Mindfulness Interventions in Chronic Pain Treatment in El Paso, TX

by spinedoctors | Chiropractic, Chronic Pain, Physical Rehabilitation, Stress, Treatments

Stress has become a new standard in today’s society, however, a huge proportion of the United States population has experienced a significant impact on their health due to the stress in their lives. Approximately 77 percent of Americans claim they suffer stress related physical ailments on a regular basis. Also, 73 percent report experiencing stress related emotional symptoms, such as anxiety and depression. Stress management methods and techniques, including chiropractic and mindfulness interventions, are a valuable treatment option for a variety of diseases. Before addressing the symptoms associated with stress, its essential to first understand what stress is, what are the signs and symptoms of stress, and how can stress impact health.

What is Stress?

Stress is a condition of emotional or mental pressure which result from issues, adverse scenarios, or exceptionally demanding circumstances. However, the nature of stress by definition makes it rather subjective. A stressful situation to one person may not be considered stressful to another. This makes it challenging to come up with a universal definition. Stress is much more often used to refer to its symptoms and those symptoms can be as varied as the men and women who experience them.

What are the Signs and Symptoms of Stress?

The signs and symptoms of stress can impact the whole body, both physically and emotionally. Common signs and symptoms of stress include:

Sleep problems
Depression
Anxiety
Muscle tension
Lower back pain
Gastrointestinal problems
Fatigue
Lack of motivation
Irritability
Headache
Restlessness
Chest pain
Feelings of being overwhelmed
Decrease or increase in sex drive
Inability to focus
Undereating or overeating

How can Stress Impact Health?

People can experience different signs and symptoms of stress. Stress itself doesn’t directly impact an individual’s health. Instead, it is a combination of the signs and symptoms of stress as well how the person handles those that adversely impact health.

Ultimately, stress may result in some very serious ailments including: heart disease, hypertension, diabetes, obesity, and even certain cancers. Psychologically, stress can lead to social withdrawal and social phobias. It is also often directly linked to alcohol and drug abuse.

Chiropractic for Stress Management

Mindfulness interventions are common stress management methods and techniques which can help reduce the signs and symptoms of stress. According to several research studies, however, chiropractic care is an effective stress management treatment option, which together with mindfulness interventions, could help improve as well as manage stress.�Because the spine is the root of the nervous system, the health of your spine can determine how you will feel each day, both physically and emotionally. Chiropractic can help restore the balance of the body, aligning the spine, and decreasing pain.

A subluxation, or misalignment of the spine, can interfere with the way the nervous system communicates with the different parts of the body. This can lead to increased signs and symptoms of stress. A subluxation may also result in chronic pain, such as headaches, neck pain or back pain. The stress of a misalignment of the spine can aggravate the signs and symptoms of stress and make a person more susceptible to stress.�Correcting the alignment of the spine can help ease stress.

Regular chiropractic care can help effectively manage stress. Through the use of spinal adjustments and manual manipulations, a chiropractor can gently realign the spine, releasing the pressure being placed on the spinal vertebrae as well as reducing the muscle tension surrounding the spine. Furthermore, a balanced spine also helps boost the immune system, promotes better sleeping habits and helps to improve circulation, all of which are essential towards reducing stress. Finally, chiropractic care can “turn off” the flight or fight response which is commonly associated with stress, allowing the entire body to rest and heal.

Stress should not be ignored. The signs and symptoms of stress aren’t very likely to go away on their own. The purpose of the following article is to demonstrate an evidence-based review on the use of stress management methods and techniques along with mindfulness interventions in chronic pain treatment as well as to discuss the effects of these treatment options towards improving overall health and wellness. Chiropractic, physical rehabilitation and mindfulness interventions are fundamental stress management methods and/or techniques recommended for the improvement and management of stress.

Mindfulness Interventions in Physical Rehabilitation: A Scoping Review

Name: El Paso Back Clinic | Spine Specialists - El Paso, TX
Price range: $$

Abstract

A scoping review was conducted to describe how mindfulness is used in physical rehabilitation, identify implications for occupational therapy practice, and guide future research on clinical mindfulness interventions. A systematic search of four literature databases produced 1,524 original abstracts, of which 16 articles were included. Although only 3 Level I or II studies were identified, the literature included suggests that mindfulness interventions are helpful for patients with musculoskeletal and chronic pain disorders and demonstrate trends toward outcome improvements for patients with neurocognitive and neuromotor disorders. Only 2 studies included an occupational therapist as the primary mindfulness provider, but all mindfulness interventions in the selected studies fit within the occupational therapy scope of practice according to the American Occupational Therapy Association�s Occupational Therapy Practice Framework: Domain and Process. Higher-level research is needed to evaluate the effects of mindfulness interventions in physical rehabilitation and to determine best practices for the use of mindfulness by occupational therapy practitioners.

MeSH TERMS: complementary therapies, mindfulness, occupational therapy, rehabilitation, therapeutics

Mindfulness interventions are frequently used in health care to assist patients in managing pain, stress, and anxiety and in targeting additional health, wellness, and quality-of-life outcomes. Although mindfulness practices originate from Buddhism, mindfulness interventions have become largely secular and are based on the philosophy that full and nonjudgmental experience of the present moment creates positive outcomes for mental and physical health (Williams & Kabat-Zinn, 2011). This paradigm assumes that many people experience a high volume of future- or past-focused thoughts that produce anxiety. Hence, mindfulness is the practice of refocusing away from these distractions and toward lived experiences.

The prevalence of mindfulness interventions in health care has grown substantially in recent decades, and several types of mindfulness interventions have emerged. The first and most widely recognized mindfulness intervention is mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982). Initially called the stress reduction and relaxation program, MBSR was developed more than 30 years ago for patients with chronic pain and involves guided sitting meditation, mindful movement, and education on the effect of stress and anxiety on health and wellness. The evidence supporting mindfulness interventions in health care has grown since the inception of MBSR, and modern mindfulness interventions are shown to be effective at reducing pain severity (Reiner, Tibi, & Lipsitz, 2013), reducing anxiety (Shennan, Payne, & Fenlon, 2011), and enhancing well-being (Chiesa & Serretti, 2009).

Mindfulness-based interventions fit well with the strong emphasis on holism within occupational therapy practice (Dale et al., 2002). Specifically, valuing the mind�body whole is a core tenet that distinguishes occupational therapy practitioners from other health care providers (Bing, 1981; Kielhofner, 1995; Wood, 1998). Emerging literature suggests that mindfulness may enhance occupational engagement and be related to flow state (i.e., a state of timelessness within optimal experiences of activity engagement; Elliot, 2011; Reid, 2011). Mindfulness is both the meditative practice, which is an occupation itself, and a means to enhance the experience of occupations (Elliot, 2011). Moreover, a parallel exists between mindfulness practices and the occupational process of doing, being, and becoming (Stroh-Gingrich, 2012; Wilcock, 1999).

Mindfulness-based interventions in health care continue to grow in scope with the description of novel protocols, application of mindfulness to new populations, and targeting of diverse symptoms. The majority of current mindfulness literature focuses on helping people with mental health conditions and improving wellness in people, providing a wealth of evidence for occupational therapy practitioners who work in mental health or health promotion. However, the applicability and effect of mindfulness interventions for clients in rehabilitation for physical dysfunction are not as well established. Current literature that links mindfulness and occupational therapy is largely theoretical, and a translation to practice-based settings has yet to be fully explored. Therefore, the purpose of this review was to describe how mindfulness is currently used in physical rehabilitation, identify the potential applications of mindfulness interventions to occupational therapy practice, and illuminate gaps in knowledge to be explored in future research.

Method

Scoping reviews are rigorous review processes used to present the landscape of the literature on a broad topic, identify gaps in knowledge, and draw implications for further research and clinical application (Arksey & O�Malley, 2005). This type of review differs from a systematic review because it is not intended to answer questions about the efficacy of an intervention or provide specific recommendations for best practice. A scoping review is typically done in place of a systematic review when high-quality literature for a given topic is limited. Although the purpose and outcome of a scoping review differ from those of a systematic review, a systematic process is involved to ensure rigor and minimize bias (Arksey & O�Malley, 2005). A description of the methods used in this study for each of the systematic steps follows.

The question that guided this scoping review was, How is mindfulness being used in physical rehabilitation, and what are the implications for occupational therapy practice and research? Because the purpose of this review was to provide an overview of available literature, an exhaustive search using terms for all potential interventions or diagnoses was not used. Instead, we elected to combine the general key word mindfulness with each of the following major medical subheadings: therapeutics, rehabilitation, and alternative medicine. Searches were conducted in PubMed, CINAHL, SPORTDiscus, and PsycINFO and were limited to articles published in English before October 10, 2014 (i.e., the date the search was conducted). No additional limits were set, and no restrictions were placed on minimum level of evidence or study design.

Abstracts from the searches were compiled, duplicates were eliminated, and two reviewers independently screened all original abstracts. Initial inclusion criteria for abstract screening were a description of a mindfulness intervention, relevance to occupational therapy, and targeting of a disorder addressed in physical rehabilitation. A broad definition of mindfulness intervention was adopted to include any meditative practice, psychological or psychosocial intervention, or other mind�body therapeutic practice that directly mentioned or addressed mindfulness. Abstracts were considered relevant to occupational therapy if the diagnosis being evaluated was within the occupational therapy scope of practice. Disorder addressed in physical rehabilitation was defined as any illness, injury, or disability of the neurological, musculoskeletal, or other body system that could be treated within a medical or rehabilitation setting.

Any abstract identified as relevant by either author was brought to the full-text stage. In large part, these studies were conducted by scientists, psychologists, psychiatrists, or other medical doctors. Additionally, the interventions were often not implemented in settings where physical rehabilitation providers work. Therefore, to most appropriately answer the research question, final inclusion required that the study focus on an applied use of mindfulness in a rehabilitation context. This additional criterion was satisfied if the mindfulness intervention was provided by a rehabilitation professional (e.g., occupational therapist, physical therapist, speech therapist), was an addition or alternative to traditional rehabilitation, or was provided after traditional rehabilitation had failed. The two authors independently reviewed the full texts, and final study inclusion required agreement by both authors. Any disagreement on study selection was settled by deliberation ending in consensus.

For reporting, studies were primarily organized by type of physical disorder being targeted and secondarily sorted and described by type of mindfulness intervention and level of evidence. These data were summarized and are provided in the Results section to answer the first portion of the research question, that is, to describe how mindfulness is being used in physical rehabilitation. The interventions were compared with the �Types of Occupational Therapy Interventions� categories within the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association [AOTA], 2014) to determine how occupational therapy practitioners might use the interventions in clinical practice. Multiple conversations and coediting of this article between the two authors resulted in the final description of implications for occupational therapy practice and research.

Results

Results of the systematic search and review process are shown in Figure 1. The searches produced a total of 1,967 abstracts across the four databases. After 443 duplicates were removed, 1,524 original abstracts were screened, and 188 full texts were evaluated for inclusion. Exclusion at the abstract review phase was largely the result of diagnoses or interventions outside the occupational therapy scope (e.g., therapy for tinnitus) or interventions not targeting a physical disorder (e.g., anxiety disorder). At the study selection stage, full-text articles were excluded if they failed to describe an applied use of mindfulness within a rehabilitation context (n = 82) or failed to meet other initial inclusion criteria (n = 90). Sixteen studies met all criteria and were included in the data extraction and synthesis.

Figure 1: Search and inclusion flow diagram.

As shown in Table 1, 14 studies used experimental or quasi-experimental designs, including pretest�posttest (n = 6), multiple case series (n = 4), randomized trials (n = 2), retrospective cohort (n = 1), and a nonrandomized comparative trial (n = 1). Two expert opinion articles were also included because both added anecdotal evidence for the applied use of mindfulness in physical rehabilitation practice settings. Five of the 16 studies reported the involvement of occupational therapists on the study team, but only 2 of these studies specified that an occupational therapist provided the mindfulness intervention. The remaining 11 studies provided mindfulness interventions to participants either in conjunction with rehabilitation interventions not described as part of the study or after rehabilitation had failed. Mindfulness interventions included MBSR (n = 6), general mindfulness and meditation (n = 5), acceptance and commitment therapy (ACT; n = 2), and other study-specific techniques (n = 3). Physical disorders targeted by mindfulness interventions in the included studies were primarily categorized as musculoskeletal and pain disorders (n = 8), neurocognitive and neuromotor disorders (n = 6), or disorders of other body systems (n = 2).

Table 1: Summary of research on mindfulness interventions for people with musculoskeletal and pain disorders, neurocognitive and neuromotor disorders, and other disorders.

Common Mindfulness Interventions

Mindfulness-Based Stress Reduction. As referenced in Table 1, 3 studies used MBSR, each with an emphasis on meditation provided in a 2-hr group session, once a week for 8 wk. Three additional studies used an adapted MBSR protocol to meet the needs of the target population. Common adaptations of the MBSR protocol were to change the number of weeks the MBSR group met (Azulay, Smart, Mott, & Cicerone, 2013; B�dard et al., 2003, 2005) as well as to reduce the group size and session length (Azulay et al., 2013). The primary goal of MBSR and MBSR-based programs was to enhance trait-level mindfulness within the participants. Sessions included body scans (i.e., bringing attention to various parts of the body and the sensations felt), mindful yoga, guided mindful meditation, or education about stress and health. One or two people with intensive training in MBSR and who were practitioners of mindfulness themselves always facilitated MSBR sessions. Participants were expected to use recordings to meditate at home on a daily basis. Studies that implemented MBSR used it as a primary intervention to enhance mindfulness through mindfulness practices that patients were expected to integrate into their daily lives. This approach cast mindfulness as a new meaningful occupation for participants facilitated by the intervention. Therefore, the description and use of MBSR in these studies match with occupations and activities, education and training, and group interventions within occupational therapy practice (AOTA, 2014).

General Mindfulness. Five studies applied mindfulness principles generally, failed to fully describe the mindfulness portion of their intervention, or used mindfulness components (e.g., body scan only or guided meditation only) within a comprehensive rehabilitation intervention (see Table 1). Interventions varied widely between group or individual formats, in duration and frequency of sessions, and in duration of the full course of treatment. General mindfulness techniques were used as an opening to, as a closing to, or in parallel with traditional rehabilitation treatments. Therefore, the application of mindfulness was individually targeted to meet the specific needs and goals of clients. Examples of these goals included occupational engagement, engagement in therapy, reduced anxiety, awareness of bodily sensations, and nonjudgmental attitude. Given the holistic targets, general mindfulness interventions as used in these studies would be described as activities, education, or preparatory methods and tasks (AOTA, 2014).

Acceptance and Commitment Therapy. ACT is a psychological intervention stemming from clinical behavioral analysis and mindfulness principles. Two studies implemented ACT with different strategies. In 1 study (McCracken & Guti�rrez-Mart�nez, 2011), an intensive intervention was provided to participants in a group setting, 5 days per week, 6 hr per day, over a 4-wk interval. The other study (Mahoney & Hanrahan, 2011) integrated ACT as part of individual routine physical therapy interventions. In both studies, the primary goals of ACT were to improve psychological flexibility and engagement in therapy through pain acceptance and buffering of other psychological experiences. Similar to the integrative use previously described for general mindfulness, ACT was also used in these studies as activities, education, or preparatory methods and tasks (AOTA, 2014).

Targets of Mindfulness Interventions

Musculoskeletal and Pain Disorders. Musculoskeletal and pain disorders targeted by mindfulness interventions included chronic musculoskeletal pain (n = 6), work-related musculoskeletal injury (n = 1), and knee surgery (n = 1). Five of the 6 studies using mindfulness for chronic pain were experimental. In 3 of these studies, a significant reduction in pain severity was found after participation in mindfulness interventions (Kabat-Zinn, Lipworth, & Burney, 1985; McCracken & Guti�rrez-Mart�nez, 2011; Zangi et al., 2012). One randomized trial contrasted with the other studies; Wong et al. (2011) found that pain was reduced over time, but the amount of pain reduction was not significantly different between clients receiving the mindfulness intervention and a control group. The fifth experimental study (Kristj�nsd�ttir et al., 2011) piloted a mindfulness intervention by using a mobile phone application. This study�s sample size was not large enough to evaluate a significant change in the outcome measures; however, the participants reported that the mobile mindfulness intervention was helpful and appropriate for treating their symptoms. Although these studies demonstrated varied results in reducing pain severity, secondary outcomes such as increased acceptance of pain, improved functioning with pain, and decreased distress produced larger effect sizes and were consistently significant.

A retrospective study (Vindholmen, H�igaard, Espnes, & Seiler, 2014) sought to predict treatment outcomes based on the trait-level mindfulness of patients at a vocational rehabilitation center receiving therapeutic interventions for work-related musculoskeletal disorders. The observational facet of trait-level mindfulness was found to significantly predict time until return to work, but only for highly educated patients. The authors noted that mindfulness interventions may moderate quality of life, which was a significant predictor of time until return to work for all participants.

Two studies, 1 with Level IV (i.e., case series; Mahoney & Hanrahan, 2012) and 1 with Level V (i.e., expert opinion; Pike, 2008) evidence, suggested that combining traditional therapeutic rehabilitation interventions with mindfulness for patients with musculoskeletal and pain disorders has benefits. Clients receiving ACT integrated into their physical therapy sessions after knee surgery reported that the mindfulness intervention was helpful to their rehabilitation process and increased their engagement in therapy (Mahoney & Hanrahan, 2012). In his commentary, Pike (2008) argued for implementing mindfulness interventions in combination with physical therapy for patients who suffer from chronic pain, noting that mindfulness is similar to more widely used awareness-based interventions (e.g., Pilates). Similar to the positive reception noted by Mahoney and Hanrahan (2012), Pike noted that integrating mindfulness into his physical therapy practice had proven to be clinically useful and well tolerated by patients. He hypothesized that the mechanism of mindfulness interventions may either directly reduce pain or improve functional outcomes despite pain, concepts validated by the experimental studies previously discussed in this section.

Neurocognitive and Neuromotor Disorders. Studies using mindfulness interventions for people with neurocognitive and neuromotor disorders included participants with diagnoses of aphasia (n = 1), traumatic brain injury (TBI; n = 4), and developmental coordination disorder (n = 1). Orenstein, Basilakos, and Marshall (2012) found no change attributed to a mindfulness intervention on divided attention tasks or symptoms of aphasia when used with 3 clients. However, 3 pretest�posttest studies using mindfulness interventions for patients with TBI showed more promising results. Azulay et al. (2013) reported a trend (p = .07) toward improved cognitive functioning, with moderate effect sizes (d = 0.31 and 0.32). B�dard et al. (2003) found trends toward reduced symptom distress and improved physical health, with small to moderate effect sizes (0.296 < d < 0.32). They also demonstrated significant improvements in secondary measures such as self-efficacy, quality of life, and mental health. Moreover, a 12-mo postintervention follow-up of their 2003 study showed significant maintenance or improvement in patients with TBI across time in vitality, emotional role, and mental health, but fluctuating pain (B�dard et al., 2005). Of note is that although participants reported that they valued the mindfulness intervention, gender played a role in recruitment and retention because most young men either chose to not participate in or dropped out of the study (B�dard et al., 2005).

In Meili and Kabat-Zinn (2004), Meili, a woman who sustained a TBI, recounted that mindfulness was central to her journey of healing. Using Meili�s experience as an example, Kabat-Zinn asserted that helping patients understand, accept, and adjust to their illness or disability through both inner adjustment to new bodily experiences, or mindfulness, and external restoration of physical functioning, or physical rehabilitation, are essential to the healing process. Moreover, Kabat-Zinn stated that occupational therapy practitioners and other rehabilitation professionals are well equipped to implement mindfulness interventions because these interventions complement their existing practice of facilitating the outer work of healing the body. Adding mindfulness interventions would be clinically appropriate to foster the inner work necessary for patients to heal. Jackman (2014) also suggested that mindfulness is appropriate as part of the rehabilitative process. Jackman discussed the use of mindfulness in occupational therapy for children with developmental coordination disorder. Children who participated in mindfulness-enhanced therapy improved on at least one component of motor coordination. This therapy also helped parent�child dyads meet their self-directed goals.

Other Conditions. Two additional studies targeted physical diagnoses that were not explicitly musculoskeletal or neuromotor. In the first, MBSR was provided to women with urge-predominant urinary incontinence by an occupational therapist who had received intensive training in mindfulness (Baker, Costa, & Nygaard, 2012). Seven women who had an average of 4.14 episodes of urinary incontinence per day participated in an 8-wk MBSR group. In contrast to other studies that combined mindfulness with traditional rehabilitation, participants in this study received no other treatment or traditional interventions for urinary incontinence (e.g., pelvic floor muscle exercises, bladder education). At posttest, participants had significantly fewer episodes (p = .005), averaging 1.23 per day. Although limited by a small sample size and lack of a control group, this study demonstrated preliminary support for stand-alone mindfulness interventions provided by occupational therapists for a physical condition.

The second study used mindfulness-based cognitive therapy in the rehabilitation of vestibular dysfunction and dizziness (Naber et al., 2011). In this study, group-based mindfulness components were nested within standard vestibular rehabilitation practices, dialectical behavioral therapy, and cognitive�behavioral therapy over five biweekly sessions. In addition, participants met individually with a physical therapist who provided personalized exercises. Significant improvement in vestibular symptoms, including functional level, impairment, coping, and skill use (p < .0001), was noted.

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Mindfulness interventions, such as mindfulness-based stress reduction, general mindfulness and acceptance and commitment therapy, are prevalent stress management methods and techniques frequently used in health care to help�relieve symptoms of stress, mental health issues and physical pain as well as to address and treat a variety of symptoms and diseases. Mindfulness interventions are believed to increase the outcome measures of alternative and complementary treatment options. Chiropractic care is another popular stress management option which can help improve as well as manage stress. The use of mindfulness interventions and chiropractic care with other treatments, such as physical rehabilitation, has been determined to increase their results. The article above demonstrated evidence-based results on the effectiveness of mindfulness interventions for symptoms of stress, including chronic pain.

Discussion

This scoping review describes how mindfulness is used in physical rehabilitation, identifies implications for occupational therapy, and illuminates gaps in current research. The studies included in the review provide preliminary support that mindfulness interventions can improve urinary incontinence, chronic pain, and vestibular functioning. These studies also show a promising trend toward improved outcomes for cognitive and behavior targets for patients with TBI. Across the studies, the strongest findings were for improvements in adaptation to illness or disability such as self-efficacy for disease management, increased quality of life, and acceptance of pain symptoms. In addition, mindfulness interventions for these outcomes not only were immediately effective but also maintained effectiveness at follow-up at a clinically significant level. This result suggests that adaptation-based outcomes are an important complement to function- and symptom-based outcomes in clinical mindfulness research. Moreover, patient appraisals of mindfulness interventions were positive, and no studies reported adverse or negative effects.

Occupational therapists were the primary providers of mindfulness interventions in 2 studies (Baker et al., 2012; Jackman, 2014). Although these studies showed promising results, both were limited by small sample size and lack of control conditions. In addition, Jackman (2014) failed to report numeric values for the findings, limiting interpretation. In 3 additional studies, occupational therapists had an ancillary role in providing mindfulness interventions (McCracken & Guti�rrez-Mart�nez, 2011; Vindholmen et al., 2014; Zangi et al., 2012). However, because of the complementary nature of the interventions with the occupational therapy scope of practice (AOTA, 2014) and the manner in which they were implemented, occupational therapy practitioners could have been active providers of the mindfulness interventions in these studies, highlighting the feasibility of integrating mindfulness into occupational therapy practice in future research. Moreover, although MBSR was the primary intervention that promoted engagement in mindfulness as an occupation, general mindfulness interventions and ACT also served as appropriate activity-based, preparatory, and educational interventions in these studies. Given the results of these studies and support from additional literature describing the use of mindfulness by occupational therapists (Moll, Tryssenaar, Good, & Detwiler, 2013; Stroh-Gingrich, 2012), further investigation of best practices for integrating mindfulness techniques into physical rehabilitation is warranted.

Although the literature suggests that mindfulness interventions can have positive effects in physical rehabilitation, substantial limitations exist in the current evidence. First, the majority of the positive studies are limited by their study design, being, at best, Level III evidence (i.e., cohort design). In contrast, an appropriately powered randomized controlled trial found a significant pretest�posttest effect of mindfulness interventions on pain reduction but also noted a similar reduction in pain for control group participants (Wong et al., 2011). Second, the wide variability in mindfulness intervention protocols makes it challenging to reach any general conclusions about intervention effectiveness. Finally, many studies overrepresented middle-aged White women, limiting interpretation of the acceptability of mindfulness interventions by or their effects in other demographics. Specifically, B�dard et al. (2005) noted decreased interest and adherence to their mindfulness intervention by male participants.

More information is needed to understand best practices for integration of mindfulness into occupational therapy practice. Specifically, the mindfulness interventions included in this review were generally complex, used a standardized protocol, were not fully integrated with standard rehabilitation interventions, and required intensive training for providers. Thus, further investigation is needed to:

Establish the effectiveness of mindfulness interventions in various settings and patient populations with physical diagnoses in high-level, randomized trials;
Examine the utility of training methods for occupational therapy practitioners in the delivery of mindfulness interventions for physical disorders as part of professional curricula, through continuing education programs or other postprofessional training;
Describe best practices for clinical integration of mindfulness into occupational therapy practice; and
Explore the implications related to reimbursement for and cost-effectiveness of the delivery of mindfulness interventions in occupational therapy practice.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

Mindfulness in physical rehabilitation is primarily used to help clients with chronic pain and TBI adapt to illness and disability, which promotes functional recovery as complementary to symptom remediation.
Mindfulness for physical disorders has yet to be substantiated as an evidence-based intervention within occupational therapy; however, promising preliminary evidence exists, and current mindfulness protocols fit within the occupational therapy scope of practice as preparatory, activity, or occupation-based interventions.
Higher level research is needed to address the substantial limitations in current efficacy studies on mindfulness for physical conditions and to determine best practices for the use of mindfulness in physical rehabilitation by occupational therapy practitioners.

Acknowledgments

Many thanks for the support and guidance received from Dr. Gelya Frank. Work on this review was partially supported by Grant No. K12�HD055929, National Institute of Child Health and Human Development/National Institute of Neurological Disorders and Stroke Rehabilitation Research Career Development Program. The contents of this article are solely the responsibility of the authors and do not necessarily represent the views of the National Institutes of Health. Portions of this work were presented at the 2015 Occupational Therapy Summit of Scholars in Los Angeles, CA.

Footnotes

Indicates studies that were included in the scoping review for this article.

Contributor Information

Ncbi.nlm.nih.gov/pmc/articles/PMC4834757/

In conclusion,�although stress is common in today’s society, stress can lead to a variety of physical and emotional diseases. Stress management methods and techniques are growing as popular treatment options to treat stress and its associated ailments, including chronic pain. Chiropractic care helps reduce stress by correcting subluxations, or spinal misalignments, to release pressure on the vertebrae and reduce muscle tension. The article above also demonstrates the effectiveness of mindfulness interventions in physical rehabilitation, although further research studies are needed. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

blog picture of cartoon paperboy big news

EXTRA IMPORTANT TOPIC: Managing Workplace Stress

Stress Management Techniques for Chronic Pain in El Paso, TX

by spinedoctors | Chronic Pain, Conditions Treated, Randomized Controlled Trial, Treatments

In the modern world, it’s easy to find circumstances to stress about. Whether it involves work, financial issues, health emergencies, relationship problems, media stimulation and/or other factors, stress can begin to weigh in on our overall health and wellness if not managed properly. Also, we often tend to create stress ourselves through poor nutrition and a lack of sleep.

In fact, more than three-fourths of the population in the United States experiences stress on a regular basis, where one-third of those individuals characterize their stress levels as “extreme”. Although short-term stress can be helpful, long-term stress can lead to a variety of health issues. Stress has been considered the cause of so many diseases, healthcare professionals estimate it accounts for half of the country’s healthcare-related expenses, according to the U.S. News & World Report.

How Stress Affects the Body

Stress signals the sympathetic nervous system to trigger the “fight or flight” response, a defense mechanism which prepares the body for perceived danger by causing the heart rate, blood volume and blood pressure to rise. This diverts blood away from the digestive system and limbs. The adrenal glands also secrete a special mixture of hormones and chemicals, including adrenaline, epinephrine and norepinephrine, which could affect an individual’s well-being if they’re constantly being secreted into the body.

Also, chronic stress can cause muscle tension. Excess muscle tension along the neck and back may result in the misalignment of the spine, known as a subluxation, ultimately interfering with the proper function of the nervous system and causing symptoms of back pain and sciatica. Fortunately, a variety of stress management techniques, including chiropractic care and mindfulness meditation, can help reduce chronic pain, commonly associated with chronic stress.

Chiropractic Care for Stress

Chiropractic care is a well-known, alternative treatment option utilized to treat a variety of injuries and conditions associated with the musculoskeletal and nervous system.�Correcting spinal misalignments is the first step for reducing stress. If there is a subluxation in the spine, the nervous system may often not be able to properly send signals throughout the rest of the body. By using spinal adjustments and manual manipulations, a doctor of chiropractic can carefully realign the spine,�releasing muscle tension, soothing irritated spinal nerves and improving blood flow, changes which could will alert the brain to switch off the “fight or flight” response so that the body can return to a more relaxed state.

Furthermore, a chiropractor can also recommend lifestyle modifications, together with spinal adjustments and manual manipulations, to help reduce stress. Nutritional supplementation, rehabilitative exercises, deep-tissue massage, relaxation techniques and posture changes recommended by a chiropractor are several stress management techniques which can help improve symptoms of chronic pain associated with stress. The following article is a systematic review and meta-analysis demonstrating the use of mindfulness medication for chronic pain, including back pain and sciatica.

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

Abstract

Background: Chronic pain patients increasingly seek treatment 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) with meta-analyses using the Hartung-Knapp-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 reported on safety. We found low-quality evidence that mindfulness 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.
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.
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 consequences, 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 $560�635 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 medication dependence, has led to increased interest in treatment plans that include adjunctive therapy or alternatives to medication [4]. One such modality that pain patients are using is mindfulness meditation. Based on ancient Eastern meditation practices, mindfulness facilitates an attentional stance of detached 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 one�s external surroundings and inner sensations, allowing the individual to step back and reframe experiences. Current research using neuroimaging to elucidate neurological mechanisms 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 [9], tobacco cessation [10], stress reduction [11], and treatment of chronic pain [12�14].

Early mindfulness studies in pain patients showed promising 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 focused on controlled trials of mindfulness interventions for chronic pain including a review [4] that showed improvements in depressive symptoms and coping, another review [18] on mindfulness for chronic back pain, 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 acceptance, 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 meditation for chronic pain symptoms could be made.

The purpose of this study was to conduct a systematic review and meta-analysis of the effects and safety of mindfulness meditation, as an adjunctive or monotherapy to treat individuals 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 controlled trials from inception through June 2016. We combined pain conditions and design terms with the following mindfulness 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 satipa??h?na 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 reviews 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 minimum 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 meditation, 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 conference abstracts were excluded.

Procedures

Two independent reviewers screened titles and abstracts of retrieved citations�following 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 dually 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 publications were recorded. Data abstraction was also conducted in dual. Risk of bias was assessed using the Cochrane Risk of Bias tool [20]. Other biases related to the US Preventive Services Task Force�s (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 heterogeneity 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 [23�25]. For studies reporting multiple pain outcomes, we used specific pain measures, 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 conducted subgroup analyses and 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 databases and 11 additional records identified through other sources (see Figure 1). Full texts were obtained for 125 citations identified as potentially eligible by two independent reviewers; 38 RCTs met inclusion criteria. Details of study characteristics are displayed in Table ?1 and effects for individual studies are displayed in Table ?2.

Table 1: Characteristics of included studies.

Table 2: Effects for individual studies.

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 different conditions.) Osteoarthritis was reported in two studies and rheumatoid arthritis in three. Migraine headache was reported in three studies and another type of headache in five studies. Three studies reported irritable bowel syndrome (IBS). Eight studies reported other causes of pain and three studies did not specify a medical condition or source of chronic pain.

The total length of the interventions ranged from 3 to 12 weeks; the majority of interventions (29 studies) were 8 weeks in length. Twenty-one studies were conducted on mindfulness-based stress reduction (MBSR) and six on mindfulness-based cognitive therapy (MBCT). Eleven additional studies reported results on other types of mindfulness training. Thirteen RCTs provided the mindfulness intervention as monotherapy, and eighteen utilized a mindfulness intervention as adjunctive therapy, specifying that all participants received this in addition to other treatment such as medication. Seven of the studies were unclear as to whether the mindfulness intervention was monotherapy or adjunctive therapy. Nineteen RCTs used treatment as usual as comparators, thirteen used passive comparators, and ten used education/support groups as comparators. Beyond these common comparators, one study each used stress management, massage, a multidisciplinary pain intervention, relaxation/stretching, and nutritional information/food diaries as comparators; two studies used cognitive-behavioral therapy. Several studies had two comparison arms.

Study Quality and Risk of Bias

The study quality for each included study is displayed in Table ?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 primarily 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 [53�62] and three due to unclear methods [63�65]. Details of the quality ratings and risk of bias for each included study is displayed in Electronic Supplementary Material 1.

Measures

Studies reported patient pain measures such as the Visual Analog Scale, the SF-36 pain subscale, and McGill Pain Questionnaire. Secondary outcome measures included depression symptoms (e.g., Beck Depression Inventory, Patient Health Questionnaire), physical and mental health-related quality of life (e.g., SF-36 mental and physical components), and functional impairment/disability (e.g., Roland-Morris Disability Questionnaire, Sheehan Disability Scale).

Chronic Pain Treatment Response

Thirty RCTs reported continuous outcome data on scales assessing chronic pain [29, 31�33, 36, 39�49, 51�60, 62�64, 66].

Eight studies met screening inclusion criteria but did not contribute to the meta-analysis because they did not report poolable data [28, 30, 34, 35, 38, 50, 61, 65]. Their study characteristics are displayed in Table ?1, and study level effects along with the reasons they were not in pooled analyses are displayed in Table ?2.

Pain scales and comparators varied from study to study. The median follow-up time was 12 weeks, with a range of 4 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 effect of mindfulness meditation compared with treatment as usual, passive controls, and education/support groups (SMD, 0.32; 95 % CI, 0.09, 0.54; 30 RCTs). Substantial heterogeneity was detected (I 2 = 77.6 %). There was no evidence of publication bias (Begg�s p = 0.26; Egger�s test p = 0.09). To investigate whether the treatment estimate is robust when excluding poor-quality studies and to explore the possible source of the substantial heterogeneity, we conducted a sensitivity analysis including only fair or good quality studies. The improvement remained significant, the effect size was smaller (SMD, 0.19; 95 % CI, 0.03, 0.34; 19 RCTs), and there was less heterogeneity (I 2 = 50.5 %). Meta-regressions showed that changes in pain outcomes in good- (p = 0.42) and fair-quality (p = 0.13) studies were not significantly different from changes in poor-quality studies.

Figure 2: Mindfulness meditation effects on chronic pain.

In subgroup analyses, the effect was not statistically significant at 12 weeks or less (SMD, 0.25; 95 % CI, ?0.13, 0.63; 15 RCTs; I 2 = 82.6 %) but was significant for follow-up periods beyond 12 weeks (SMD, 0.31; 95 % CI, 0.04, 0.59; 14 RCTs, I 2 = 69.0 %). Begg�s test was not statistically significant (p = 0.16) but Egger�s test showed evidence of publication bias (p = 0.04). The quality of evidence that mindfulness meditation is associated with a decrease in chronic pain compared with control is low overall and for both short- and long-term follow-up due to inconsistency, heterogeneity, and possible publication bias. A detailed table displays the quality of evidence for findings for each major outcome in Electronic Supplementary Material 2.

In order to present clinically meaningful results, we calculated the percent change in pain symptoms from baseline to follow-up for mindfulness meditation and comparison groups for each study and displayed findings in Table ?2. We then calculated the overall weighted mean percent change for mindfulness meditation groups versus comparison groups for effects of meditation for pain at longest follow-up. The mean percent change in pain for meditation groups was ?0.19 % (SD, 0.91; min, ?0.48; max, 0.10) while the mean percent change in pain for control groups was ?0.08 % (SD, 0.74; min, ?0.35; max, 0.11). The p value for the difference between 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 significantly lowered depression scores as compared with treatment as usual, support, education, stress management, and waitlist control groups (SMD, 0.15; 95 % CI, 0.03, 0.26; 12 RCTs; I 2 = 0 %). No heterogeneity was detected. The quality of evidence was rated as high due to lack of heterogeneity, consistent study results, and precision of effect (small confidence intervals).

Quality of Life

Sixteen studies reported mental health-related quality of life; the effect of mindfulness meditation was significant in the pooled analysis as compared with treatment as usual, support groups, education, stress management, and waitlist controls (SMD, 0.49; 95 % CI, 0.22, 0.76; I 2, 74.9 %). [32�34, 45�49, 52, 54, 56, 59, 60, 62�64]. Sixteen studies measured physical health-related quality of life [32�34, 36, 45�49, 52, 54, 56, 60, 62�64]. Pooled analyses showed a significant effect of mindfulness meditation as compared with treatment as usual, support groups, education, stress management, and waitlist controls (SMD, 0.34; 95 % CI, 0.03, 0.65; I 2, 79.2 %). Both quality-of-life analyses detected substantial heterogeneity, and the quality of evidence was rated as moderate for mental health (small confidence intervals, more consistent results) and low for physical health-related quality of life.

Functional Impairment (Disability Measures)

Four studies reported poolable disability scores from the Roland-Morris Disability Questionnaire and the Sheehan Disability Scale [33, 36, 47, 55]. The difference between the mindfulness and comparison groups in follow-up was not statistically significant (SMD, 0.30; 95 % CI, ?0.02, 0.62; I 2 = 1.7 %), although the results approached significance. No heterogeneity was detected. The quality of evidence was rated low due to imprecision and small total sample size.

Analgesic Use

Only four studies reported use of analgesics as an outcome. In a study of MBSR for treatment of chronic pain due to failed back surgery syndrome [55], at 12-week follow-up, the analgesic medication logs of the intervention group documented a decrease in analgesic use compared with those in the control group (?1.5 (SD = 1.8) vs. 0.4 (SD = 1.1), p = <0.001). A study of mindfulness meditation and cognitive-behavioral therapy vs. usual care for low back pain [35] reported that the mean morphine equivalent dose (mg/day) of opioids was not significantly different between groups at both 8 and 26 weeks. Likewise, a trial of MBSR for back pain [38] found no significant difference between groups in self-reported use of pain medication. Finally, a trial of mindfulness-oriented recovery enhancement (MORE) for chronic pain of various etiologies [44] found intervention participants significantly more likely to no longer meet criteria for opioid use disorder immediately following treatment (p = 0.05); however, these effects were not 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]; one described that two participants experienced temporary strong feelings of anger toward their pain condition and two of the participants experienced greater anxiety [46]; two studies recorded mild side effects from yoga and progressive muscle relaxation [35, 38].

Study Characteristic Moderators

Meta-regressions were run to determine if changes in pain outcomes systematically differed by several subcategories. 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 (16 studies) to all other interventions (14 studies), there was also no difference in effect (p = 0.45). As stated in more detail above, medical conditions reported included fibromyalgia, back pain, arthritis, headache, and irritable bowel syndrome (IBS). Meta-regressions did not suggest differences between headache (six studies) and other conditions (p = 0.93), back pain (eight studies) and other conditions (p = 0.15), and fibromyalgia (eight studies) and other conditions (p = 0.29). Gender composition (% male) had no association with effect on pain (p = 0.26). The total length of the intervention program ranged from 3 to 12 weeks (mean was 8 weeks). Meta-regression did not suggest differences between high-frequency interventions and medium- (p = 0.16) or low-frequency (p = 0.44) interventions. No systematic difference in effect on pain between adjunctive therapy and monotherapy (p = 0.62) or between adjunctive therapy and interventions where this was unclear (p = 0.10) was found. Finally, there was no systematic difference in effect whether the comparator was treatment as usual, waitlist, or another intervention (p = 0.21).

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Chronic stress is a massive issue in the United States and it has had a detrimental impact on the overall health and wellness of the American population. Stress can affect different areas of the body. Stress can increase heart rate and cause rapid breathing, or hyperventilation, as well as muscle tension. Additionally, stress triggers the “fight or flight” response, which causes the sympathetic nervous system to release a mixture of hormones and chemicals into the body. Fortunately, chiropractic care can help with stress management. Chiropractic treatment activates the parasympathetic system which calms the “fight or flight” response. Furthermore, chiropractic care can help reduce muscle tension, improving chronic pain symptoms.

Discussion

In sum, mindfulness meditation was associated with a small effect of improved pain symptoms compared with treatment as usual, passive controls, and education/support groups in a meta-analysis of 30 randomized controlled trials. However, there was evidence of substantial heterogeneity among studies and possible publication bias resulting in a low quality of evidence. The efficacy of mindfulness meditation on pain did not differ systematically by type of intervention, medical condition, or by length or frequency of intervention. Mindfulness meditation was associated with statistically significant improvement in depression, physical health-related quality of life, and mental health-related quality of life. Quality of evidence was high for depression, moderate for mental health-related quality of life, and low for physical health-related quality of life. Only four studies reported on change in analgesic use; results were mixed. Adverse events in the included RCTs were rare and not serious, but the vast majority of studies did not collect adverse events data.

This review has several methodological strengths: an a priori research design, duplicate study selection and data abstraction of study information, a comprehensive search of electronic databases, risk of bias assessments, and comprehensive quality of evidence assessments used to formulate review conclusions. One limitation is that we did not contact individual study authors; results reported in the review are based on published data. We excluded conference abstracts which do not contain enough data to evaluate study quality. In addition, we included only studies published in English.

The included studies had many limitations. Thirteen of the thirty-eight studies were rated as poor quality, primarily due to lack of ITT, poor follow-up, or poor reporting of methods for randomization and concealment of allocation. The authors of ten studies reported inadequate statistical power to detect differences in pain outcomes between mindfulness meditation and the comparator; the authors considered these pilot studies. Ten other studies did not report a power calculation. Sample sizes were small; 15 studies randomized fewer than 50 participants.

More well-designed, rigorous, and large RCTs are needed in order to develop an evidence base that can more decisively provide estimates of its effectiveness. Studies should enroll samples large enough to detect statistical differences in outcomes and should follow-up with participants for 6 to 12 months in order to assess the long-term effects of meditation. Adherence to mindfulness practice and simultaneous use of other therapies should be monitored frequently. Intervention characteristics, including the optimal dose, have also not yet conclusively been established. In order to detect intervention specific effects, studies need to have attention-matched controls. Smaller trials may be conducted to answer these questions. Other outcomes that were outside the scope of this review may be important to explore. As the impact of mindfulness may be related to the appraisal of the pain, it may be useful for future trials to focus primary outcomes on symptoms associated with pain such as quality of life, pain-related interference, pain tolerance, analgesic, and related issues such as opioid craving. Future publications on RCTs of mindfulness meditation should adhere to Consolidated Standards of Reporting Trials (CONSORT) standards.

Only three RCTs attributed minor adverse events to mindfulness meditation. However, only 7 of the 38 included RCTs mentioned whether adverse events were monitored and collected. Thus quality of evidence for adverse events reported in RCTs is inadequate for a comprehensive assessment. Given published reports of adverse events during meditation, including psychosis [67], future trials should actively collect adverse events data. In addition, a systematic review of observational studies and case reports would shed additional light on adverse events during mindfulness meditation.

Further research examining the effect of mindfulness meditation on chronic pain should also focus on better understanding whether there is a minimum frequency or duration of meditation practice for it to be effective. While recent studies have yielded similar positive effects of mindfulness for pain, these effects tend to be small to medium and based on a body of evidence that is, at best, of moderate quality. A potential way to advance research on chronic pain would be to improve intervention and control group descriptions, identify different effects of various components of complex interventions, and work toward a standard criterion for assessing therapeutic gain [68]. Head-to-head trials that compare mindfulness interventions of a similar category but with variations in components or dose may be helpful to tease out the most effective elements of these interventions [69].

Similar to previous reviews in this area, we conclude that while mindfulness meditation interventions showed significant improvements for chronic pain, depression, and quality of life, the weaknesses in the body of evidence prevent strong conclusions. The available evidence did not yield consistent effects for pain outcomes, and few studies were available for forms of mindfulness meditation other than MBSR. Quality of evidence for the efficacy of mindfulness interventions in reducing chronic pain is low. There was higher quality evidence of the efficacy of mindfulness meditation on depression and mental health-related quality-of-life outcomes. This review is consistent with previous reviews concluding that more well-designed, rigorous, and large RCTs are needed in order to develop an evidence base that can more decisively provide estimates of the efficacy of mindfulness meditation for chronic pain. In the meantime, chronic pain continues to pose a tremendous burden on society and individuals. A novel therapeutic approach for chronic pain management such as mindfulness meditation would likely be welcomed by patients suffering from pain.

Electronic Supplementary Material

Ncbi.nlm.nih.gov/pmc/articles/PMC5368208/

Compliance with Ethical Standards

Funding and Disclaimer

The systematic review was sponsored by the Department of Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (contract number 14-539.2). The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the Department of Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Authors Statement of Conflict of Interest and Adherence to Ethical Standards Authors

Authors Hilton, Hempel, Ewing, Apaydin, Xenakis, Newberry, Colaiaco, Maher, Shanman, Sorbero, and Maglione declare that they have no conflict of interest. All procedures, including the informed consent process, were conducted in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000.

In conclusion,�stress can ultimately affect our overall health and wellness if not managed properly. Fortunately, several stress management techniques, including chiropractic care and mindfulness meditation, can help reduce stress as well as improve chronic pain associated with stress. Chiropractic treatment is an important stress management technique because it can calm the “fight or flight” response associated with chronic stress. The article above also demonstrated how mindfulness meditation can be a fundamental stress management technique for improving overall health and wellness. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

blog picture of cartoon paperboy big news

EXTRA IMPORTANT TOPIC: Managing Workplace Stress

Stress Management & Chiropractic Treatment in El Paso, TX

by spinedoctors | Back Pain, Chiropractic, Physical Rehabilitation, Stress, Treatments

Many people utilize chiropractic treatment for stress management. If you haven’t already considered chiropractic to help reduce your stress, then it might still be in your best interest to know if it actually can help manage stress. If that’s the case, how exactly can chiropractic treatment help reduce stress levels? Every individual experiences stress. If chiropractic is so effective for stress management, why isn’t it more well-known? Although the answer to that is complex, the popularity of chiropractic treatment for stress management is growing. The article below discusses how chiropractic can help reduce your stress.

What Causes Stress?

Stress is difficult to define, however, it can be identified as a physical and/or psychological reaction to pressure. Stress may be caused by numerous factors, including environmental, bodily and emotional channels. When we become stressed, the sympathetic nervous system triggers the “fight or flight” response, a defense mechanism which prepares the body for perceived danger. While short-term stress is helpful, long-term stress has been connected to a variety of health issues. For instance, too much stress can create excess tension on the neck, back and low back, which may in turn lead to subluxation or spinal misalingment. This can ultimately also be bad for the heart, digestion, metabolism, and the immune system.

How Can Chiropractic Care Help?

As mentioned above, stress can frequently take a toll on the spine. Tension may continue to build up as a result of chronic stress, eventually resulting in pain and discomfort, among other symptoms, such as back pain and sciatica. Chiropractic care can help in two ways. First, through the use of spinal adjustments and manual manipulations, a chiropractor will carefully correct the misalignment of the spine, or subluxation, releasing tension and stress and relaxing the body to decrease the physical and psychological strain on the body. Second, once the spine is properly realigned, the central nervous system can function effectively.

A doctor of chiropractic will always be happy to speak with you and get you on the path towards a healthy and stress free life. A chiropractor can offer stress management chiropractic treatment to help you feel healthy. The purpose of the following systematic review is to demonstrated how effective mindfulness-based stress reduction methods and techniques can help low back pain.

Mindfulness-Based Stress Reduction for Low Back Pain: A Systematic Review

Abstract

Background

Mindfulness-based stress reduction (MBSR) is frequently used for pain conditions. While systematic reviews on MBSR for chronic pain have been conducted, there are no reviews for specific pain conditions. Therefore a systematic review of the effectiveness of MBSR in low back pain was performed.

Methods

MEDLINE, the Cochrane Library, EMBASE, CAMBASE, and PsycInfo were screened through November 2011. The search strategy combined keywords for MBSR with keywords for low back pain. Randomized controlled trials (RCTs) comparing MBSR to control conditions in patients with low back pain were included. Two authors independently assessed risk of bias using the Cochrane risk of bias tool. Clinical importance of group differences was assessed for the main outcome measures pain intensity and back-specific disability.

Results

Three RCTs with a total of 117 chronic low back pain patients were included. One RCT on failed back surgery syndrome reported significant and clinically important short-term improvements in pain intensity and disability for MBSR compared to no treatment. Two RCTs on older adults (age???65 years) with chronic specific or non-specific low back pain reported no short-term or long-term improvements in pain or disability for MBSR compared to no treatment or health education. Two RCTs reported larger short-term improvements of pain acceptance for MBSR compared to no treatment.

Conclusion

This review found inconclusive evidence of effectiveness of MBSR in improving pain intensity or disability in chronic low back pain patients. However, there is limited evidence that MBSR can improve pain acceptance. Further RCTs with larger sample sizes, adequate control interventions, and longer follow-ups are needed before firm conclusions can be drawn.

Keywords: Low back pain, Mindfulness-based stress reduction, MBSR, Complementary therapies, Review

Background

Low back pain is a major public health problem, with 76 % of the population experiencing low back pain in a given year [1]. It has become the largest category of medical claims, placing a major burden on individuals and health care systems [2]. Low back pain is the most common condition for which complementary therapies are used [3]. In the US, more than half of patients suffering from low back pain use complementary therapies [4].

Mindfulness is the common ground of several complementary therapies. Derived from Buddhist spiritual tradition, mindfulness has been secularized and integrated into behavioral treatment approaches [5]. While mindfulness has been described as the core construct of Buddhist meditation [5], it also comprises a specific state of consciousness that has been characterized as non-elaborative, non-judgmental moment-to moment awareness, a way to accept and trust in one�s own experience [6]. Therefore, mindfulness-based therapies not only include training in so-called formal practice of mindfulness, this is meditation, but also training in so-called informal practice of mindfulness, this is retaining a mindful state of consciousness during routine activities in everyday life [7,8].

The most commonly used mindfulness-based intervention is mindfulness-based stress reduction (MBSR). MBSR has originally been developed in a behavioral medicine setting for patients with chronic pain and stress-related complaints [9,10]. MBSR is a structured 8-week group program of weekly 2.5-hour sessions and 1 all-day (7 to 8-hour) silent retreat. Key components of the program are sitting meditation, walking meditation, hatha yoga and body scan, a sustained mindfulness practice in which attention is sequentially focused on different parts of the body [6]. Another important component is the transition of mindfulness into everyday life.

Mindfulness-based cognitive therapy (MBCT) combines MBSR with cognitive-behavioral techniques [11,12]. It retains the original 8-week group-based approach. Originally developed as a treatment for major depression [11], MBCT is more and more adapted for other specific conditions [12]. Other mindfulness-based interventions include mindful exercise [13] and acceptance and commitment therapy [14] that do not necessarily include formal meditation practice.

Pain has been a key topic of research on MBSR from the beginning [9]. Several trials assessed the effect of MBSR on patients with heterogeneous chronic pain conditions, mainly reporting positive results [15-19]. A recent comprehensive meta-analysis of mindfulness-based interventions for chronic pain conditions found small effects on pain, depression and physical well-being when considering only randomized controlled trials [14]. However, this meta-analysis included only one trial on low back pain.

The aim of this review was to systematically assess and – if possible – meta-analyze the effectiveness of MBSR and MBCT in patients with low back pain.

Methods

PRISMA guidelines for systematic reviews and meta-analyses [20] and the recommendations of the Cochrane Collaboration [21] were followed.

Literature Search

The literature search comprised the following electronical databases from their inception through November 2011: Medline, EMBASE, the Cochrane Library, PsycINFO, and CAMBASE. The complete search strategy for Medline was as follows: (MBSR[Title/Abstract] OR MBCT[Title/Abstract] OR mindful*[Title/Abstract]) AND (low back pain[MeSH Terms] OR low back pain[Title/Abstract] OR lower back pain[Title/Abstract] OR lumbago[Title/Abstract] OR low backache[Title/Abstract] OR low back ache[Title/Abstract] OR sciatica[MeSH Terms] OR sciatica[Title/Abstract]). The search strategy was adapted for each database as necessary. No language restrictions were applied. In addition, reference lists of identified original articles were searched manually. All retrieved articles were read in full to determine eligibility.