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Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis

TL;DR: Low-quality evidence is found that mindfulness meditation is associated with a small decrease in pain compared with all types of controls in 30 RCTs, suggesting additional well-designed, rigorous, and large-scale RCTS are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain.
Abstract: Background Chronic pain patients increasingly seek treatment through mindfulness meditation.

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ORIGINAL ARTICLE
Mindfulness Meditation for Chronic Pain: Systematic
Review and Meta-analysis
Lara Hilton, MPH
1
& Susanne Hempel, PhD
1
& Brett A. Ewing, MS
1
&
Eric Apaydin, MPP
1
& Lea Xenakis, MPA
1
& Sydne Newberry , PhD
1
&
Ben Colaiaco, MA
1
& Alicia Ruelaz Maher, MD
1
& Roberta M. Shanman, MS
1
&
Melony E. Sorbero, PhD
1
& Margaret A. Maglione, MPP
1
Published online: 22 September 2016
#
The Author(s) 2016. This article is published with open access at Springerlink.com
Abstract
Background Chronic pain patients increasingly seek treat-
ment through mindfulness meditation.
Purpose This study aims to synthesize evidence on efficacy
and safety of mindfulness meditation interventions for the
treatment of chronic pain in adults.
Method We conducted a systematic review on randomized
controlled trials (RCTs) wi th meta-analyses using the
Hartung-K napp-Sidik-Jonkman method for random-effects
models. Quality of evidence was assessed using the GRADE
approach. 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 pain
compared with all types of controls in 30 RCTs. Statistically
significant effects were also found for depression symptoms
and quality of life.
Conclusions While mindfulness meditation improves pain
and depression symptoms and quality of life, additional
well-designed, rigorous, and large-scale RCTs are needed to
decisively provide estimates of the efficacy of mindfulness
meditation for chronic pain.
Keywords Chronic pain
.
Mindfulness
.
Meditation
.
Systematic review
Introduction
Chronic pain, often defined as pain lasting longer than
3 months or past the normal time for tissue healing [1], can
lead to significant medical, social, and economic conse-
quences, relationship issues, lost productivity, and larger
health care costs. The Institute of Medicine recognizes pain
as a significant public health problem that costs our nation at
least $560635 billion annually, including costs of health care
and lost productivity [2]. Further, chronic pain is frequently
accompanied by psychiatric disorders such as pain medication
addiction and depression that make treatment complicated [3].
The high prevalence and refractory nature of chronic pain, in
conjunction with the negative consequences of pain medica-
tion dependence, has led to increased interest in treatment
plans that include adjunctive therapy or alternatives to medi-
cation [4]. One such modality that pain patients are using is
mindfulness meditation. Based on ancient Eastern meditation
practices, mindfulness facilitates an attentional stance of de-
tached observation. It is characterized by paying attention to
the present moment with openness, curiosity, and acceptance
[5, 6]. Mindfulness meditation is thought to work by
refocusing the mind on the present and increasing awareness
of ones external surroundings and inner sensations, allowing
the individual to step back and reframe experiences. Current
research using neuroimaging to elucidate neurological mech-
anisms underlying effects of mindfulness has focused on brain
structures such as the posterior cingulate cortex, which appear
to be involved in self-referential processing [7, 8]. Clinical
uses 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 Hilton
hilton@rand.org
1
RAND Corporation, 1776 Main Street, PO Box 2138, Santa
Monica, CA 90407-2138, USA
ann. behav. med. (2017) 51:199213
DOI 10.1007/s12160-016-9844-2

[9], tobacco cessation [10], stress reduction [11], and treat-
ment of chronic pain [1214].
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 mindfulness
meditation have been published in recent years. Of those that
report pain outcomes, several have focused on specific types
of pain such as low back pain [13], fibromyalgia [15], or
somatization disorder [16]. Others were not limited to RCTs
[14, 17]. There have been several comprehensive reviews fo-
cused on controlled trials of mindfulness interventions for
chronic pain including a review [4] that showed improve-
ments in depressive symptoms and coping, another review
[18] on mindfulne ss for chronic bac k p ain, fibromyalgia,
and musculoskeletal pain that showed small positive effects
for pain, and the most recent review [19] on various pain
conditions which found improvements in pain, pain accep-
tance, quality of life, and functional status. Authors of these
reviews echoed concerns that there is limited evidence for
efficacy of mindfulness-based interventions for patients with
chronic pain because of methodological issues. They have
concluded that additional high-quality research was needed
before 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 mindfulness
meditation, 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 as
usual, waitlists, no treatment, or other active treatments. Pain
was the primary outcome, and secondary outcomes included
depression, quality of life, and analgesic use. The systematic
review protocol is registered in an international registry for
systematic reviews (PROSPERO 2015:CRD42015025052).
Methods
Search Strategy
We searched the electronic databases PubMed, Cumulative
Index to Nursing and Allied Health Literature (CINAHL),
PsycINFO, and Cochrane Central Register of Controlled
Trials (CENTRAL) for English-language-randomized con-
trolled trials from inception through June 2016. We combined
pain conditions and design terms with the following mindful-
ness search terms: Mindfulness [Mesh]) or Meditation
[Mesh] or mindfulness* or mindfulness-based or MBSR or
MBCT or M-BCT or meditation or meditat* or Vipassana or
satipaṭṭhāna or anapanasati or Zen or Pranayama or Sudarshan
or Kriya or zazen or shambhala or buddhis*. In addition to
this 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 report
chronic pain were included. Studies where the author defined
chronic pain and studies in patients reporting pain for a min-
imum of 3 months were included. Studies were required to
involve mindfulness meditation, either as an adjunctive or
monotherapy; studies testing other meditation interventions
such as yoga, tai chi, qigong, and transcendental meditation
techniques without reference to mindfulness were excluded.
Mindfulness interventions that did not require formal medita-
tion, such as acceptance and commitment therapy (ACT) were
also excluded. Only studies that reported pain measures or
change in analgesic use were included. Dissertations and con-
ference abstracts were excluded.
Procedures
Two independent reviewers screened titles and abstracts of
retrieved citationsfollowing a pilot session to ensure similar
interpretation of the inclusion and exclusion criteria. Citations
judged as potentially eligible by one or both reviewers were
obtained as full text. The full text publications were then du-
ally screened against the specified inclusion criteria. The flow
of citations throughout this process was documented in an
electronic database, and reasons for exclusion of full-text pub-
lications were recorded. Data abstraction was also conducted
in dual. Risk of bias was assessed using the Cochrane Risk of
Bias tool [20]. Other b iases related to the US Preventive
Services Task Forces (USPSTF) criteria for internal validity
of included studies were assessed [21, 22]. These criteria were
used to rate the quality of evidence as good, fair, or poor for
each 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 the
outcomes of interest and present a forest plot for the main
meta-analysis. We used the Hartung-Knapp-Sidik-Jonkman
method for random effects meta-analysis using unadjusted
means and measures of dispersion [2325]. For studies
reporting multiple pain outcomes, we used specific pain mea-
sures, such as the McGill Pain Questionnaire (MPQ) for the
main meta-analysis rather than the pain subscale of the SF-36,
and average or general pain measures rather than situational
measures such as pain at the time of assessment. Due to the
small number of adverse events reported, quantitative analysis
was not conducted. We condu cted subgroup analyses and
200 ann. behav. med. (2017) 51:199213

meta-regressions to address whether there were differences in
effect 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 the
GRADE 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 addition al records identified through other
sources (see Fig. 1). Full texts were obtained for 125 citations
identified 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 individual
studies are displayed in Table 2.
In total, studies assigned 3536 participants; sample sizes
ranged from 19 to 342. Fifteen studies reported an a priori
power calculation with targeted sample size achieved, ten
studies did not report information about a power calculation,
and three studies were unclear in the reporting of a power
calculation. Ten studies noted there was insufficient power;
the authors considered these pilot studies. The majority of
the studies were conducted in North America or Europe.
The mean age of participants ranged from 30 (SD, 9.08) to
78 years (SD, 7.1. Eight studies included only female
participants.
Medical conditions reported included fibromyalgia in eight
studies and back pain in eight studies. (Categories are not
mutually exclusive; some studies included patients with dif-
ferent conditions.) Osteoarthritis was reported in two studies
and rheumatoid arthritis in three. Migraine headache was re-
ported in three studies and another type of headache in five
studies. Three studies report ed irritable bowel syndrome
(IBS). Eight studies reported other causes of pain and three
studies did not specify a medical condition or source of chron-
ic pain.
The total length of the interv entio ns ranged from 3 to
12 weeks; th e majo rity of interventions (29 studies) wer e
8 weeks in length. Twenty-one studies were conducted on
mindfulness-based stress reduction (MBSR) and six on
mindfulness-based cognitive therapy (MBCT). Eleven addi-
tional studies reported results on other types of mindfulness
training. 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 the
mindfulness 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, a
multidisciplinary pain intervention, relaxation/stretching, and
nutritional information/food diaries as comparators; two stud-
ies used cognitive-behavioral therapy. Several studies had two
comparison arms.
Study Quality and Risk of Bias
The study quality for each included study is dis played in
Table 1. Eleven studies obtained a good quality rating
[2838]. Fourteen studies were judged to be of fair quality,
primarily due to being unclear in some aspects of the methods
[3952]. Thirteen studies were judged to be poor; ten primar-
ily due to issues with completeness of reporting outcome data
such as inadequate or missing intention to treat (ITT) analysis
and/or less than 80 % follow-up [5362] and three due to
unclear methods [6365]. Details of the quality ratings and
risk of bias for each included study is displayed in
Electronic Supplementary Material 1.
Fig. 1 Literature flow diagram
ann. behav. med. (2017) 51:199213 201

Table 1 Characteristics of included studies
Study Sample size Location Source of pain % male Age (M (SD)) Intervention Comparators Quality
rating
Astin et al. [53] 128 USA Fibromyalgia 0.7 48 (10.6) MBSR and Qigong for 8 weeks Education support group Poor
Bakhshani et al. [61] 40 Middle East Migraine, headache 35.1 Intervention, 30 (9.08);
control, 31 (9.57)
MBSR for 8 weeks with TAU TAU Poor
Banth and Ardebil [60] 88 Middle East Back pain 0 40.3(8.2) MBSR for 8 weeks with TAU TAU Poor
Brown and Jones [54] 40 Europe Fibromyalgia,
rheumatoid
arthritis, other
musculoskeletal
26 Intervention, 48 (10);
control, 45 (12)
Mindfulness-based pain
management program: breath
awareness, body awareness,
gentle movement, pain
management, compassion
training for 8 weeks
TAU Poor
Cash et al. [39] 91 USA Fibromyalgia 0 Not reported MBSR for 8 weeks Waitlist control group Fair
Cathcart et al. [40] 58 Australia Headache 37 Intervention, 46 (13.10);
control, 45 (14.2)
Brief mindfulness-based therapy,
based on MBSR and
MBCT for 3 weeks
Waitlist control group Fair
Cherkin et al. [38] 342 USA Back pain 34.3 49 (12.3) MBSR for 8 weeks with TAU CBT with TAU or TAU
alone
Good
Davis and Zautra [42] 79 USA Fibromyalgia 2 46; range = 2281 Mindful social emotional
regulation internet intervention
in 12 modules for 6 weeks
Healthy lifestyle tips
via internet
Fair
Day et al. [41] 36 USA Migraine, headache 11 42 (12.0) MBCT for 8 weeks adapted for
headache pain with TAU
Waitlist control group Fair
Dowd et al. [43] 124 Europe Headache, back pain,
osteoarthritis,
fibromyalgia,
nerve pain, neuropathy
10 45 (12.25) MBCT computerized: included
audio-recorded meditation,
psychoeducation, mindfulness,
and a cognitive and behavioral
change for 6 weeks
Psychoeducation Fair
Esmer et al. [55] 40 USA Back pain, leg pain 56 Intervention, 55 (11.2);
control, 58 (9.5)
MBSR for 8 weeks with TAU TAU Poor
Fjorback et al. [32] 120 Europe Bodily distress
syndrome
20 Intervention, 38 (9);
control, 40 (8)
MBSR for 8 weeks with TAU Enhanced TAU of 2-h
specialist medical
care and brief CBT
Good
Fogarty et al. [30] 51 New Zealand Rheumatoid arthritis 12 Intervention, 52 (12);
control, 55 (13)
MBSR for 8 weeks and TAU TAU Good
Garland et al. [44] 1 15 USA Osteoarthritis,
fibromyalgia
32 48 (14) MORE: multimodal intervention
of mindfulness, CBT, positive
psychology for 8 weeks with
TA
U
Support group
with TAU
Fair
Gaylord et al. [45] 75 USA Irritable bowel
syndrome
0 Intervention, 45 (12.55);
control, 41 (14.68)
Mindfulness training tailored for
IBS population for 8 weeks
with TAU
TAU and support
group
Fair
Jay et al. [50] 1 12 Europe Musculoskeletal pain 0 Intervention, 45.5 (9.0);
control, 47.6 (8.2)
Mindfulness pain and stress
workplace program for 10
weeks
TAU Fair
202 ann. behav. med. (2017) 51:199213

Table 1 (continued)
Study Sample size Location Source of pain % male Age (M (SD)) Intervention Comparators Quality
rating
Johns et al. [37] 71 USA Cancer 9.9 Intervention, 56 (9.9);
control, 56 (12.7)
MBSR for 8 weeks Psychoeducation
support group
Good
Kanter et al. [62] 20 USA Interstitia l cystitis, bladder
pain syndrome
0 Intervention, 46 (15.2);
control, 44 (13.9)
MBSR for 8 weeks with TAU TAU Poor
Kearney et al. [51] 55 USA Gulf War illness 85.5 Intervention,51 (6.8);
control, 48 (7.4)
MBSR for 8 weeks with TAU TAU Fair
la Cour and Petersen [46] 109 Europe Varied, non-specific pain 15 Intervention, 47 (12.42);
control, 49 (12.20)
MBSR: Standard program modified
for chronic pain patients for 8
weeks with co-intervention TAU
Waitlist, TAU Fair
Lengacher et al. [52] 322 USA Cancer 0 56.6 (9.7) MBSR modified for breast cancer
patients for 6 weeks with TAU
TAU Fair
Ljotsson et al. [33] 85 Europe Irritable bowel syndrome 15 35 (9.4) MBCT protocol via Internet for IBS
group treatment for 10 weeks
Online discussion
forum
Good
Ljotsson et al. [34] 195 Europe Irritable bowel syndrome 21 39 (1 1.1) MBCT protocol via internet for IBS
group treatment for 10 weeks
Online stress
management
program
Good
Meize-Grochowski
et al. [56]
31 USA Postherpetic neuralgia 44 Overall, 72 (9.6) MBSR: 1 h instruction focusing
breathing while seated comfortably,
daily meditation using CD, phone
call reminders, daily journal, for 6
weeks with TAU
TAU Poor
Morone et al. [47] 37 USA Back pain 43 Intervention, 74 (6.1);
controls, 76 (5.0)
Modified MBSR: (1) the body scan;
(2) sitting practice; (3) walking
meditation for 8 weeks
Waitlist controls Fair
Morone et al. [57] 40 USA Back pain 37 Intervention, 78(7.1);
control, 73(6.2)
Modified MBSR: (1) the body scan;
(2) sitting practice; (3) walking
meditation for 8 weeks; Over the
counter and prescribed medications
Over the counter and
prescribed medications
Poor
Morone et al. [36] 282 USA Back pain 33.7 74.5 (6.6) MBSR for 8 weeks Health education program Good
Omidi and Zargar [58] 66 Middle East Headache 20 Intervention, 35 (2.41);
contro
l, 32 (3.2)
MBSR for 8 weeks TAU Poor
Parra-Delgado and
Latorre-Postigo [31]
33 Europe Fibromyalgia 0 53 (10.08) MBCT for 12 weeks with TAU TAU Good
Plews-Ogan et al. [59] 30 USA Musculoskeletal pain 23 47 (NR) MBSR for 8 weeks TAU (this group used in
analysis) or massage
Poor
Rahmani and
Talepasand [63]
24 Middle East Cancer 0 Intervention, 43 (3.07);
control, 45 (3.28)
MBSR and group conscious yoga
for 8 weeks
No treatment Poor
Schmidtetal.[48] 177 Europe Fibromyalgia 0 53 (9.6) Modified MBSR: mindfulness,
yoga, and social interaction
topics for 8 weeks
Waitlist (this group used
in analysis), relaxation
and stretching support
group
Fair
Teixeira [64] 22 USA Diabetic peripheral
neuropathy
25 75 (10.8) Modified MBSR: mindfulness
meditation instruction and
compact
Nutritional information
and food diary
Poor
ann. behav. med. (2017) 51:199213 203

Citations
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Journal ArticleDOI
TL;DR: The biopsychosocial model of chronic pain this paper presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors, which can be classified as nociceptive (from tissue injury), neuropathic (from nerve injury), or nociplastic (from a sensitised nervous system).

456 citations

Journal ArticleDOI
TL;DR: The current understanding of mindfulness meditation through the lens of clinical neuroscience is reviewed, outlining the core capacities targeted by mindfulness meditation and mapping them onto cognitive and affective constructs of the Research Domain Criteria matrix proposed by the National Institute of Mental Health.
Abstract: Mindfulness meditation is increasingly incorporated into mental health interventions, and theoretical concepts associated with it have influenced basic research on psychopathology. Here, we review the current understanding of mindfulness meditation through the lens of clinical neuroscience, outlining the core capacities targeted by mindfulness meditation and mapping them onto cognitive and affective constructs of the Research Domain Criteria matrix proposed by the National Institute of Mental Health. We review efficacious applications of mindfulness meditation to specific domains of psychopathology including depression, anxiety, chronic pain, and substance abuse, as well as emerging efforts related to attention disorders, traumatic stress, dysregulated eating, and serious mental illness. Priorities for future research include pinpointing mechanisms, refining methodology, and improving implementation. Mindfulness meditation is a promising basis for interventions, with particular potential relevance to psychiatric comorbidity. The successes and challenges of mindfulness meditation research are instructive for broader interactions between contemplative traditions and clinical psychological science.

167 citations

ReportDOI
05 Sep 2018
TL;DR: This guide to treatments for low back pain, fibromyalgia, and tension headache can be helpful in finding the right treatment for individual patients.
Abstract: Objectives Many interventions are available to manage chronic pain; understanding the durability of treatment effects may assist with treatment selection. We sought to assess which noninvasive nonpharmacological treatments for selected chronic pain conditions are associated with persistent improvement in function and pain outcomes at least 1 month after the completion of treatment. Data sources Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews) through November 2017, reference lists, and ClinicalTrials.gov . Review methods Using predefined criteria, we selected randomized controlled trials of noninvasive nonpharmacological treatments for five common chronic pain conditions (chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to Results Two hundred eighteen publications (202 trials) were included. Many included trials were small. Evidence on outcomes beyond 1 year after treatment completion was sparse. Most trials enrolled patients with moderate baseline pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale) and duration of symptoms ranging from 3 months to >15 years. The most common comparison was against usual care. Chronic low back pain : At short term, massage, yoga, and psychological therapies (primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain. Effects on intermediate-term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: low), and psychological therapies (SOE: moderate). Improvements in pain continued into intermediate term for exercise, massage, and yoga (moderate effect, SOE: low); mindfulness-based stress reduction (small effect, SOE: low); spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (SOE: low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than non–high-intensity programs. Chronic neck pain : At short and intermediate terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: low), but no improvement in pain was seen at any time (SOE: llow). Short-term low-level laser therapy was associated with moderate improvement in function and pain (SOE: moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long term (SOE: low). Osteoarthritis : For knee osteoarthritis, exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control, or sham procedure (SOE: moderate for exercise, low for ultrasound), which persisted into the intermediate term only for exercise (SOE: low). Exercise was also associated with moderate improvement in pain (SOE: low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: low). Evidence was sparse on interventions for hip and hand osteoarthritis. Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (SOE: low). The effect on function was sustained intermediate term (SOE: low). Fibromyalgia : In the short term, acupuncture (SOE: moderate), CBT, tai chi, qigong, and exercise (SOE: low) were associated with slight improvements in function compared with an attention control, sham, no treatment, or usual care. Exercise (SOE: moderate) and CBT improved pain slightly, and tai chi and qigong (SOE: low) improved pain moderately in the short term. At intermediate term for exercise (SOE: moderate), acupuncture, and CBT (SOE: low), slight functional improvements persisted; they were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate term (SOE: low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: low for all); massage (SOE: low) improved long-term pain slightly, but no clear impact on pain for exercise (SOE: moderate) or multidisciplinary rehabilitation (SOE: low) was seen. Short-term CBT was associated with a slight improvement in function but not pain compared with pregabalin. Chronic tension headache : Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short term versus usual care, and laser acupuncture was associated with slight pain improvement short term compared with sham (SOE: low). There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited. Conclusions Exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.

160 citations

Journal ArticleDOI
TL;DR: A systematic review of pharmacotherapy, neurostimulation, surgery, psychotherapies and other types of therapy for peripheral or central neuropathic pain, based on studies published in peer-reviewed journals before January 2018, concludes that psychotherapy (cognitive behavioral therapy and mindfulness) is recommended as a second-line therapy, as an add-on to other therapies.

154 citations

Journal ArticleDOI
TL;DR: It is suggested that brief mindfulness training has a beneficial impact on several aspects of psychosocial well-being, and that smartphone apps are an effective delivery medium for mindfulness training.
Abstract: Mindfulness training, which involves observing thoughts and feelings without judgment or reaction, has been shown to improve aspects of psychosocial well-being when delivered via in-person training programs such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). Less is known about the efficacy of digital training mediums, such as smartphone apps, which are rapidly rising in popularity. In this study, novice meditators were randomly allocated to an introductory mindfulness meditation program or to a psychoeducational audiobook control featuring an introduction to the concepts of mindfulness and meditation. The interventions were delivered via the same mindfulness app, were matched across a range of criteria, and were presented to participants as well-being programs. Affect, irritability, and two distinct components of stress were measured immediately before and after each intervention in a cohort of healthy adults. While both interventions were effective at reducing stress associated with personal vulnerability, only the mindfulness intervention had a significant positive impact on irritability, affect, and stress resulting from external pressure (between group Cohen’s d = 0.44, 0.47, 0.45, respectively). These results suggest that brief mindfulness training has a beneficial impact on several aspects of psychosocial well-being, and that smartphone apps are an effective delivery medium for mindfulness training.

151 citations


Cites background from "Mindfulness Meditation for Chronic ..."

  • ...There is mounting evidence that mindfulness-based interventions bring about positive physical and mental health outcomes in both healthy (Brown and Ryan 2003; Keng et al. 2011) and clinical (Hilton et al. 2017; Hofmann et al. 2010) populations....

    [...]

  • ...…a host of psychological benefits such as reduced stress and anxiety (Khoury et al. 2015; Vøllestad et al. 2012), reduced depressive symptomatology (Hofmann et al. 2010), and increased quality of life in both cancer patients (Zhang et al. 2015) and those with chronic pain (Hilton et al. 2017)....

    [...]

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13 Sep 1997-BMJ
TL;DR: Funnel plots, plots of the trials' effect estimates against sample size, are skewed and asymmetrical in the presence of publication bias and other biases Funnel plot asymmetry, measured by regression analysis, predicts discordance of results when meta-analyses are compared with single large trials.
Abstract: Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews . Main outcome measure: Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision. Results: In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias. Conclusions: A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution. Key messages Systematic reviews of randomised trials are the best strategy for appraising evidence; however, the findings of some meta-analyses were later contradicted by large trials Funnel plots, plots of the trials9 effect estimates against sample size, are skewed and asymmetrical in the presence of publication bias and other biases Funnel plot asymmetry, measured by regression analysis, predicts discordance of results when meta-analyses are compared with single large trials Funnel plot asymmetry was found in 38% of meta-analyses published in leading general medicine journals and in 13% of reviews from the Cochrane Database of Systematic Reviews Critical examination of systematic reviews for publication and related biases should be considered a routine procedure

37,989 citations


"Mindfulness Meditation for Chronic ..." refers methods in this paper

  • ...The quality of the body of evidence was assessed using the GRADE approach [22, 26] by which a determination of high, moderate, low, or very low was made for each major outcome [27]....

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Book
23 Sep 2019
TL;DR: The Cochrane Handbook for Systematic Reviews of Interventions is the official document that describes in detail the process of preparing and maintaining Cochrane systematic reviews on the effects of healthcare interventions.
Abstract: The Cochrane Handbook for Systematic Reviews of Interventions is the official document that describes in detail the process of preparing and maintaining Cochrane systematic reviews on the effects of healthcare interventions.

21,235 citations

01 Jan 2011

12,469 citations


"Mindfulness Meditation for Chronic ..." refers methods in this paper

  • ...Risk of bias was assessed using the Cochrane Risk of Bias tool [20]....

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  • ...Meta-analytic Techniques When sufficient data were available and statistical heterogeneity was below agreed thresholds [20], we performed metaanalysis to pool efficacy results across included studies for the outcomes of interest and present a forest plot for the main meta-analysis....

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Journal ArticleDOI
TL;DR: The approach of GRADE to rating quality of evidence specifies four categories-high, moderate, low, and very low-that are applied to a body of evidence, not to individual studies.

5,228 citations


"Mindfulness Meditation for Chronic ..." refers methods in this paper

  • ...The quality of the body of evidence was assessed using the GRADE approach [22, 26] by which a determination of high, moderate, low, or very low was made for each major outcome [27]....

    [...]