ORIGINAL ARTICLE

Mindfulness Meditation for Chronic Pain: SystematicReview and Meta-analysis

Lara Hilton, MPH1& Susanne Hempel, PhD1

& Brett A. Ewing, MS1&

Eric Apaydin, MPP1& Lea Xenakis, MPA1

& Sydne Newberry, PhD1&

Ben Colaiaco, MA1& Alicia Ruelaz Maher, MD1

& Roberta M. Shanman, MS1&

Melony E. Sorbero, PhD1& Margaret A. Maglione, MPP1

Published online: 22 September 2016# The Author(s) 2016. This article is published with open access at Springerlink.com

AbstractBackground Chronic pain patients increasingly seek treat-ment through mindfulness meditation.Purpose This study aims to synthesize evidence on efficacyand safety of mindfulness meditation interventions for thetreatment of chronic pain in adults.Method We conducted a systematic review on randomizedcontrolled trials (RCTs) with meta-analyses using theHartung-Knapp-Sidik-Jonkman method for random-effectsmodels. Quality of evidence was assessed using the GRADEapproach. Outcomes included pain, depression, quality of life,and analgesic use.Results Thirty-eight RCTs met inclusion criteria; seven re-ported on safety. We found low-quality evidence that mind-fulness meditation is associated with a small decrease in paincompared with all types of controls in 30 RCTs. Statisticallysignificant effects were also found for depression symptomsand quality of life.Conclusions While mindfulness meditation improves painand depression symptoms and quality of life, additionalwell-designed, rigorous, and large-scale RCTs are needed todecisively provide estimates of the efficacy of mindfulnessmeditation for chronic pain.

Keywords Chronic pain .Mindfulness .Meditation .

Systematic review

Introduction

Chronic pain, often defined as pain lasting longer than3 months or past the normal time for tissue healing [1], canlead to significant medical, social, and economic conse-quences, relationship issues, lost productivity, and largerhealth care costs. The Institute of Medicine recognizes painas a significant public health problem that costs our nation atleast $560–635 billion annually, including costs of health careand lost productivity [2]. Further, chronic pain is frequentlyaccompanied by psychiatric disorders such as pain medicationaddiction and depression that make treatment complicated [3].The high prevalence and refractory nature of chronic pain, inconjunction with the negative consequences of pain medica-tion dependence, has led to increased interest in treatmentplans that include adjunctive therapy or alternatives to medi-cation [4]. One such modality that pain patients are using ismindfulness meditation. Based on ancient Eastern meditationpractices, mindfulness facilitates an attentional stance of de-tached observation. It is characterized by paying attention tothe present moment with openness, curiosity, and acceptance[5, 6]. Mindfulness meditation is thought to work byrefocusing the mind on the present and increasing awarenessof one’s external surroundings and inner sensations, allowingthe individual to step back and reframe experiences. Currentresearch using neuroimaging to elucidate neurological mech-anisms underlying effects of mindfulness has focused on brainstructures such as the posterior cingulate cortex, which appearto be involved in self-referential processing [7, 8]. Clinicaluses of mindfulness include applications in substance abuse

Electronic supplementary material The online version of this article(doi:10.1007/s12160-016-9844-2) contains supplementary material,which is available to authorized users.

* Lara Hiltonhilton@rand.org

1 RAND Corporation, 1776 Main Street, PO Box 2138, SantaMonica, CA 90407-2138, USA

ann. behav. med. (2017) 51:199–213DOI 10.1007/s12160-016-9844-2

[9], tobacco cessation [10], stress reduction [11], and treat-ment of chronic pain [12–14].

Early mindfulness studies in pain patients showed promis-ing outcomes on pain symptoms, mood disturbance, anxiety,and depression, as well as pain-related drug utilization [5].Numerous systematic reviews on the effects of mindfulnessmeditation have been published in recent years. Of those thatreport pain outcomes, several have focused on specific typesof pain such as low back pain [13], fibromyalgia [15], orsomatization disorder [16]. Others were not limited to RCTs[14, 17]. There have been several comprehensive reviews fo-cused on controlled trials of mindfulness interventions forchronic pain including a review [4] that showed improve-ments in depressive symptoms and coping, another review[18] on mindfulness for chronic back pain, fibromyalgia,and musculoskeletal pain that showed small positive effectsfor pain, and the most recent review [19] on various painconditions which found improvements in pain, pain accep-tance, quality of life, and functional status. Authors of thesereviews echoed concerns that there is limited evidence forefficacy of mindfulness-based interventions for patients withchronic pain because of methodological issues. They haveconcluded that additional high-quality research was neededbefore a recommendation for the use of mindfulness medita-tion for chronic pain symptoms could be made.

The purpose of this study was to conduct a systematic re-view and meta-analysis of the effects and safety of mindfulnessmeditation, as an adjunctive or monotherapy to treat individ-uals with chronic pain due to migraine, headache, back pain,osteoarthritis, or neuralgic pain compared with treatment asusual, waitlists, no treatment, or other active treatments. Painwas the primary outcome, and secondary outcomes includeddepression, quality of life, and analgesic use. The systematicreview protocol is registered in an international registry forsystematic reviews (PROSPERO 2015:CRD42015025052).

Methods

Search Strategy

We searched the electronic databases PubMed, CumulativeIndex to Nursing and Allied Health Literature (CINAHL),PsycINFO, and Cochrane Central Register of ControlledTrials (CENTRAL) for English-language-randomized con-trolled trials from inception through June 2016. We combinedpain conditions and design terms with the following mindful-ness search terms: “Mindfulness” [Mesh]) or “Meditation”[Mesh] or mindfulness* or mindfulness-based or MBSR orMBCT or M-BCT or meditation or meditat* or Vipassana orsatipaṭṭhāna or anapanasati or Zen or Pranayama or Sudarshanor Kriya or zazen or shambhala or buddhis*.” In addition tothis search and the reference mining of all included studies

identified through it, we reference mined prior systematic re-views and retrieved all studies included therein.

Eligibility Criteria

Parallel group, individual or cluster RCTs of adults who reportchronic pain were included. Studies where the author definedchronic pain and studies in patients reporting pain for a min-imum of 3 months were included. Studies were required toinvolve mindfulness meditation, either as an adjunctive ormonotherapy; studies testing other meditation interventionssuch as yoga, tai chi, qigong, and transcendental meditationtechniques without reference to mindfulness were excluded.Mindfulness interventions that did not require formal medita-tion, such as acceptance and commitment therapy (ACT) werealso excluded. Only studies that reported pain measures orchange in analgesic use were included. Dissertations and con-ference abstracts were excluded.

Procedures

Two independent reviewers screened titles and abstracts ofretrieved citations—following a pilot session to ensure similarinterpretation of the inclusion and exclusion criteria. Citationsjudged as potentially eligible by one or both reviewers wereobtained as full text. The full text publications were then du-ally screened against the specified inclusion criteria. The flowof citations throughout this process was documented in anelectronic database, and reasons for exclusion of full-text pub-lications were recorded. Data abstraction was also conductedin dual. Risk of bias was assessed using the Cochrane Risk ofBias tool [20]. Other biases related to the US PreventiveServices Task Force’s (USPSTF) criteria for internal validityof included studies were assessed [21, 22]. These criteria wereused to rate the quality of evidence as good, fair, or poor foreach included study.

Meta-analytic Techniques

When sufficient data were available and statistical heteroge-neity was below agreed thresholds [20], we performed meta-analysis to pool efficacy results across included studies for theoutcomes of interest and present a forest plot for the mainmeta-analysis. We used the Hartung-Knapp-Sidik-Jonkmanmethod for random effects meta-analysis using unadjustedmeans and measures of dispersion [23–25]. For studiesreporting multiple pain outcomes, we used specific pain mea-sures, such as the McGill Pain Questionnaire (MPQ) for themain meta-analysis rather than the pain subscale of the SF-36,and average or general pain measures rather than situationalmeasures such as pain at the time of assessment. Due to thesmall number of adverse events reported, quantitative analysiswas not conducted. We conducted subgroup analyses and

200 ann. behav. med. (2017) 51:199–213

meta-regressions to address whether there were differences ineffect 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 theGRADE approach [22, 26] by which a determination of high,moderate, low, or very low was made for each major outcome[27].

Results

Description of Included Studies

We identified 744 citations through searches of electronic da-tabases and 11 additional records identified through othersources (see Fig. 1). Full texts were obtained for 125 citationsidentified as potentially eligible by two independent re-viewers; 38 RCTs met inclusion criteria. Details of study char-acteristics are displayed in Table 1 and effects for individualstudies are displayed in Table 2.

In total, studies assigned 3536 participants; sample sizesranged from 19 to 342. Fifteen studies reported an a priori

power calculation with targeted sample size achieved, tenstudies did not report information about a power calculation,and three studies were unclear in the reporting of a powercalculation. Ten studies noted there was insufficient power;the authors considered these pilot studies. The majority ofthe studies were conducted in North America or Europe.The mean age of participants ranged from 30 (SD, 9.08) to78 years (SD, 7.1. Eight studies included only femaleparticipants.

Medical conditions reported included fibromyalgia in eightstudies and back pain in eight studies. (Categories are notmutually exclusive; some studies included patients with dif-ferent conditions.) Osteoarthritis was reported in two studiesand rheumatoid arthritis in three. Migraine headache was re-ported in three studies and another type of headache in fivestudies. Three studies reported irritable bowel syndrome(IBS). Eight studies reported other causes of pain and threestudies did not specify a medical condition or source of chron-ic pain.

The total length of the interventions ranged from 3 to12 weeks; the majority of interventions (29 studies) were8 weeks in length. Twenty-one studies were conducted onmindfulness-based stress reduction (MBSR) and six onmindfulness-based cognitive therapy (MBCT). Eleven addi-tional studies reported results on other types of mindfulnesstraining. Thirteen RCTs provided the mindfulness interven-tion as monotherapy, and eighteen utilized a mindfulness in-tervention as adjunctive therapy, specifying that all partici-pants received this in addition to other treatment such as med-ication. Seven of the studies were unclear as to whether themindfulness intervention was monotherapy or adjunctive ther-apy. Nineteen RCTs used treatment as usual as comparators,thirteen used passive comparators, and ten used education/support groups as comparators. Beyond these common com-parators, one study each used stress management, massage, amultidisciplinary pain intervention, relaxation/stretching, andnutritional information/food diaries as comparators; two stud-ies used cognitive-behavioral therapy. Several studies had twocomparison arms.

Study Quality and Risk of Bias

The study quality for each included study is displayed inTable 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 primar-ily due to issues with completeness of reporting outcome datasuch as inadequate or missing intention to treat (ITT) analysisand/or less than 80 % follow-up [53–62] and three due tounclear methods [63–65]. Details of the quality ratings andrisk of bias for each included study is displayed inElectronic Supplementary Material 1.Fig. 1 Literature flow diagram

ann. behav. med. (2017) 51:199–213 201

Tab

le1

Characteristicsof

included

studies

Study

Samplesize

Location

Source

ofpain

%male

Age

(M(SD))

Interventio

nCom

parators

Quality

ratin

g

Astin

etal.[53]

128

USA

Fibromyalgia

0.7

48(10.6)

MBSR

andQigongfor8weeks

Educatio

nsupportg

roup

Poor

Bakhshani

etal.[61]

40MiddleEast

Migraine,headache

35.1

Interventio

n,30

(9.08);

control,31

(9.57)

MBSRfor8weeks

with

TAU

TAU

Poor

Banth

andArdebil[60]

88MiddleEast

Backpain

040.3(8.2)

MBSRfor8weeks

with

TAU

TAU

Poor

BrownandJones[54]

40Europe

Fibrom

yalgia,

rheumatoid

arthritis,other

musculoskeletal

26Interventio

n,48

(10);

control,45

(12)

Mindfulness-based

pain

managem

entp

rogram

:breath

awareness,body

awareness,

gentlemovem

ent,pain

managem

ent,compassion

training

for8weeks

TAU

Poor

Cashetal.[39]

91USA

Fibromyalgia

0Not

reported

MBSR

for8weeks

Waitlistcontrolg

roup

Fair

Cathcartetal.[40]

58Australia

Headache

37Interventio

n,46

(13.10);

control,45

(14.2)

Brief

mindfulness-based

therapy,

basedon

MBSRand

MBCTfor3weeks

Waitlistcontrolg

roup

Fair

Cherkin

etal.[38]

342

USA

Backpain

34.3

49(12.3)

MBSRfor8weeks

with

TAU

CBTwith

TAUor

TAU

alone

Good

DavisandZautra[42]

79USA

Fibrom

yalgia

246;range

=22–81

Mindful

socialem

otional

regulatio

ninternetinterventio

nin

12modules

for6weeks

Health

ylifestyletip

sviainternet

Fair

Day

etal.[41]

36USA

Migraine,headache

1142

(12.0)

MBCTfor8weeks

adaptedfor

headache

pain

with

TAU

Waitlistcontrolg

roup

Fair

Dow

detal.[43]

124

Europe

Headache,back

pain,

osteoarthritis,

fibrom

yalgia,

nervepain,neuropathy

1045

(12.25)

MBCTcomputerized:

included

audio-recorded

meditatio

n,psychoeducation,mindfulness,

andacognitive

andbehavioral

change

for6weeks

Psychoeducation

Fair

Esm

eretal.[55]

40USA

Backpain,leg

pain

56Interventio

n,55

(11.2);

control,58

(9.5)

MBSRfor8weeks

with

TAU

TAU

Poor

Fjorback

etal.[32]

120

Europe

Bodily

distress

syndrome

20Interventio

n,38

(9);

control,40

(8)

MBSR

for8weeks

with

TAU

EnhancedTA

Uof

2-h

specialistm

edical

care

andbriefCBT

Good

Fogartyetal.[30]

51New

Zealand

Rheum

atoidarthritis

12Interventio

n,52

(12);

control,55

(13)

MBSRfor8weeks

andTA

UTA

UGood

Garland

etal.[44]

115

USA

Osteoarthritis,

fibrom

yalgia

3248

(14)

MORE:m

ultim

odalinterventio

nof

mindfulness,C

BT,

positiv

epsychology

for8weeks

with

TAU

Supportg

roup

with

TAU

Fair

Gaylord

etal.[45]

75USA

Irritablebowel

syndrome

0Interventio

n,45

(12.55);

control,41

(14.68)

Mindfulness

training

tailo

redfor

IBSpopulatio

nfor8weeks

with

TAU

TAUandsupport

group

Fair

Jayetal.[50]

112

Europe

Musculoskeletalpain

0Interventio

n,45.5

(9.0);

control,47.6(8.2)

Mindfulness

pain

andstress

workplace

program

for10

weeks

TAU

Fair

202 ann. behav. med. (2017) 51:199–213

Tab

le1

(contin

ued)

Study

Samplesize

Location

Source

ofpain

%male

Age

(M(SD))

Interventio

nCom

parators

Quality

ratin

g

Johnsetal.[37]

71USA

Cancer

9.9

Interventio

n,56

(9.9);

control,56

(12.7)

MBSR

for8weeks

Psychoeducation

supportg

roup

Good

Kanteretal.[62]

20USA

Interstitialcystitis,bladder

pain

syndrome

0Interventio

n,46

(15.2);

control,44

(13.9)

MBSRfor8weeks

with

TAU

TAU

Poor

Kearney

etal.[51]

55USA

GulfWar

illness

85.5

Interventio

n,51

(6.8);

control,48

(7.4)

MBSRfor8weeks

with

TAU

TAU

Fair

laCourandPetersen[46]

109

Europe

Varied,non-specificpain

15Interventio

n,47

(12.42);

control,49

(12.20)

MBSR

:Standardprogram

modified

forchronicpain

patientsfor8

weeks

with

co-interventionTA

U

Waitlist,T

AU

Fair

Lengacher

etal.[52]

322

USA

Cancer

056.6

(9.7)

MBSR

modifiedforbreastcancer

patientsfor6weeks

with

TAU

TAU

Fair

Ljotssonetal.[33]

85Europe

Irritablebowelsyndrome

1535

(9.4)

MBCTprotocol

viaInternetforIBS

grouptreatm

entfor

10weeks

Onlinediscussion

forum

Good

Ljotssonetal.[34]

195

Europe

Irritablebowelsyndrome

2139

(11.1)

MBCTprotocol

viainternetforIBS

grouptreatm

entfor

10weeks

Onlinestress

managem

ent

program

Good

Meize-G

rochow

ski

etal.[56]

31USA

Postherpetic

neuralgia

44Overall,

72(9.6)

MBSR:1

hinstructionfocusing

breathingwhileseated

comfortably,

daily

meditatio

nusingCD,phone

callreminders,daily

journal,for6

weeks

with

TAU

TAU

Poor

Moroneetal.[47]

37USA

Backpain

43Interventio

n,74

(6.1);

controls,76(5.0)

ModifiedMBSR

:(1)

thebody

scan;

(2)sitting

practice;(3)walking

meditatio

nfor8weeks

Waitlistcontrols

Fair

Moroneetal.[57]

40USA

Backpain

37Interventio

n,78(7.1);

control,73(6.2)

ModifiedMBSR

:(1)

thebody

scan;

(2)sitting

practice;(3)walking

meditatio

nfor8weeks;O

verthe

counterandprescribed

medications

Overthecounterand

prescribed

medications

Poor

Moroneetal.[36]

282

USA

Backpain

33.7

74.5

(6.6)

MBSR

for8weeks

Health

educationprogram

Good

Omidiand

Zargar[58]

66MiddleEast

Headache

20Interventio

n,35

(2.41);

control,32

(3.2)

MBSRfor8weeks

TAU

Poor

Parra-D

elgado

and

Latorre-Postig

o[31]

33Europe

Fibrom

yalgia

053

(10.08)

MBCTfor12

weeks

with

TAU

TAU

Good

Plews-Oganetal.[59]

30USA

Musculoskeletalpain

2347

(NR)

MBSRfor8weeks

TAU(thisgroupused

inanalysis)or

massage

Poor

Rahmaniand

Talepasand

[63]

24MiddleEast

Cancer

0Interventio

n,43

(3.07);

control,45

(3.28)

MBSR

andgroupconsciousyoga

for8weeks

Notreatm

ent

Poor

Schmidtetal.[48]

177

Europe

Fibrom

yalgia

053

(9.6)

ModifiedMBSR

:mindfulness,

yoga,and

socialinteraction

topics

for8weeks

Waitlist(thisgroupused

inanalysis),relaxatio

nandstretching

support

group

Fair

Teixeira

[64]

22USA

Diabetic

peripheral

neuropathy

2575

(10.8)

ModifiedMBSR

:mindfulness

meditatio

ninstructionand

compact

Nutritio

nalinformation

andfood

diary

Poor

ann. behav. med. (2017) 51:199–213 203

Measures

Studies reported patient pain measures such as the VisualAnalog Scale, the SF-36 pain subscale, and McGill PainQuestionnaire. Secondary outcomemeasures included depres-sion symptoms (e.g., Beck Depression Inventory, PatientHealth Questionnaire), physical and mental health-relatedquality of life (e.g., SF-36 mental and physical components),and functional impairment/disability (e.g., Roland-MorrisDisability Questionnaire, Sheehan Disability Scale).

Chronic Pain Treatment Response

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

Eight studies met screening inclusion criteria but did notcontribute to the meta-analysis because they did not reportpoolable data [28, 30, 34, 35, 38, 50, 61, 65]. Their studycharacteristics are displayed in Table 1, and study level effectsalong with the reasons they were not in pooled analyses aredisplayed in Table 2.

Pain scales and comparators varied from study to study.The median follow-up time was 12 weeks, with a range of4 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 ef-fect of mindfulness meditation compared with treatment asusual, passive controls, and education/support groups(SMD, 0.32; 95 % CI, 0.09, 0.54; 30 RCTs). Substantialheterogeneity was detected (I2 = 77.6 %). There was noevidence of publication bias (Begg’s p = 0.26; Egger’s testp = 0.09). To investigate whether the treatment estimate isrobust when excluding poor-quality studies and to explorethe possible source of the substantial heterogeneity, we con-ducted a sensitivity analysis including only fair or goodquality studies. The improvement remained significant, theeffect size was smaller (SMD, 0.19; 95 % CI, 0.03, 0.34;19 RCTs), and there was less heterogeneity (I2 = 50.5 %).Meta-regressions showed that changes in pain outcomes ingood- (p = 0.42) and fair-quality (p = 0.13) studies werenot significantly different from changes in poor-qualitystudies.

In subgroup analyses, the effect was not statistically sig-nificant at 12 weeks or less (SMD, 0.25; 95 % CI, −0.13,0.63; 15 RCTs; I2 = 82.6 %) but was significant for follow-up periods beyond 12 weeks (SMD, 0.31; 95 % CI, 0.04,0.59; 14 RCTs, I2 = 69.0 %). Begg’s test was not statisti-cally significant (p = 0.16) but Egger’s test showed evi-dence of publication bias (p = 0.04). The quality of evi-dence that mindfulness meditation is associated with a de-crease in chronic pain compared with control is low overalland for both short- and long-term follow-up due toT

able1

(contin

ued)

Study

Samplesize

Location

Source

ofpain

%male

Age

(M(SD))

Interventio

nCom

parators

Quality

ratin

g

disk

5days/weekover

a4-week

period

for4weeks

Wellsetal.[49]

19USA

Migraine

11Interventio

n,46

(17);

control,45

(12)

MBSRfor8weeks

TAU

Fair

Wong[65]

100

Asia

Unspecified

NR

NR

MBSRfor8weeks

Multid

isciplinary

educationprogram

Poor

Wong[28]

100

Asia

Unspecified

NR

48(7.84)

MBSR

for8weeks

Multid

isciplinarypain

interventio

nGood

Zautraetal.[29]

144

USA

Rheum

atoidarthritis

32Men,62(N

R);

wom

en,51(N

R)

Mindfulness

meditatio

nbasedon

MBSR

andem

otionregulatio

ntherapyofferedin

sessions

and

homepracticefor8weeks

Educatio

ngroup(this

groupused

inanalysis),

cognitive

behavioral

therapy

Good

Zgierskaetal.[35]

35USA

Backpain

2051.8

(9.7)

MBCT-manualized

program

6days/

weekfor8weeks

with

TAU

TAUandopioid

therapy

Good

Note.Age

(M(SD))agemean(standarddeviation,range,ornotreported),C

BTcognitive

behavioraltherapy,IBSirritablebowelsyndrome,MBCTmindfulness-based

cognitive

therapy,MBSR

mindfulness-

basedstress

reduction,MOREmindfulness-orientedrecovery

enhancem

ent,NRnotreported,TA

Utreatm

entasusual

204 ann. behav. med. (2017) 51:199–213

Tab

le2

Effectsforindividualstudies

Study

Outcome

Measure

%pain

change

TxGrp

%pain

change

CtrlG

rpSMD(95%

CI)

Follow-up

(week)

Astin

etal.[53]

Pain

SF-36pain

score

−31.58

%−3

4.39

%0.02

(−0.47,0.5)

14

−28.79

%−3

5.03

%−0

.04(−0.52,0.45)

24

−23.22

%−2

9.94

%−0

.05(−0.54,0.43)

8

Depression

BDI

––

0.15

(−0.35,0.64)

24

Bakhshani

etal.[61]

Pain

Significantimprovem

entin

pain,qualityof

life;

samplesize

ofgroups

atfollo

w-upnotreported

Qualityof

life

Banth

andArdebil[60]

Pain

MPQ

−47.92

%−1

1.62

%2.5(1.94,3.07)

12

Qualityof

life

SF-12mentalh

ealth

––

1.11

(0.65,1.56)

8

––

1.49

(1.01,1.97)

12

SF-12physicalhealth

––

1.34

(0.88,1.81)

8

––

1.86

(1.36,2.37)

12

BrownandJones[54]

Pain

Laser

pain

unpleasantness

9.26

%6.78

%0.24

(−0.51,0.98)

24

Qualityof

life,mental

SF-36mentalcom

posite

––

1.16

(0.36,1.96)

24

Qualityof

life,physical

SF-36physicalcomposite

––

−0.42(−1.17,0.33)

24

Cashetal.[39]

Pain

VAS

−4.26%

−5.92%

0(−0.42,0.41)

16

−11.31

%−1

.01%

0.32

(−0.1,0.74)

8

Cathcartetal.[40]

Pain

Headacheintensity

−4.42%

−11.16

%0.08

(−0.52,0.69)

8

Cherkin

etal.[38]

Pain

Significantreductio

nsin

pain

anddisability;

Reportedonly

adjusted

data

Disability

DavisandZautra[42]

Pain

Pain

−0.93%

−1.52%

−0.24(−0.69,0.2)

6

Day

etal.[41]

Pain

BPI

intensity

−11.98

%−6

.53%

−0.01(−0.66,0.65)

8

Dow

detal.[43]

Pain

Average

pain

1.26

%−1

1.77

%0(−0.36,0.35)

6

7.18

%1.71

%−0

.19(−0.54,0.17)

30

Esm

eretal.[55]

Pain

VAS

−29.74

%−0

.82%

0.3(−0.5,1.1)

12

Disability

Roland-Morrisdisability

––

0.90

(0.06

,1.74)

12

Fjorback

etal.[32]

Pain

SF-36bodily

pain

−31.25

%−7

.38%

0.15

(−0.23,0.53)

12

−44.12

%−1

2.08

%0.23

(−0.18,0.63)

36

−34.93

%−3

1.54

%−0

.1(−0.51,0.31)

60

Qualityof

life,mental

SF-36mentalcom

posite

––

−0.04(−0.42,0.34)

60

Qualityof

life,physical

SF-36physicalcomposite

––

0.22

(−0.16,0.61)

60

ann. behav. med. (2017) 51:199–213 205

Tab

le2

(contin

ued)

Study

Outcome

Measure

%pain

change

TxGrp

%pain

change

CtrlG

rpSMD(95%

CI)

Follow-up

(week)

Fogartyetal.[30]

Pain

Significantreductio

nreported;

nousabledataas

only

reported

change

with

ingroup

Garland

etal.[44]

Pain

BPI

−12.32

%11.11%

0.76

(0.38,1.14)

20

−10.66

%4.01

%0.57

(0.19,0.94)

8

Gaylord

etal.[45]

Pain

Pain

severity

−42.96

%−1

4.73

%0.53

(0.06,0.99)

20

−35.83

%−5

.36%

0.54

(0.08,1)

8

Depression

BSI-18depression

––

0.03

(−0.42,0.49)

20

Qualityof

life,general

IBSquality

oflife

––

0.25

(−0.21,0.7)

20

Jayetal.[50]

Pain

Significantreductio

nreported;

nousabledataas

only

reported

differences

Johnsetal.[37]

Pain

BPI

−35.19

%−3

0.90

%−0

.07(−0.54,0.41)

24

Kanteretal.[62]

Pain

VAS

−16.95

%−1

9.30

%−0

.14(−1.05,0.77)

8

Qualityof

life

SF-12MCS

0.7(−0.24,1.64)

8

SF-12PCS

−0.02(−0.93,0.89)

8

Kearney

etal.[51]

Pain

MPQ

−23.87

%−5

.67%

0.41

(−0.13,0.94)

24

Depression

PHQ

––

0.34

(−0.2,0.87)

8

––

0.47

(−0.07,1)

24

laCourandPetersen[46]

Pain

BPI

−1.05%

−6.77%

−0.16(−0.53,0.22)

8

Depression

HADS

––

0.37

(−0.01,0.75)

8

Qualityof

life,mental

SF-36mentalcom

posite

––

0.53

(0.15,0.91)

8

Qualityof

life,physical

SF-36physicalcomposite

––

0.00

(−0.38,0.38)

8

Lengacher

etal.[52]

Pain

BPI

−25.92

%−1

0.63

%0.02

(−0.2,0.25)

12

Depression

CES-Dscore

––

0.12

(−0.11,0.35)

6

––

0.04

(−0.18,0.27)

12

Qualityof

life

QoL

MOSSF

-36

––

−0.05(−0.28,0.17)

6

––

0.01

(−0.21,0.24)

12

Ljotssonetal.[33]

Pain

Totalp

ain

−46.15

%0.00

%0.64

(0.19,1.08)

10

Depression

MADRS-S

––

0.43

(−0.02,0.87)

10

Qualityof

life,general

IBSquality

oflife

––

0.95

(0.49,1.41)

10

Disability

Sheehandisabilityscale

––

0.47

(0.02,0.91)

10

Ljotssonetal.[34]

Pain

Significantreductio

nIBS

pain/discomfort;n

o24

206 ann. behav. med. (2017) 51:199–213

Tab

le2

(contin

ued)

Study

Outcome

Measure

%pain

change

TxGrp

%pain

change

CtrlG

rpSMD(95%

CI)

Follow-up

(week)

usabledataas

did

notreportp

ainmeasure

Depression

HADS

––

0(−0.28,0.28)

24

Qualityof

life,general

IBSquality

oflife

––

0.51

(0.22,0.8)

24

Meize-G

rochow

skietal.[56]

Pain

SFMPQ—totalp

ain

−8.57%

−4.17%

−0.48(−1.25,0.28)

2

SFMPQ—totalp

ain

−25.71

%−1

2.50

%−0

.31(−1.07,0.45)

8

Depression

CES-D

––

0.32

(−1.08,0.44)

8

Qualityof

life,mental

Emotionalw

ellb

eing

––

0.07

(−0.69,0.82)

8

Qualityof

life,physical

Average

physicalsubscales

––

−0.02(−0.77,0.74)

8

Moroneetal.[47]

Pain

SFMPQ

−11.61

%3.29

%0.23

(−0.42,0.88)

8

Qualityof

life,mental

SF-36mentalcom

posite

––

0.22

(−0.43,0.86)

8

Qualityof

life,physical

SF-36physicalcomposite

––

0.11

(−0.53,0.76)

8

Disability

Roland-Morrisdisability

––

0.23

(−0.42,0.87)

8

Moroneetal.[57]

Pain

SFMPQ—totalp

ain

−22.44

%−2

6.71

%−0

.04(−0.7,0.63)

24

SFMPQ—totalp

ain

−26.28

%−2

9.19

%−0

.01(−0.68,0.65)

8

Moroneetal.[36]

Pain

Num

ericpain

ratin

g—average

−13.64

%0.95

%0.22

(−0.01,0.46)

24

Qualityof

life

SF-36globalhealth

composite

––

0.17

(−0.06,0.41)

8

––

0.03

(−0.2,0.26)

24

SF-36physicalhealth

composite

––

0.17

(−0.06,0.4)

8

––

0(−0.23,0.23)

24

Plews-Oganetal.[59]

Pain

Pain

unpleasantness

vs.T

AU

−7.46%

−8.70%

0.02

(CI,−1

.04,1.07)

12

Pain

unpleasantness

vs.m

assage

−7.46%

−25.35

%−0

.16(−1.19,0.88)

12

Pain

unpleasantness

vs.T

AU

−16.42

%−1

3.04

%0.07

(CI,−0

.99,1.13)

4

Pain

unpleasantness

vs.m

assage

−16.42

%−1

2.68

%−0

.11(CI,−0

.92,1.14)

4

Pain

unpleasantness

vs.T

AU

−13.43

%−1

.45%

0.17

(CI,−0

.89,1.23)

8

Pain

unpleasantness

vs.m

assage

−13.43

%−3

9.44

%−0

.3(CI,−1

.34,0.74)

8

Qualityof

Life,mental

SF-12mentalcom

posite

––

0.67

(−0.42,1.75)

12

Rahmaniand

Talepasand[63]

Pain

Globalq

ualitysymptom

s—pain

−26.52

%11.11%

1.85

(0.89,2.8)

16

−44.89

%−1

.85%

3.24

(2.02,4.46)

8

Qualityof

life,general

Globalq

ualitytotalscore

––

1.18

(0.32,2.05)

16

Schmidtetal.[48]

Pain

Pain

perceptio

nscalevs.w

aitlist

−13.19

%−6

.90%

0.17

(−0.2,0.55)

16

Pain

perceptio

nscalevs.active

−13.19

%−7

.40%

0.15

(−0.22,0.53)

16

Pain

PerceptionScalevs.w

aitlist

−11.87

%−8

.00%

0.08

(−0.3,0.45)

8

Pain

perceptio

nscalevs.active

−11.87

%−4

.86%

0.22

(−0.16,0.6)

8

Depression

CES-D

––

0.1(−0.27,0.48)

16

ann. behav. med. (2017) 51:199–213 207

Tab

le2

(contin

ued)

Study

Outcome

Measure

%pain

change

TxGrp

%pain

change

CtrlG

rpSMD(95%

CI)

Follow-up

(week)

Qualityof

Life,General

QoL

profile

forchronically

ill–

–0.26

(−0.12,0.63)

16

Teixeira

[64]

Pain

NeuroQoL

pain

Missing

baselin

emean

0.14

(−0.74,1.01)

4

Qualityof

life,general

NeuroQoL

overall

––

0.79

(−0.12,1.7)

4

Wellsetal.[49]

Pain

Headacheseverity

−25.00

%0.00

%0.99

(0.04,1.95)

12

Headacheseverity

−27.27

%8.33

%1.5(0.48,2.51)

8

Depression

PHQ

––

0.59

(−0.33,1.51)

8

Qualityof

life,general

Migraine-specificQoL

––

−0.43(−1.34,0.48)

8

Wong[65]

Pain

Significantp

aindecrease;

nousabledata

Wong[28]

Pain

Nosignificanteffect;

nousabledata

Zautraetal.[29]

Pain

Pain

vs.educatio

n−1

4.49

%−1

7.70

%0.22

(−0.2,0.63)

8

Pain

vs.cognitiv

ebehavior

therapy

−14.49

%−1

4.34

%0.56

(0.16,0.96)

8

Depression

Depressivesymptom

s–

–0.28

(−0.13,0.7)

8

Zgierskaetal.[35]

Pain

Significantp

aindecrease;

nofollo

w-updataavailable

Note.BDIB

eckdepression

inventory,BPIb

riefpainindex;BSbriefsymptom

inventory,CES-DThe

Centerfor

EpidemiologicalS

tudies-D

epressionScale,CIconfidenceinterval,M

ADRSMontgom

ery-

AsbergDepressionRatingScale,H

ADSHospitalA

nxietyandDepressionScale;MPQMcG

illPainQuestionnaire,N

PSNeuropathicPainScale,N

euroQoL

QualityofLifeinNeurologicalD

isorders;P

HQ

PatientHealth

Questionnaire,Q

oLquality

oflife,SF

-36Sh

ort-Fo

rmHealth

Survey

36,SFMPQSh

ort-Fo

rmMcG

illPainQuestionnaire,SMDstandardized

meandifference,TAUtreatm

entasusual,VA

SVisualA

nalogScale

208 ann. behav. med. (2017) 51:199–213

inconsistency, heterogeneity, and possible publication bias.A detailed table displays the quality of evidence for find-ings for each major outcome in Electronic SupplementaryMaterial 2.

In order to present clinically meaningful results, wecalculated the percent change in pain symptoms frombaseline to follow-up for mindfulness meditation andcomparison groups for each study and displayed find-ings in Table 2. We then calculated the overall weightedmean percent change for mindfulness meditation groupsversus comparison groups for effects of meditation forpain at longest follow-up. The mean percent change inpain for meditation groups was −0.19 % (SD, 0.91;min, −0.48; max, 0.10) while the mean percent changein pain for control groups was −0.08 % (SD, 0.74; min,−0.35; max, 0.11). The p value for the difference be-tween 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 significant-ly lowered depression scores as compared with treatment asusual, support, education, stress management, and waitlist

control groups (SMD, 0.15; 95 % CI, 0.03, 0.26; 12 RCTs;I2 = 0 %). No heterogeneity was detected. The quality ofevidence was rated as high due to lack of heterogeneity, con-sistent study results, and precision of effect (small confidenceintervals).

Quality of Life

Sixteen studies reported mental health-related quality oflife; the effect of mindfulness meditation was significantin the pooled analysis as compared with treatment asusual, support groups, education, stress management,and waitlist controls (SMD, 0.49; 95 % CI, 0.22, 0.76;I2, 74.9 %). [32–34, 45–49, 52, 54, 56, 59, 60, 62–64].Sixteen studies measured physical health-related qualityof life [32–34, 36, 45–49, 52, 54, 56, 60, 62–64].Pooled analyses showed a significant effect of mindful-ness meditation as compared with treatment as usual,support groups, education, stress management, andwaitlist controls (SMD, 0.34; 95 % CI, 0.03, 0.65; I2,79.2 %). Both quality-of-life analyses detected substan-tial heterogeneity, and the quality of evidence was ratedas moderate for mental health (small confidence

Fig. 2 Mindfulness meditationeffects on chronic pain

ann. behav. med. (2017) 51:199–213 209

intervals, more consistent results) and low for physicalhealth-related quality of life.

Functional Impairment (Disability Measures)

Four studies reported poolable disability scores from theRoland-Morris Disability Questionnaire and the SheehanDisability Scale [33, 36, 47, 55]. The difference be-tween the mindfulness and comparison groups infollow-up was not statistically significant (SMD, 0.30;95 % CI, −0.02, 0.62; I2 = 1.7 %), although the resultsapproached significance. No heterogeneity was detected.The quality of evidence was rated low due to impreci-sion and small total sample size.

Analgesic Use

Only four studies reported use of analgesics as an out-come. In a study of MBSR for treatment of chronicpain due to failed back surgery syndrome [55], at 12-week follow-up, the analgesic medication logs of theintervention group documented a decrease in analgesicuse compared with those in the control group (−1.5(SD = 1.8) vs. 0.4 (SD = 1.1), p = <0.001). A studyof mindfulness meditation and cognitive-behavioral ther-apy vs. usual care for low back pain [35] reported thatthe mean morphine equivalent dose (mg/day) of opioidswas not significantly different between groups at both 8and 26 weeks. Likewise, a trial of MBSR for back pain[38] found no significant difference between groups inself-reported use of pain medication. Finally, a trial ofmindfulness-oriented recovery enhancement (MORE) forchronic pain of various etiologies [44] found interven-tion participants significantly more likely to no longermeet criteria for opioid use disorder immediately fol-lowing treatment (p = 0.05); however, these effects werenot 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]; onedescribed that two participants experienced temporary strongfeelings of anger toward their pain condition and two of theparticipants experienced greater anxiety [46]; two studies re-corded mild side effects from yoga and progressive musclerelaxation [35, 38].

Study Characteristic Moderators

Meta-regressions were run to determine if changes inpain outcomes systematically differed by several subcat-egories. 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 (16studies) to all other interventions (14 studies), therewas also no difference in effect (p = 0.45). As statedin more detail above, medical conditions reported in-cluded fibromyalgia, back pain, arthritis, headache, andirritable bowel syndrome (IBS). Meta-regressions didnot suggest differences between headache (six studies)and other conditions (p = 0.93), back pain (eight stud-ies) and other conditions (p = 0.15), and fibromyalgia(eight studies) and other conditions (p = 0.29). Gendercomposition (% male) had no association with effect onpain (p = 0.26). The total length of the interventionprogram ranged from 3 to 12 weeks (mean was8 weeks). Meta-regression did not suggest differencesbetween high-frequency interventions and medium-(p = 0.16) or low-frequency (p = 0.44) interventions.No systematic difference in effect on pain between ad-junctive therapy and monotherapy (p = 0.62) or betweenadjunctive therapy and interventions where this was un-clear (p = 0.10) was found. Finally, there was no sys-tematic difference in effect whether the comparator wastreatment as usual, waitlist, or another intervention(p = 0.21).

Discussion

In sum, mindfulness meditation was associated with asmall effect of improved pain symptoms compared withtreatment as usual, passive controls, and education/support groups in a meta-analysis of 30 randomizedcontrolled trials. However, there was evidence of sub-stantial heterogeneity among studies and possible publi-cation bias resulting in a low quality of evidence. Theefficacy of mindfulness meditation on pain did not dif-fer systematically by type of intervention, medical con-dition, or by length or frequency of intervention.Mindfulness meditation was associated with statisticallysignificant improvement in depression, physical health-related quality of life, and mental health-related qualityof life. Quality of evidence was high for depression,moderate for mental health-related quality of life, andlow for physical health-related quality of life. Only fourstudies reported on change in analgesic use; results weremixed. Adverse events in the included RCTs were rareand not serious, but the vast majority of studies did notcollect adverse events data.

This review has several methodological strengths: ana priori research design, duplicate study selection anddata abstraction of study information, a comprehensivesearch of electronic databases, risk of bias assessments,

210 ann. behav. med. (2017) 51:199–213

and comprehensive quality of evidence assessments usedto formulate review conclusions. One limitation is thatwe did not contact individual study authors; results re-ported in the review are based on published data. Weexcluded conference abstracts which do not containenough data to evaluate study quality. In addition, weincluded only studies published in English.

The included studies had many limitations. Thirteen of thethirty-eight studies were rated as poor quality, primarily due tolack of ITT, poor follow-up, or poor reporting of methods forrandomization and concealment of allocation. The authors often studies reported inadequate statistical power to detect dif-ferences in pain outcomes between mindfulness meditationand the comparator; the authors considered these pilot studies.Ten other studies did not report a power calculation. Samplesizes were small; 15 studies randomized fewer than 50participants.

More well-designed, rigorous, and large RCTs are need-ed in order to develop an evidence base that can moredecisively provide estimates of its effectiveness. Studiesshould enroll samples large enough to detect statisticaldifferences in outcomes and should follow-up with partic-ipants for 6 to 12 months in order to assess the long-termeffects of meditation. Adherence to mindfulness practiceand simultaneous use of other therapies should be moni-tored frequently. Intervention characteristics, including theoptimal dose, have also not yet conclusively beenestablished. In order to detect intervention specific effects,studies need to have attention-matched controls. Smallertrials may be conducted to answer these questions. Otheroutcomes that were outside the scope of this review maybe important to explore. As the impact of mindfulnessmay be related to the appraisal of the pain, it may beuseful for future trials to focus primary outcomes onsymptoms associated with pain such as quality of life,pain-related interference, pain tolerance, analgesic, and re-lated issues such as opioid craving. Future publications onRCTs of mindfulness meditation should adhere toConsolidated Standards of Reporting Trials (CONSORT)standards.

Only three RCTs attributed minor adverse events tomindfulness meditation. However, only 7 of the 38 in-cluded RCTs mentioned whether adverse events weremonitored and collected. Thus quality of evidence foradverse events reported in RCTs is inadequate for acomprehensive assessment. Given published reports ofadverse events during meditation, including psychosis[67], future trials should actively collect adverse eventsdata. In addition, a systematic review of observationalstudies and case reports would shed additional light onadverse events during mindfulness meditation.

Further research examining the effect of mindfulnessmeditation on chronic pain should also focus on better

understanding whether there is a minimum frequency orduration of meditation practice for it to be effective.While recent studies have yielded similar positive ef-fects of mindfulness for pain, these effects tend to besmall to medium and based on a body of evidence thatis, at best, of moderate quality. A potential way to ad-vance research on chronic pain would be to improveintervention and control group descriptions, identify dif-ferent effects of various components of complex inter-ventions, and work toward a standard criterion forassessing therapeutic gain [68]. Head-to-head trials thatcompare mindfulness interventions of a similar categorybut with variations in components or dose may be help-ful to tease out the most effective elements of theseinterventions [69].

Similar to previous reviews in this area, we concludethat while mindfulness meditation interventions showedsignificant improvements for chronic pain, depression,and quality of life, the weaknesses in the body of evi-dence prevent strong conclusions. The available evi-dence did not yield consistent effects for pain outcomes,and few studies were available for forms of mindfulnessmeditation other than MBSR. Quality of evidence forthe efficacy of mindfulness interventions in reducingchronic pain is low. There was higher quality evidenceof the efficacy of mindfulness meditation on depressionand mental health-related quality-of-life outcomes. Thisreview is consistent with previous reviews concludingthat more well-designed, rigorous, and large RCTs areneeded in order to develop an evidence base that canmore decisively provide estimates of the efficacy ofmindfulness meditation for chronic pain. In the mean-time, chronic pain continues to pose a tremendous bur-den on society and individuals. A novel therapeutic ap-proach for chronic pain management such as mindful-ness meditation would likely be welcomed by patientssuffering from pain.

Compliance with Ethical Standards

Funding andDisclaimer The systematic review was sponsored bythe Depar tment of Defense Centers of Excel lence forPsychological Health and Traumatic Brain Injury (contract number14-539.2). The findings and conclusions in this manuscript arethose of the authors and do not necessarily represent the viewsof the Department of Defense Centers of Excellence forPsychological Health and Traumatic Brain Injury.

Authors Statement of Conflict of Interest and Adherence to EthicalStandards Authors Authors Hilton, Hempel, Ewing, Apaydin,Xenakis, Newberry, Colaiaco, Maher, Shanman, Sorbero, andMaglione declare that they have no conflict of interest. All pro-cedures, including the informed consent process, were conductedin accordance with the ethical standards of the responsible com-mittee on human experimentation (institutional and national) andwith the Helsinki Declaration of 1975, as revised in 2000.

ann. behav. med. (2017) 51:199–213 211

Open Access This article is distributed under the terms of the CreativeCommons At t r ibut ion 4 .0 In te rna t ional License (h t tp : / /creativecommons.org/licenses/by/4.0/), which permits unrestricted use,distribution, and reproduction in any medium, provided you giveappropriate credit to the original author(s) and the source, provide a linkto the Creative Commons license, and indicate if changes were made.

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