(−0.02,0.87)
10
Qualityof
life,general
IBSquality
oflife
––
0.95
(0.49,1.41)
10
Disability
Sheehandisabilityscale
––
0.47
(0.02,0.91)
10
Ljotssonetal.[34]
Pain
Significantreductio
nIBS
pain/discomfort;n
o24
206 ann. behav. med. (2017) 51:199–213
Tab
le2
(contin
ued)
Study
Outcome
Measure
%pain
change
TxGrp
%pain
change
CtrlG
rpSMD(95%
CI)
Follow-up
(week)
usabledataas
did
notreportp
ainmeasure
Depression
HADS
––
0(−0.28,0.28)
24
Qualityof
life,general
IBSquality
oflife
––
0.51
(0.22,0.8)
24
Meize-G
rochow
skietal.[56]
Pain
SFMPQ—totalp
ain
−8.57%
−4.17%
−0.48(−1.25,0.28)
2
SFMPQ—totalp
ain
−25.71
%−1
2.50
%−0
.31(−1.07,0.45)
8
Depression
CES-D
––
0.32
(−1.08,0.44)
8
Qualityof
life,mental
Emotionalw
ellb
eing
––
0.07
(−0.69,0.82)
8
Qualityof
life,physical
Average
physicalsubscales
––
−0.02(−0.77,0.74)
8
Moroneetal.[47]
Pain
SFMPQ
−11.61
%3.29
%0.23
(−0.42,0.88)
8
Qualityof
life,mental
SF-36mentalcom
posite
––
0.22
(−0.43,0.86)
8
Qualityof
life,physical
SF-36physicalcomposite
––
0.11
(−0.53,0.76)
8
Disability
Roland-Morrisdisability
––
0.23
(−0.42,0.87)
8
Moroneetal.[57]
Pain
SFMPQ—totalp
ain
−22.44
%−2
6.71
%−0
.04(−0.7,0.63)
24
SFMPQ—totalp
ain
−26.28
%−2
9.19
%−0
.01(−0.68,0.65)
8
Moroneetal.[36]
Pain
Num
ericpain
ratin
g—average
−13.64
%0.95
%0.22
(−0.01,0.46)
24
Qualityof
life
SF-36globalhealth
composite
––
0.17
(−0.06,0.41)
8
––
0.03
(−0.2,0.26)
24
SF-36physicalhealth
composite
––
0.17
(−0.06,0.4)
8
––
0(−0.23,0.23)
24
Plews-Oganetal.[59]
Pain
Pain
unpleasantness
vs.T
AU
−7.46%
−8.70%
0.02
(CI,−1
.04,1.07)
12
Pain
unpleasantness
vs.m
assage
−7.46%
−25.35
%−0
.16(−1.19,0.88)
12
Pain
unpleasantness
vs.T
AU
−16.42
%−1
3.04
%0.07
(CI,−0
.99,1.13)
4
Pain
unpleasantness
vs.m
assage
−16.42
%−1
2.68
%−0
.11(CI,−0
.92,1.14)
4
Pain
unpleasantness
vs.T
AU
−13.43
%−1
.45%
0.17
(CI,−0
.89,1.23)
8
Pain
unpleasantness
vs.m
assage
−13.43
%−3
9.44
%−0
.3(CI,−1
.34,0.74)
8
Qualityof
Life,mental
SF-12mentalcom
posite
––
0.67
(−0.42,1.75)
12
Rahmaniand
Talepasand[63]
Pain
Globalq
ualitysymptom
s—pain
−26.52
%11.11%
1.85
(0.89,2.8)
16
−44.89
%−1
.85%
3.24
(2.02,4.46)
8
Qualityof
life,general
Globalq
ualitytotalscore
––
1.18
(0.32,2.05)
16
Schmidtetal.[48]
Pain
Pain
perceptio
nscalevs.w
aitlist
−13.19
%−6
.90%
0.17
(−0.2,0.55)
16
Pain
perceptio
nscalevs.active
−13.19
%−7
.40%
0.15
(−0.22,0.53)
16
Pain
PerceptionScalevs.w
aitlist
−11.87
%−8
.00%
0.08
(−0.3,0.45)
8
Pain
perceptio
nscalevs.active
−11.87
%−4
.86%
0.22
(−0.16,0.6)
8
Depression
CES-D
––
0.1(−0.27,0.48)
16
ann. behav. med. (2017) 51:199–213 207
Tab
le2
(contin
ued)
Study
Outcome
Measure
%pain
change
TxGrp
%pain
change
CtrlG
rpSMD(95%
CI)
Follow-up
(week)
Qualityof
Life,General
QoL
profile
forchronically
ill–
–0.26
(−0.12,0.63)
16
Teixeira
[64]
Pain
NeuroQoL
pain
Missing
baselin
emean
0.14
(−0.74,1.01)
4
Qualityof
life,general
NeuroQoL
overall
––
0.79
(−0.12,1.7)
4
Wellsetal.[49]
Pain
Headacheseverity
−25.00
%0.00
%0.99
(0.04,1.95)
12
Headacheseverity
−27.27
%8.33
%1.5(0.48,2.51)
8
Depression
PHQ
––
0.59
(−0.33,1.51)
8
Qualityof
life,general
Migraine-specificQoL
––
−0.43(−1.34,0.48)
8
Wong[65]
Pain
Significantp
aindecrease;
nousabledata
Wong[28]
Pain
Nosignificanteffect;
nousabledata
Zautraetal.[29]
Pain
Pain
vs.educatio
n−1
4.49
%−1
7.70
%0.22
(−0.2,0.63)
8
Pain
vs.cognitiv
ebehavior
therapy
−14.49
%−1
4.34
%0.56
(0.16,0.96)
8
Depression
Depressivesymptom
s–
–0.28
(−0.13,0.7)
8
Zgierskaetal.[35]
Pain
Significantp
aindecrease;
nofollo
w-updataavailable
Note.BDIB
eckdepression
inventory,BPIb
riefpainindex;BSbriefsymptom
inventory,CES-DThe
Centerfor
EpidemiologicalS
tudies-D
epressionScale,CIconfidenceinterval,M
ADRSMontgom
ery-
AsbergDepressionRatingScale,H
ADSHospitalA
nxietyandDepressionScale;MPQMcG
illPainQuestionnaire,N
PSNeuropathicPainScale,N
euroQoL
QualityofLifeinNeurologicalD
isorders;P
HQ
PatientHealth
Questionnaire,Q
oLquality
oflife,SF
-36Sh
ort-Fo
rmHealth
Survey
36,SFMPQSh
ort-Fo
rmMcG
illPainQuestionnaire,SMDstandardized
meandifference,TAUtreatm
entasusual,VA
SVisualA
nalogScale
208 ann. behav. med. (2017) 51:199–213
inconsistency, heterogeneity, and possible publication bias.A detailed table displays the quality of evidence for find-ings for each major outcome in Electronic SupplementaryMaterial 2.
In order to present clinically meaningful results, wecalculated the percent change in pain symptoms frombaseline to follow-up for mindfulness meditation andcomparison groups for each study and displayed find-ings in Table 2. We then calculated the overall weightedmean percent change for mindfulness meditation groupsversus comparison groups for effects of meditation forpain at longest follow-up. The mean percent change inpain for meditation groups was −0.19 % (SD, 0.91;min, −0.48; max, 0.10) while the mean percent changein pain for control groups was −0.08 % (SD, 0.74; min,−0.35; max, 0.11). The p value for the difference be-tween groups was significant (p = 0.0031).
Depression
Depression outcomes were reported in 12 RCTs [29, 31, 33,34, 45, 46, 48, 49, 51–53, 56]. Overall, meditation significant-ly lowered depression scores as compared with treatment asusual, support, education, stress management, and waitlist
control groups (SMD, 0.15; 95 % CI, 0.03, 0.26; 12 RCTs;I2 = 0 %). No heterogeneity was detected. The quality ofevidence was rated as high due to lack of heterogeneity, con-sistent study results, and precision of effect (small confidenceintervals).
Quality of Life
Sixteen studies reported mental health-related quality oflife; the effect of mindfulness meditation was significantin the pooled analysis as compared with treatment asusual, support groups, education, stress management,and waitlist controls (SMD, 0.49; 95 % CI, 0.22, 0.76;I2, 74.9 %). [32–34, 45–49, 52, 54, 56, 59, 60, 62–64].Sixteen studies measured physical health-related qualityof life [32–34, 36, 45–49, 52, 54, 56, 60, 62–64].Pooled analyses showed a significant effect of mindful-ness meditation as compared with treatment as usual,support groups, education, stress management, andwaitlist controls (SMD, 0.34; 95 % CI, 0.03, 0.65; I2,79.2 %). Both quality-of-life analyses detected substan-tial heterogeneity, and the quality of evidence was ratedas moderate for mental health (small confidence
Fig. 2 Mindfulness meditationeffects on chronic pain
ann. behav. med. (2017) 51:199–213 209
intervals, more consistent results) and low for physicalhealth-related quality of life.
Functional Impairment (Disability Measures)
Four studies reported poolable disability scores from theRoland-Morris Disability Questionnaire and the SheehanDisability Scale [33, 36, 47, 55]. The difference be-tween the mindfulness and comparison groups infollow-up was not statistically significant (SMD, 0.30;95 % CI, −0.02, 0.62; I2 = 1.7 %), although the resultsapproached significance. No heterogeneity was detected.The quality of evidence was rated low due to impreci-sion and small total sample size.
Analgesic Use
Only four studies reported use of analgesics as an out-come. In a study of MBSR for treatment of chronicpain due to failed back surgery syndrome [55], at 12-week follow-up, the analgesic medication logs of theintervention group documented a decrease in analgesicuse compared with those in the control group (−1.5(SD = 1.8) vs. 0.4 (SD = 1.1), p = <0.001). A studyof mindfulness meditation and cognitive-behavioral ther-apy vs. usual care for low back pain [35] reported thatthe mean morphine equivalent dose (mg/day) of opioidswas not significantly different between groups at both 8and 26 weeks. Likewise, a trial of MBSR for back pain[38] found no significant difference between groups inself-reported use of pain medication. Finally, a trial ofmindfulness-oriented recovery enhancement (MORE) forchronic pain of various etiologies [44] found interven-tion participants significantly more likely to no longermeet criteria for opioid use disorder immediately fol-lowing treatment (p = 0.05); however, these effects werenot sustained at 3-month follow-up.
Adverse Events
Only 7 of the 38 included RCTs reported on adverse events.Four stated no adverse events occurred [36, 47, 50, 57]; onedescribed that two participants experienced temporary strongfeelings of anger toward their pain condition and two of theparticipants experienced greater anxiety [46]; two studies re-corded mild side effects from yoga and progressive musclerelaxation [35, 38].
Study Characteristic Moderators
Meta-regressions were run to determine if changes inpain outcomes systematically differed by several subcat-egories. There was no difference in effect on pain
between MBSR (16 studies) and MBCT (4 studies;p = 0.68) or other types of mindfulness interventions(10 studies; p = 0.68). When comparing MBSR (16studies) to all other interventions (14 studies), therewas also no difference in effect (p = 0.45). As statedin more detail above, medical conditions reported in-cluded fibromyalgia, back pain, arthritis, headache, andirritable bowel syndrome (IBS). Meta-regressions didnot suggest differences between headache (six studies)and other conditions (p = 0.93), back pain (eight stud-ies) and other conditions (p = 0.15), and fibromyalgia(eight studies) and other conditions (p = 0.29). Gendercomposition (% male) had no association with effect onpain (p = 0.26). The total length of the interventionprogram ranged from 3 to 12 weeks (mean was8 weeks). Meta-regression did not suggest differencesbetween high-frequency interventions and medium-(p = 0.16) or low-frequency (p = 0.44) interventions.No systematic difference in effect on pain between ad-junctive therapy and monotherapy (p = 0.62) or betweenadjunctive therapy and interventions where this was un-clear (p = 0.10) was found. Finally, there was no sys-tematic difference in effect whether the comparator wastreatment as usual, waitlist, or another intervention(p = 0.21).
Discussion
In sum, mindfulness meditation was associated with asmall effect of improved pain symptoms compared withtreatment as usual, passive controls, and education/support groups in a meta-analysis of 30 randomizedcontrolled trials. However, there was evidence of sub-stantial heterogeneity among studies and possible publi-cation bias resulting in a low quality of evidence. Theefficacy of mindfulness meditation on pain did not dif-fer systematically by type of intervention, medical con-dition, or by length or frequency of intervention.Mindfulness meditation was associated with statisticallysignificant improvement in depression, physical health-related quality of life, and mental health-related qualityof life. Quality of evidence was high for depression,moderate for mental health-related quality of life, andlow for physical health-related quality of life. Only fourstudies reported on change in analgesic use; results weremixed. Adverse events in the included RCTs were rareand not serious, but the vast majority of studies did notcollect adverse events data.
This review has several methodological strengths: ana priori research design, duplicate study selection anddata abstraction of study information, a comprehensivesearch of electronic databases, risk of bias assessments,
210 ann. behav. med. (2017) 51:199–213
and comprehensive quality of evidence assessments usedto formulate review conclusions. One limitation is thatwe did not contact individual study authors; results re-ported in the review are based on published data. Weexcluded conference abstracts which do not containenough data to evaluate study quality. In addition, weincluded only studies published in English.
The included studies had many limitations. Thirteen of thethirty-eight studies were rated as poor quality, primarily due tolack of ITT, poor follow-up, or poor reporting of methods forrandomization and concealment of allocation. The authors often studies reported inadequate statistical power to detect dif-ferences in pain outcomes between mindfulness meditationand the comparator; the authors considered these pilot studies.Ten other studies did not report a power calculation. Samplesizes were small; 15 studies randomized fewer than 50participants.
More well-designed, rigorous, and large RCTs are need-ed in order to develop an evidence base that can moredecisively provide estimates of its effectiveness. Studiesshould enroll samples large enough to detect statisticaldifferences in outcomes and should follow-up with partic-ipants for 6 to 12 months in order to assess the long-termeffects of meditation. Adherence to mindfulness practiceand simultaneous use of other therapies should be moni-tored frequently. Intervention characteristics, including theoptimal dose, have also not yet conclusively beenestablished. In order to detect intervention specific effects,studies need to have attention-matched controls. Smallertrials may be conducted to answer these questions. Otheroutcomes that were outside the scope of this review maybe important to explore. As the impact of mindfulnessmay be related to the appraisal of the pain, it may beuseful for future trials to focus primary outcomes onsymptoms associated with pain such as quality of life,pain-related interference, pain tolerance, analgesic, and re-lated issues such as opioid craving. Future publications onRCTs of mindfulness meditation should adhere toConsolidated Standards of Reporting Trials (CONSORT)standards.
Only three RCTs attributed minor adverse events tomindfulness meditation. However, only 7 of the 38 in-cluded RCTs mentioned whether adverse events weremonitored and collected. Thus quality of evidence foradverse events reported in RCTs is inadequate for acomprehensive assessment. Given published reports ofadverse events during meditation, including psychosis[67], future trials should actively collect adverse eventsdata. In addition, a systematic review of observationalstudies and case reports would shed additional light onadverse events during mindfulness meditation.
Further research examining the effect of mindfulnessmeditation on chronic pain should also focus on better
understanding whether there is a minimum frequency orduration of meditation practice for it to be effective.While recent studies have yielded similar positive ef-fects of mindfulness for pain, these effects tend to besmall to medium and based on a body of evidence thatis, at best, of moderate quality. A potential way to ad-vance research on chronic pain would be to improveintervention and control group descriptions, identify dif-ferent effects of various components of complex inter-ventions, and work toward a standard criterion forassessing therapeutic gain [68]. Head-to-head trials thatcompare mindfulness interventions of a similar categorybut with variations in components or dose may be help-ful to tease out the most effective elements of theseinterventions [69].
Similar to previous reviews in this area, we concludethat while mindfulness meditation interventions showedsignificant improvements for chronic pain, depression,and quality of life, the weaknesses in the body of evi-dence prevent strong conclusions. The available evi-dence did not yield consistent effects for pain outcomes,and few studies were available for forms of mindfulnessmeditation other than MBSR. Quality of evidence forthe efficacy of mindfulness interventions in reducingchronic pain is low. There was higher quality evidenceof the efficacy of mindfulness meditation on depressionand mental health-related quality-of-life outcomes. Thisreview is consistent with previous reviews concludingthat more well-designed, rigorous, and large RCTs areneeded in order to develop an evidence base that canmore decisively provide estimates of the efficacy ofmindfulness meditation for chronic pain. In the mean-time, chronic pain continues to pose a tremendous bur-den on society and individuals. A novel therapeutic ap-proach for chronic pain management such as mindful-ness meditation would likely be welcomed by patientssuffering from pain.
Compliance with Ethical Standards
Funding andDisclaimer The systematic review was sponsored bythe Depar tment of Defense Centers of Excel lence forPsychological Health and Traumatic Brain Injury (contract number14-539.2). The findings and conclusions in this manuscript arethose of the authors and do not necessarily represent the viewsof the Department of Defense Centers of Excellence forPsychological Health and Traumatic Brain Injury.
Authors Statement of Conflict of Interest and Adherence to EthicalStandards Authors Authors Hilton, Hempel, Ewing, Apaydin,Xenakis, Newberry, Colaiaco, Maher, Shanman, Sorbero, andMaglione declare that they have no conflict of interest. All pro-cedures, including the informed consent process, were conductedin accordance with the ethical standards of the responsible com-mittee on human experimentation (institutional and national) andwith the Helsinki Declaration of 1975, as revised in 2000.
ann. behav. med. (2017) 51:199–213 211
Open Access This article is distributed under the terms of the CreativeCommons At t r ibut ion 4 .0 In te rna t ional License (h t tp : / /creativecommons.org/licenses/by/4.0/), which permits unrestricted use,distribution, and reproduction in any medium, provided you giveappropriate credit to the original author(s) and the source, provide a linkto the Creative Commons license, and indicate if changes were made.
References
1. Chou R, Turner JA, Devine EB, et al.: The effectiveness and risksof long-term opioid therapy for chronic pain: a systematic reviewfor a National Institutes of Health pathways to prevention work-shop. Annals of Internal Medicine 2015, 162:276–286.
2. Institute of Medicine: Relieving pain in America: A blueprint fortransforming prevention, care, education, and research (reportbrief). www.iom.edu/relievingpain. 2011.
3. Department of Veterans Affairs Department of Defense: VA/DoDclinical practice guideline for management of opioid therapy forchronic pain. May 2010.
4. Chiesa A, Serretti A: Mindfulness-based interventions for chronicpain: a systematic review of the evidence. Journal of Alternativeand Complementary Medicine 2011, 17:83–93.
5. Kabat-Zinn J, Lipworth L, Burney R: The clinical use of mindful-ness meditation for the self-regulation of chronic pain. Journal ofBehavioral Medicine 1985, 8:163–190.
6. MARC:UCLAMindfulness Awareness Research Center. AccessedMay 29, 2015. http://marc.ucla.edu/default.cfm
7. Brewer JA, Garrison KA: The posterior cingulate cortex as a plau-sible mechanistic target of meditation: findings from neuroimaging.Ann NYAcad Sci 2014, 1307:19–27.
8. Boccia M, Piccardi L, Guariglia P: The meditative mind: a compre-hensive meta-analysis of MRI studies. Biomed Res Int 2015,Article ID 419808:1–11.
9. Chiesa A, Serretti A: Are mindfulness-based interventions effectivefor substance use disorders? A systematic review of the evidence.Substance Use and Misuse 2014, 49:492–512.
10. de Souza IC, de Barros VV, Gomide HP, et al.: Mindfulness-basedinterventions for the treatment of smoking: a systematic literaturereview. Journal of Alternative and Complementary Medicine 2015,21:129–140.
11. Goyal M, Singh S, Sibinga EM, et al.: Meditation programs forpsychological stress and well-being: a systematic review and me-ta-analysis. JAMA Intern Med 2014, 174:357–368.
12. Kozasa EH, Tanaka LH, Monson C, et al.: The effects ofmeditation-based interventions on the treatment of fibromyalgia.Curr Pain Headache Rep 2012, 16:383–387.
13. Cramer H, Haller H, Lauche R, Dobos G: Mindfulness-based stressreduction for low back pain. A systematic review. BMCComplementary and Alternative Medicine 2012, 12:162.
14. Reiner K, Tibi L, Lipsitz JD: Do mindfulness-based interventionsreduce pain intensity? A critical review of the literature. PainMedicine 2013, 14:230–242.
15. Lauche R, Cramer H, Dobos G, Langhorst J, Schmidt S: A system-atic review and meta-analysis of mindfulness-based stress reductionfor the fibromyalgia syndrome. Journal of Psychosomatic Research2013, 75:500–510.
16. Lakhan SE, Schofield KL:Mindfulness-based therapies in the treat-ment of somatization disorders: a systematic review and meta-anal-ysis. PloS One 2013, 8:e71834.
17. Merkes M: Mindfulness-based stress reduction for people withchronic diseases. Aust J Prim Health 2010, 16:200–210.
18. Lee C, Crawford C, Hickey A: Mind-body therapies for the self-management of chronic pain symptoms. Pain Medicine 2014, 15Suppl 1:S21–39.
19. Bawa FL, Mercer SW, Atherton RJ, et al.: Does mindfulness im-prove outcomes in patients with chronic pain? Systematic reviewand meta-analysis. British Journal of General Practice 2015,65:e387–400.
20. Higgins J, Green S: Cochrane handbook for systematic reviews ofinterventions, version 5.1.0; 2011.
21. US Preventive Services Task Force: US Preventive Services TaskForce Procedure Manual. Rockville, MD: Agency for HealthcareResearch and Quality; 2008.
22. The Lewin Group and ECRI Institute: Management of dyslipid-emia: Evidence synthesis report. Clinical practice guideline. 2014.
23. Hartung J: An alternative method for meta-analysis. BiometricalJournal 1999, 41:901–916.
24. Hartung J, Knapp G: A refined method for the meta-analysis ofcontrolled clinical trials with binary outcome. Statistics inMedicine 2001, 20:3875–3889.
25. Sidik K, Jonkman JN: Robust variance estimation for random ef-fects meta-analysis. Computational Statistics & Data Analysis2006, 50:3681–3701.
26. Balshem H, Helfand M, Schunemann HJ, et al.: GRADE guide-lines: 3. Rating the quality of evidence. Journal of ClinicalEpidemiology 2011, 64:401–406.
27. Egger M, Davey Smith G, Schneider M, Minder C: Bias in meta-analysis detected by a simple, graphical test. BMJ 1997, 315:629–634.
28. Wong SY, Chan FW, Wong RL, et al.: Comparing the effectivenessof mindfulness-based stress reduction and multidisciplinary inter-vention programs for chronic pain: a randomized comparative trial.Clinical Journal of Pain 2011, 27:724–734.
29. Zautra AJ, Davis MC, Reich JW, et al.: Comparison of cognitivebehavioral and mindfulness meditation interventions on adaptationto rheumatoid arthritis for patients with and without history of re-current depression. Journal of Consulting and Clinical Psychology2008, 76:408–421.
30. Fogarty FA, Booth RJ, Gamble GD, Dalbeth N, Consedine NS: Theeffect of mindfulness-based stress reduction on disease activity inpeople with rheumatoid arthritis: a randomised controlled trial.Annals of the Rheumatic Diseases 2015, 74:472–474.
31. Parra-Delgado M, Latorre-Postigo JM: Effectiveness ofmindfulness-based cognitive therapy in the treatment of fibromy-algia: a randomised trial. Cognitive Therapy and Research 2013,37:1015–1026.
32. Fjorback LO, Arendt M, Ornbol E, et al.: Mindfulness therapy forsomatization disorder and functional somatic syndromes: random-ized trial with one-year follow-up. Journal of PsychosomaticResearch 2013, 74:31–40.
33. Ljotsson B, Falk L, Vesterlund AW, et al.: Internet-delivered expo-sure and mindfulness based therapy for irritable bowel syndrome–arandomized controlled trial. Behaviour Research and Therapy2010, 48:531–539.
34. Ljotsson B, Hedman E, Andersson E, et al.: Internet-delivered ex-posure-based treatment vs. stress management for irritable bowelsyndrome: a randomized t r ia l . Amer ican Journal ofGastroenterology 2011, 106:1481–1491.
35. Zgierska AE, Burzinski CA, Cox J, et al. 2016 Mindfulness med-itation and cognitive behavioral therapy intervention reduces painseverity and sensitivity in opioid-treated chronic low back pain:pilot findings from a randomized controlled trial. Pain Medicine
36. Morone NE, Greco CM, Moore CG, et al.: A mind-body programfor older adults with chronic low back pain: a randomized clinicaltrial. JAMA Intern Med 2016, 176:329–337.
37. Johns SA, Brown LF, Beck-Coon K, et al. 2016 Randomized con-trolled pilot trial of mindfulness-based stress reduction compared to
212 ann. behav. med. (2017) 51:199–213
psychoeducational support for persistently fatigued breast and co-lorectal cancer survivors. Supportive Care in Cancer
38. Cherkin DC, Sherman KJ, Balderson BH, et al.: Effect ofmindfulness-based stress reduction vs cognitive behavioral therapyor usual care on back pain and functional limitations in adults withchronic low back pain: a randomized clinical trial. JAMA 2016,315:1240–1249.
39. Cash E, Salmon P, Weissbecker I, et al.: Mindfulness meditationalleviates fibromyalgia symptoms in women: results of a random-ized clinical trial. Annals of Behavioral Medicine 2015, 49:319–330.
40. Cathcart S, Galatis N, Immink M, Proeve M, Petkov J: Briefmindfulness-based therapy for chronic tension-type headache: arandomized controlled pilot study. Behavioural and CognitivePsychotherapy 2014, 42:1–15.
41. Day MA, Thorn BE, Ward LC, et al.: Mindfulness-based cognitivetherapy for the treatment of headache pain: a pilot study. ClinicalJournal of Pain 2014, 30:152–161.
42. Davis MC, Zautra AJ: An online mindfulness interventiontargeting socioemotional regulation in fibromyalgia: resultsof a randomized controlled trial. Annals of BehavioralMedicine 2013, 46:273–284.
43. Dowd H, Hogan MJ, McGuire BE, et al.: Comparison of an onlinemindfulness-based cognitive therapy intervention with online painmanagement psychoeducation: a randomized controlled study.Clinical Journal of Pain 2015, 31:517–527.
44. Garland EL,Manusov EG, Froeliger B, et al.: Mindfulness-orientedrecovery enhancement for chronic pain and prescription opioid mis-use: results from an early-stage randomized controlled trial. Journalof Consulting and Clinical Psychology 2014, 82:448–459.
45. Gaylord SA, Palsson OS, Garland EL, et al.: Mindfulness trainingreduces the severity of irritable bowel syndrome in women: resultsof a randomized controlled trial. American Journal ofGastroenterology. 2011, 106:1678–1688.
46. la Cour P, PetersenM: Effects of mindfulnessmeditation on chronicpain: a randomized controlled trial. Pain Medicine. 2015, 16:641–652.
47. Morone NE, Greco CM, Weiner DK: Mindfulness meditation forthe treatment of chronic low back pain in older adults: a randomizedcontrolled pilot study. Pain. 2008, 134:310–319.
48. Schmidt S, Grossman P, Schwarzer B, et al.: Treating fibromyalgiawith mindfulness-based stress reduction: results from a 3-armedrandomized controlled trial. Pain. 2011, 152:361–369.
49. Wells RE, Burch R, Paulsen RH, et al.: Meditation for migraines: apilot randomized controlled trial. Headache. 2014, 54:1484–1495.
50. Jay K, Brandt M, Hansen K, et al.: Effect of individually tailoredbiopsychosocial workplace interventions on chronic musculoskele-tal pain and stress among laboratory technicians: randomized con-trolled trial. Pain Physician. 2015, 18:459–471.
51. Kearney DJ, Simpson TL, Malte CA, et al.: Mindfulness-basedstress reduction in addition to usual care is associated with improve-ments in pain, fatigue, and cognitive failures among veterans withgulf war illness. American Journal of Medicine. 2016, 129:204–214.
52. Lengacher CA, Reich RR, Paterson CL, et al. (2016) Examinationof broad symptom improvement resulting from mindfulness-basedstress reduction in breast cancer survivors: A randomized controlledtrial. Journal of Clinical Oncology
53. Astin JA, Berman BM, Bausell B, et al.: The efficacy of mindful-ness meditation plus qigong movement therapy in the treatment of
fibromyalgia: a randomized controlled trial. Journal ofRheumatology 2003, 30:2257–2262.
54. Brown CA, Jones AK: Psychobiological correlates of improvedmental health in patients with musculoskeletal pain after amindfulness-based pain management program. Clinical Journal ofPain. 2013, 29:233–244.
55. Esmer G, Blum J, Rulf J, Pier J: Mindfulness-based stress reductionfor failed back surgery syndrome: a randomized controlled trial.Journal of the American Osteopathic Association. 2010, 110:646–652.
56. Meize-Grochowski R, Shuster G, Boursaw B, et al.: Mindfulnessmeditation in older adults with postherpetic neuralgia: a random-ized controlled pilot study. Geriatric Nursing (New York, N.Y.).2015, 36:154–160.
57. Morone NE, Rollman BL, Moore CG, Li Q, Weiner DK: A mind-body program for older adults with chronic low back pain: results ofa pilot study. Pain Medicine 2009, 10:1395–1407.
58. Omidi A, Zargar F: Effect of mindfulness-based stress reduction onpain severity and mindful awareness in patients with tension head-ache: a randomized controlled clinical trial. Nursing and MidwiferyStudies. 2014, 3:e21136.
59. Plews-Ogan M, Owens JE, Goodman M, Wolfe P, Schorling J: Apilot study evaluating mindfulness-based stress reduction and mas-sage for the management of chronic pain. Journal of GeneralInternal Medicine. 2005, 20:1136–1138.
60. Banth S, Ardebil MD: Effectiveness of mindfulness meditation onpain and quality of life of patients with chronic low back pain. Int JYoga. 2015, 8:128–133.
61. Bakhshani NM, Amirani A, Amirifard H, Shahrakipoor M: Theeffectiveness of mindfulness-based stress reduction on perceivedpain intensity and quality of life in patients with chronic headache.Glob J Health Sci 2016, 8:47326.
62. Kanter G, Komesu YM, Qaedan F, et al.: Mindfulness-based stressreduction as a novel treatment for interstitial cystitis/bladder painsyndrome: A randomized controlled trial. Int Urogynecol J. 2016.
63. Rahmani S, Talepasand S: The effect of group mindfulness—basedstress reduction program and conscious yoga on the fatigue severityand global and specific life quality in women with breast cancer.Medical Journal of the Islamic Republic of Iran 2015, 29:175.
64. Teixeira E: The effect of mindfulness meditation on painful diabeticperipheral neuropathy in adults older than 50 years. HolisticNursing Practice. 2010, 24:277–283.
65. Wong SY: Effect of mindfulness-based stress reduction programmeon pain and quality of life in chronic pain patients: a randomisedcontrolled clinical trial. Hong KongMedical Journal. Xianggang YiXue Za Zhi. 2009, 15 Suppl 6:13–14.
66. Fjorback LO, ArendtM, Ornbol E, Fink P, Walach H: Mindfulness-based stress reduction and mindfulness-based cognitive therapy: asystematic review of randomized controlled trials. ActaPsychiatrica Scandinavica 2011, 124:102–119.
67. Kuijpers HJ, van der Heijden FM, Tuinier S, Verhoeven WM:Meditation-induced psychosis. Psychopathology 2007, 40:461–464.
68. Morley S, Williams A: New developments in the psychologicalmanagement of chronic pain. Canadian Journal of Psychiatry.Revue Canadienne de Psychiatri 2015, 60:168–175.
69. Kerns RD, Burns JW, Shulman M, et al.: Can we improvecognitive-behavioral therapy for chronic back pain treatment en-gagement and adherence? A controlled trial of tailored versus stan-dard therapy. Health Psychology 2014, 33:938–947.
ann. behav. med. (2017) 51:199–213 213