Clinical Handbook of Mindfulness (103 page)

stand, or cope better with their pain and stress. A weakness of the study is

inherent in the likelihood that responders to the questionnaires might have

been more likely to be those who did benefit.

Mindfulness meditation has been found to facilitate significant improve-

ments in the mental as well as the physical aspects of chronic pain. A study

by
Sephton et al. (2007)
investigating 91 women diagnosed with fibromyalgia showed that the mindfulness meditation intervention group experienced

a significant decrease in depressive symptoms when compared to a wait-

list control group, and these effects remained stable two months after the

end of the study. When depressive symptoms were broken down into the

subtypes of cognitive and somatic symptoms, it was found that MBSR signifi-

cantly decreased the occurrence of both types in patients in the intervention

group.

Sagula and Rice
(2004)
investigated the effects of MBSR on the bereave-

ment process for their losses in chronic pain sufferers. They compared 39

participants with 18 in their control group who were on a waiting list

or receiving other therapies. The Mindfulness group advanced significantly

more quickly through the initial stages of grieving than the control group,

and demonstrated significant reductions in depression and state anxiety,

though did not differ from the control group in the final stages of grieving

and trait anxiety. Pain outcomes were not measured.

Ott et al.
(2006)
surveyed the literature for the effectiveness of Mindfulness courses for cancer patients for many parameters including depression,

fatigue, sleep, and physical parameters, but found only one conference

abstract measuring influences on pain. This was in 10 patients under-

going stem cell/autologous bone marrow transplants undergoing lengthy

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Jacqueline Gardner-Nix

hospitalization. They found a significant decrease in pain from the interven-

tion, as well as increases in happiness, relaxation and comfort, and found

that most were still using mindfulness up to three months post-discharge.

Plews-Ogan et al.
(2005)
reported on a pilot study of a comparison of 8

weekly sessions of MBSR with once a week massage, and standard care (seen

every 3 months with medication adjustments) in 30 chronic musculoskeletal

pain sufferers (23 female), randomized to the intervention. The numeric pain

scale
(Farrar et al., 2001)
and the SF 12 (brief quality of life questionnaire) were used in assessment. In the MBSR group there were three dropouts

before the start of the eight week course, only five completing seven of eight

sessions and one attending only three sessions, though completing all the

questionnaires. There was only one drop out in the massage group and two

in the standard care group. Although there was a trend toward pain decrease

in all groups the only drop in pain scale score to reach significance was in

the massage group at week eight, reducing by a mean of almost three points

on the numeric pain scale, but by week 12 it was not maintained or statisti-

cally significant. For the quality of life scores there was a significant increase

in mental health scores in both the massage and MBSR group by week 8,

but not in the standard care group, an increase which was only sustained in

the MBSR group by week 12 when the interventions had been stopped for

4 weeks.

Pradham et al.
(2007)
reported significant improvements in psychological distress (35% reduction) in 31 women suffering from rheumatoid arthritis up

to 6 months after completing an MBSR program which was followed by a

4-month maintenance program, compared to a randomized wait-list control

group, but there was no significant change in disease parameters and pain

changes were not reported.

Morone et al.
(2008a)
reported on the effect of the MBSR course on 37

older adults, 65 years and older, suffering pain, randomized to wait list con-

trol or active intervention, and also tested them three months after taking the

course. Meditation occurred on an average of 4.3 days a week, for an aver-

age of 31.6 minutes a day. Their outcomes suggested significantly improved

acceptance of their limits, increased activity, and improved physical function.

In another paper
Morone et al. (2008b)
used grounded theory and content

analysis to do a qualitative study on diary entries of 27 MBSR older adult

participants, with pain, demonstrating that they had been able to achieve

pain reduction by mindfully focusing on tasks and mindfully pacing activities

which had been causing pain increases, and had greater insight into their

emotional processing which worsened pain.

However, psychological interventions such as mindfulness and meditation

have been demonstrated to have physiological effects, which likely mediate

the improvements experienced by the participants in these programs. Stud-

ies which included looking at immune system parameters showed improve-

ments associated with Mindfulness program participation in breast and

prostate cancer
(Carlson et al., 2003),
in T cell counts in HIV positive men receiving instruction on relaxation, hypnosis and meditation
(Taylor, 1995),

in flu vaccine response in normal workers
(Davidson et al., 2003)
and that meditation increased the rate of clearing of psoriasis lesions compared to

controls
(Kabat-Zinn et al., 1998).
It is possible that inflammation and neural instability at the site of damage in chronic pain patients might change in

participants of these courses leading to reduced pain and enhanced healing.

Chapter 19 Mindfulness-Based Stress Reduction for Chronic Pain Management

373

Mindfulness-Based Chronic Pain Management Courses

We have explored the effectiveness of a mindfulness-based chronic pain man-

agement (MBCPM) program which we developed based on MBSR. The pro-

gram was modified to increase accessibility to those who had been referred

to the pain management clinics of two Toronto teaching hospitals (Gardner-

Nix et al., 2008).

A concern for most of the Mindfulness research in the literature has been

the lack of randomized controlled studies. We felt that to randomize would

bias the study in the direction of those who were of lower acuity and higher

motivation to do the course and who would therefore be prepared to agree

to a delay of possibly several months. Pre-course start drop out rates were

high as patients with severe pain (our population’s “usual” pain was scored

around 6/10 where 10 is excruciating), tended not to agree to wait long for

an intervention, which was not going to be a fast fix. We therefore used non-

randomized wait-list controls.

Classes are once a week for two hours for ten weeks, at two Toronto

teaching hospitals, or at the patients’ local hospitals linking by telemedicine.

Some classes involve mixing the onsite patients with distant site, while other

classes are conducted separately. The use of telemedicine (IP transmission

at 384 kbit/s; Gardner-Nix et al., 2008) for inclusion of those living in rural

areas has proven very important as traveling long distances increases the

pain, which is also increased by stress.

Mindfulness for Chronic Pain: Course Outline

At the initial classes participants are taught about mindfulness and the con-

cept of meditation versus relaxation, using initially the breath as a focus.

They are started on meditations of five minute durations only, and encour-

aged to participate in the class from any position: they may lie on the floor

or stand for the entire class if their physical pain requires that. Classes also

involved teaching on lifestyle habits: diet, exercise, sleep, and relationships,

as well as on the attitudes described in Kabat-Zinn’s “Full Catastrophe Living”

(p. 33–41). Large group and small group discussions on the topic of the week

are conducted in each class. Meditation tracks are provided on CDs narrated

by the class facilitator (JGN) and include a 30 minute body scan (started in

the third week) which is quite anatomical and highly relevant to pain suf-

ferers. During the body scan they are encouraged to watch what happens

emotionally and to their pain intensity and quality when scanning the part(s)

of the body that hurts, and see if there is a tendency to mentally amputate or

ignore it/them. This tends to improve over time, though some report having

to return to the scan later after using other meditations, to note that they

have now “taken back” those parts of their body.

Patients are asked to meditate daily at home to a selection of CD meditation

tracks varying from 5 to 30 minutes in length and encouraged to use medita-

tive positions which are comfortable given their pain condition. Jon Kabat-

Zinn’s lake and mountain meditation tracks are also used. Some meditations

involve visualization of their pain with guidance to decrease it For example,

they may see their pain as like a block of ice, and bring their attention fully

to it and start to observe it melt. Meditations longer than 30 minutes are

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Jacqueline Gardner-Nix

thought not to be as acceptable for those in chronic pain and might reduce

compliance after course end.

Yoga is replaced by mindful movements, most of which are based on hatha

yoga, which can all be done from a standing position, with some being done

from a sitting position. Participants are encouraged to trust their judgment

about which they can or cannot do. Walking meditation is usually assigned as

homework to see if that becomes a preferred meditation. It is suggested that

consideration be given to transforming the walking meditation into swim-

ming if the patients move with less pain in water, and mindful movements

can also be done in water rather than on dry land. Where there is agita-

tion, anxiety, panic attacks, flashbacks, an increase in stress or a tendency to

always fall asleep, movement or walking meditation is usually preferred.

Homework includes: watching their tendency to judge, rather than just

note and evaluate; determining what exacerbated their pain and what helped

it, paying attention to emotional factors as well as physical ones; doing sim-

ple or mundane tasks mindfully (showering, cleaning out a cupboard, watch-

ing a teabag diffuse), which they then described in small group work, and

mindfully preparing and eating a meal, also discussed in small group work.

Artwork or collage is requested in the latter part of the course to commit

their idea of their pain to paper, or to a 3D structure. The symbolism of the

artwork is discussed in class if the class member wishes to share it. Some pre-

fer to journal rather than draw. Homework also includes readings from Jon

Kabat-Zinn’s book “Full Catastrophe Living,” specifically on attitudes, stress,

pain, and chapters pertaining to the different types of meditation.

There is no silent day-long retreat introduced between later classes in the

course due to poor attendance at that day, apparently due to fear, during

the first year the course was offered. Participants are allowed to repeat the

courses, and frequently do. There is approximately a 33% drop out rate from

the course defined as those attending 4 of 10 classes or less, with a higher

rate of drop outs in onsite classes versus distant site.

Case Scenario 1

A 39–year-old male factory worker, was referred for pain control. He had

had four back surgeries after injuring his back at work in 1989, was

on Worker’s Compensation, and was reporting pain scores of 8 to 9/10.

He was initially optimized in the pain clinic on transdermal fentanyl

100 mcg/hr every 2 days, methadone 9 mg every 12 hours, gabapentin

900 mg 3 x a day, and acetaminophen 325 mg/oxycodone 5 mg, 4 tablets

a day for rescue analgesia. He was referred for the MBCPM course, driving

11/2 hours weekly to attend the initial course, and repeating the course

from a distant site once we were able to link through telemedicine to his

community. Towards the end of the first course he found he was able to

deal with extended family relationships, which he had found quite trou-

blesome throughout his life. He began to reduce his medications. During

the second course he was able to wean himself off the rest of his medi-

cations, and start a running program. Three years later, he is currently

working in a non manual job, and reports he continues to meditate daily,

sometimes several times a day, for 10 to 40 minutes at a time
.

Chapter 19 Mindfulness-Based Stress Reduction for Chronic Pain Management

375

Case Scenario 2

A 38-year-old female auto assembly line worker was referred to the pain

clinic with a continuous severe headache 1 month after surgical removal

of two cavernous hemangiomas from her cervical spine, reporting pain

scores of 8–9/10 (zero
=
no pain, 10
=
excruciating pain). She had