Clinical Handbook of Mindfulness (104 page)

sensory loss below T4 after her surgery but was being retrained to walk.

CT/MRI studies were negative. Tricyclic antidepressants and anticonvul-

sants were unhelpful, and she was tried on all opioids sequentially, includ-

ing methadone. Over next 2 years her opioid dose increased to 400 mg CR-

oxycodone every 8 hours, with hydromorphone 72 mg every 4 hours for

rescue analgesia. She was ambulating with a walker, was prone to pneu-

monia, was on oxygen, used a continuous positive airway pressure (CPAP)

machine at night, and received attendant care at home
.

Pain scores on her medications were usually7/10. She completed two

courses of the MBCPM, connected by telemedicine from a distant site, sep-

arating the two courses by four months. She stabilized her medication

requirements during the first course, unusual for her as she reported toler-

ance to her opioid medications approximately every 2 months. Six months

after the start of the second course she had been able to reduce her CR-

oxycodone dosage to 40 mg every 12 hours, her hydromorphone rescue

analgesic to 24 mg 3 times a day, and she was off oxygen and walking

without a walker. She no longer needed attendant care, and her “usual”

pain scores were around 3–4/10. She would have returned to work except

for the sensory loss below T4. She reported she was meditating 30 min-

utes a day, and if she missed for a few days her pain scores rose and she

experienced reduced function
.

In the next year she separated from her husband and became a single

mother of two teens. She reported her pain scores rose when in the presence

of her ex-husband
.

Two years later she has been able to convince her employers to allow

her to return to work. She was retrained for a job in her car plant which

would be safe given her sensory loss. She continues to meditate, using the

body scan, daily
.

Outcomes

We hypothesized that participants in the treatment group would experience

an overall decrease in pain ratings (Numeric pain rating scale,
Farrar et al.

2001),
pain catastrophizing
(Sullivan et al., 1995),
and suffering (Pictorial Representation of Illness and Self Measure: PRISM test,
B¨

uchi et al., 2002),

and an increase in their quality of life (SF 36 v2,
Ware
,
2000)
when compared to those in the waiting list control group by class 10. We also looked at

response by gender, hypothesizing that females in the treatment group would

show greater improvement in these areas than males, as this is the trend that

has been observed in the previous literature. Women made up 70% of the

population presenting to our pain clinics and classes, an observation in line

with reports that men are less willing to report pain than women (Robinson

376

Jacqueline Gardner-Nix

et al.,
2001)
and those men who seek pain management report greater levels of mood disturbance than women
(Fow and Smith-Seemiller, 2001).

Finally as we were offering the course through telemedicine to outlying

areas in Ontario, Canada, we compared outcomes between the course partic-

ipants taught in person and those taught through telemedicine (Gardner-Nix

et al., 2008).

Two hundred and thirty three chronic noncancer pain patients were stud-

ied, and included 178 females and 55 males, participating onsite (
N
= 95),

by telemedicine from a distant site (
N
= 79) and fifty nine wait-list controls.

Health conditions included back pain, headache and facial pain, arthritis,

fibromyalgia, and “other.” Eighty seven patients with chronic back or neck

pain were also analyzed separately from the total treatment group.

Previous research has found that pain catastrophizing, defined as “an exag-

gerated negative orientation toward pain stimuli and pain experience” is a

significant predictor of suffering and disability
(Sullivan et al., 1995, 1998).

These scores seemed the most sensitive measure to change during MBCPM.

Overall pain catastrophizing showed significant improvement over time, for

both distant and onsite groups. Both onsite and distant groups experienced

less pain magnification and helplessness over time than the control group,

and the distant group also ruminated less over time than controls. Highly sig-

nificant reductions which occurred in patients’ pain catastrophizing scores

over time did not differ between males and females, or patients with back

pain versus other pain.

Treatment with mindfulness and meditation did significantly improve

patients’ quality of life in terms of role physical, general health, vitality, social

functioning, and mental health scores, results consistent with those found

by
Sephton et al. (2007)
who studied fibromyalgia sufferers. Treatment was less successful in the physical domains of the SF-36v2 than in the mental

health domains, suggesting that ten weeks is not a long enough time period

in which to observe significant changes in the physical aspects of quality of

life in prolonged pain sufferers. Distant site participants benefited as much as

onsite participants, though they started the course with significantly lower

physical quality of life scores than onsite participants (Gardner-Nix et al.,

2008). It was speculated that participants onsite had to cope with big city

traffic and parking and were less likely to sign up for the course if too dis-

abled to manage such challenges. There were no significant differences in

effectiveness due to gender or pain type (back pain versus other pain).

It has been reported that a drop of 2 points on the numeric zero to ten

pain scale should be considered clinically significant but the authors did not

analyze the influence of this drop on disability, mood, and perceived suffering

(Farrar et al. 2001).
Patients have reported a “reframing” of their pain with mindfulness, and we have observed anecdotally reduced disability levels in

the presence of only slightly changing pain scale scores. In this study “usual”

pain scores differed between groups: the “usual” pain of the onsite patients

improved significantly by the end of the course, though by an average of

only 1 point on the pain scale, compared to controls, but not the distant

site. Males in the treatment group had lower usual pain ratings than females

at weeks 1 and 10. Significant differences were also seen between patients

with back pain versus patients with other pain conditions: initially, the back

pain patients rated their usual pain as significantly higher than patients with

Chapter 19 Mindfulness-Based Stress Reduction for Chronic Pain Management

377

other conditions, and when measured again at Week 10, this difference was

still present, though “usual” pain levels did decrease over the course.

The PRISM test is a visual/tactile tool thought to assess the burden of suf-

fering due to illness and the intrusiveness and controllability of the illness or

its symptoms, and has been validated for Rheumatoid Arthritis
(B¨

uchi et al.,

2002),
and Lupus
(Buchi et al., 2000).
We recently validated this tool for use in the chronic pain population (Kassardjian et al., in press). Patients are

presented with an 8. 5 × 11 paper with a yellow disk (7 cm diameter) in

the bottom left-hand corner representing “self,” and handed five additional

disks (5 cm diameter) representing pain, work, partner, family, and recre-

ation. Patients are asked to place the disks relative to the self-disk to describe

the intrusiveness or importance of each of these influences on their lives.

Disks that are placed in close proximity to the self-disk are considered promi-

nent features in the patient’s life. The distances (in centimeters) between the

center of the self-disk and the centers of the other disks provide quantitative

parameters. If treatment has been effective in reducing suffering due to pain,

the distance between the “pain” disk and the “self” disk will increase, while

the other disks might move closer to the self, provided they represent posi-

tive aspects of the individual’s life. Interpretations of the non-pain disks can

only be made in the context of the patients’ lives.

It was found that overall, there was a significant difference in PRISM pain

scores for both onsite and distant site groups relative to controls. Males’ and

females’ pain suffering was shown to differ significantly. The males’ mean

distances between the pain and self-disks were greater than those of females

at week 1, suggesting that males experienced less pain suffering before treat-

ment began. This is contrary to observations by
Fow and Seemiller (2001)
if mood disturbance is correlated with suffering. At week 10, males and females

distances between pain and self-disks showed similar significant improve-

ments. Patients with back pain were also found to differ in terms of pain suf-

fering when compared to those with other pain conditions, who appeared

to suffer less as a result of their pain than those with back pain at week

1. Though both groups improved significantly the difference between them

was observed again at Week 10, suggesting that the patients with chronic

back pain indicated greater suffering than patients experiencing other types

of chronic pain.

An interesting effect of the mindfulness course appeared in validating the

PRISM test for the chronic pain population using the parallel data being col-

lected to study the effectiveness of the MBCPM course. In assessing con-

vergent validity, better correlations were found at class 10 than class 1. This

suggested the patients were either more familiar with the concept of this test

at class 10, or they were more mindful of the influences of the parameters

being studied on “self.”

The Future of Mindfulness in Chronic Pain Management

A major part of the training on mindfulness involves arriving at acceptance

of the pain and disability in the present moment and a letting go of the strug-

gle to return to pre morbid status. McCracken
(McCracken et al., 2004a,
b;

McCracken and Eccleston, 2005;
McCracken and Yang, 2006;
McCracken

378

Jacqueline Gardner-Nix

et al.,
2007; McCracken, 2007; McCracken and Vowles, 2007)
has written

extensively on the role of acceptance in chronic pain and a refocusing of

participating in valued actions in life irrespective of the pain.
Hayes (2004)

has published on the effectiveness of acceptance and commitment ther-

apy, which incorporates mindfulness to train patients to engage in valued

activities regardless of pain.
McCracken and Eccleston (2005)
reported that pain intensity and functioning were unrelated, but those reporting greater

acceptance of their pain were better in terms of emotional social and phys-

ical functioning when assessed 3.9 months after first evaluation, using less

medication and report a better work status. Their work is questioning the

cognitive-behavioral beliefs, which follow the assumption that if attention

and awareness of pain are lessened, the physical and emotional effects of

pain will reduce. Acceptance correlated with better functional and emotional

outcomes than reduction in awareness of and vigilance to pain.

Along with acceptance it seems likely that a predisposition to a heightened

stress response and slower recovery which is cumulative due to past stress-

ful events
(McEwen, 2007)
might accompany the perpetuation of pain, and

Goleman and Swartz (1976)
described, 31 years ago, that recovery from the stress response was hastened by meditation practice.

These findings may question the drive of pain management programs to

work with decreasing pain perception such as on numeric scales and cor-

relating the degree of decrease with clinical improvement. The acceptance

literature also suggests that data on pain intensity reductions due to standard

interventions (such as procedures, medication) should be followed prospec-

tively to monitor whether emotional and functional improvements result,

are maintained, and continue to improve, or whether they return to pre-

intervention levels in a few months. Pain scales may prove less useful in the

future and tools such as the chronic pain acceptance questionnaire (CPAQ)

(McCracken et al., 2004b),
chronic pain values inventory (CPVI) (McCracken et al.,
2006),
and the PRISM test
(Buchi and Sensky, 1999)
may have more relevance.

Acute physical pain is a warning that something in the body is malfunc-

tioning and damaged. Chronic pain may be a warning that the body/mind

has been challenged for too long or too intensely in some way, and is not

able to remain well, heal or cope beyond a certain level of physical or emo-

tional stress, which may be cumulative. Although in the US this is the decade