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19

Mindfulness-Based Stress Reduction

for Chronic Pain Management

Jacqueline Gardner-Nix

“Pain is not just a ‘body problem’, it is a whole-systems problem.”

Jon Kabat-Zinn

It is time the medical community acknowledged the other half of the

system

Jackie Gardner-Nix

Introduction

Pain is a common complaint in primary care, with chronic pain reported in

20% of visits to general practitioners
(McCaffrey et al., 2003).
Twenty percent of adults suffer from chronic pain, rising to half of those of the older

age population
(Cousins et al., 2004).
Chronic pain, defined as “intermittent or continuous pain persisting longer than six months or beyond the regular

healing time for a given injury” can impact on patients’ physical and emo-

tional well-being
(Siddall et al., 2004)
and may be associated with disability disproportionate to degree of injury, as well as with depression and anxiety
(Bair et al., 2003).
Despite analgesics, surgeries and procedures, pain is poorly controlled by traditional Western medicine
(Cousins et al., 2004,

Furrow, 2001).
Opioids are sometimes prescribed for chronic pain, but the undesirable side-effects of these drugs and their ability to lose their effects

over time are well-documented
(Gardner-Nix, 2003).
Consequently, many

patients have turned to alternative modalities to control their suffering.

Psychological factors such as mood changes and anxiety have been

shown to alter pain perception
(Jensen et al., 1994;
Villemure and Bush-

nell,
2002).
A meta-analysis of psychological interventions for chronic low back pain
(Hoffman et al., 2007)
provided support for the efficacy of psychological interventions in reducing self-reported pain, pain-related inter-

ference, depression, and disability in sufferers of low back pain. The

study also demonstrated that multidisciplinary programs that included

psychological interventions were superior to other active treatment pro-

grams at improving work-related outcomes at both short and long-term

follow-up.

The workings of the mind in appreciating pain
(Seminowicz and Davis,

2007)
and even in permitting or clearing painful responses such as inflammation, nerve irritation and muscle spasm at painful body sites are espe-

cially interesting in view of studies showing no correlations between pain

369

370

Jacqueline Gardner-Nix

perception and imaging studies of painful areas such as with CAT scans.

Boos et al. (1995)
showed no correlation between pathological findings and back pain symptoms, and that disk herniation was just as common amongst

patients with no back pain as patients with back pain.
Boden et al. (1990)

showed abnormal MRI scans of the lumbar spines in individuals with no back

pain. Adding to the mystery of why some suffer for years with chronic pain is

the discovery of a genetic predisposition to feel and suffer more pain in cer-

tain people inheriting a variant of the catechol-O-methyltransferase (COMT)

gene versus others considered more stoical to pain
(Zubieta et al., 2003),

and the discovery that past experiences of abuse, such as in childhood, in

susceptible individuals might predispose to poor healing and chronic pain in

later adulthood (Schofferman and associates 1993;
Grzesiak, 2003).

In trying to understand what influences susceptibility to developing

chronic pain, work in other areas of illness connecting psychosocial factors

to predisposition to illness may shed light.
Kobasa (1979)
posed the question: what distinguishes those who are exposed to stressful life events and do not

get sick from those who do? She studied middle and upper level executives

and in a sample of 161, she found that those not getting sick in general show

more hardiness, having a stronger commitment to self, an attitude of vigor

toward the environment, a sense of meaningfulness, and an internal locus

of control. The work of
Rosengren et al. (2004)
found stress, anxiety and depression increased the risk of heart attacks as much as obesity, cholesterol,

and hypertension, also increasing understanding of psychological influences

on health, which might shed further light on why psychological interven-

tions are so important in illnesses involving chronic pain.

Bruehl et al.
(2002, 2003)
found correlations between trait anger and anger style (anger in versus anger out) and sensitivity to acute and chronic pain

stimuli, and response to opioids.
Carson et al. (2005)
reported lack of forgiveness correlated with an increased likelihood of life being affected by chronic

low back pain.
Carson et al. (2006)
reported an eight week loving-kindness meditation program pilot study on 43 chronic low back pain patients randomly assigned to study group or usual care controls; they showed significant

decreases in pain and psychological distress in the study group.

Baliki et al.
(2006)
have also shown that long term back pain on functional MRI imaging shows activity in the prefrontal cortex as an imprinted memory and fear of pain, and that the longer the person has suffered from the

pain the higher the activity in that part of the brain: described as cumulative

memory.
Millecamps et al. (2007)
showed that erasing the emotional pain in that area of the brain with a drug: D-cycloserine in rats, appeared to cause

them to no longer be bothered by the pain even though the physical pain,

as experienced in the thalamus where the sensation is registered, had only

partly reduced. Erasing the emotional pain also reduced the physical sensi-

tivity at the site of injury in the animal model. D-cycloserine has been used

to treat phobias in humans.

The above studies suggest that treatments targeting the higher cognitive

centers which are involved in the chronic pain experience might be more

fruitful than targeting pain sensation or pain vigilance and attention. These

reports give some insights into the ways in which Mindfulness and Medita-

tion may influence the experience of chronic pain.

Chapter 19 Mindfulness-Based Stress Reduction for Chronic Pain Management

371

Mindfulness-Based Stress Reduction (MBSR) and Pain

Kabat-Zinn
(1982)
reported on the outcomes of MBSR in a sample of 51

individuals afflicted with chronic pain. Dominant pain categories were back,

neck, shoulder and headache. Sixty-five percent of the participants showed

a reduction of ≥33% in pain ratings and 50% showed a reduction of ≥50%.

In addition, 76% of participants reported a reduction in mood disturbance of

≥33 and 62% of participants reported a reduction of ≥50%. A limitation of

the study was that there was no control group.

A follow-up study
(Kabat-Zinn et al., 1985)
compared chronic pain sufferers who participated in a 10 week mindfulness program with a group receiv-

ing traditional treatment protocols including nerve blocks and medication.

The results in the control group demonstrated no improvement in parame-

ters that were found to significantly improve in the mindfulness group: anx-

iety, depression, present moment pain, negative body image and inhibition

of activity by pain. Pain-related drug utilization reduced in the mindfulness

group and activity levels and self-esteem increased. This remained the same at

15-month follow-up for both groups, except for present moment pain which

returned to pre-intervention levels in the treatment group.

Kabat-Zinn et al.
(1987)
later reported significant reductions in medical and psychological symptoms continuing up to four years after the completion of the course in 225 participants. Response rates to questionnaires

ranged from 53 to 70%. Twenty percent cited that they had developed a “new

outlook on life” while 40% stated that they had the ability to control, under-