Chronic pain, which is commonly defined as pain lasting for at least six months, is one of the most common presenting problems in primary care settings (Gureje et al., Reference Gureje, Simon and Von Korff2001) and usually has a significant impact on patients’ lives. Current estimates suggest that anywhere from 16 to 41% of the population experiences chronic pain (Schopflocher et al., Reference Schopflocher, Taenzer and Jovey2011). It is associated with a reduction in daily activities, lower self-ratings of general health, and increased psychological distress (Gureje et al., Reference Gureje, Von Korff, Simon and Gater1998; Demyttenaere et al., Reference Demyttenaere, Bruffaerts, Lee, Posada-Villa, Kovess and Angermeyer2007). Treatment typically involves the use of medication such as anti-inflammatory agents and analgesic medications and many patients are involved in some form of non-pharmacological treatment (Moulin et al., Reference Moulin, Clark, Speechley and Morley-Forster2002). Treatments serving as adjuncts or alternatives to analgesics are essential, as medication is typically of limited effectiveness and involves one or more side-effects. Research has consistently supported cognitive behavioural treatments (CBT) in the management of chronic pain (eg, Morley et al., Reference Morley, Eccleston and Williams1999). A recent review also concluded non-specific benefits of mindfulness-based treatments for pain and depressive symptoms (Chiesa and Serretti, Reference Chiesa and Serretti2011). However, the maintenance of these changes requires further research. Specifically, a more recent review concluded that the only lasting benefit of CBT for the management of pain was to improvements in mood (Williams et al., Reference Williams, Eccleston and Morley2012).
Behavioural treatment usually targets pain, behaviours, and fear and avoidance related to pain, and has been shown to reduce pain-related disability, reduce psychological distress, and increase quality of life. CBT focuses on the above, as well as reducing maladaptive thoughts surrounding pain and learning coping strategies, such as activity pacing, and has demonstrated effectiveness for a number of chronic pain conditions. Mindfulness-Based Stress Reduction (MBSR) programmes, which are typically viewed to be under the umbrella of CBT treatments, are increasingly being used to treat a wide range of conditions, including chronic pain. These programmes have been found to improve mental health, reduce anxiety and depressive symptoms, and improve health-related quality of life (Fjorback et al., Reference Fjorback, Arendt, Ørnbøl, Fink and Walach2011). In a seminal study of a 10-week MBSR programme, Kabat-Zinn found significant reductions in pain indices and mood disturbance (Kabat-Zinn, Reference Kabat-Zinn1982). Kabat-Zinn conceptualized this programme as involving the teaching of self-regulation of pain by means of mindfulness meditation skills. The programme provided instruction on different meditation techniques to develop detached observation within the frame of a short-term group setting. Although research supports the use of MBSR in the treatment of chronic pain, similar to CBT more generally, methodological concerns have been raised (eg, patient selection). The current pilot study sought to establish the feasibility and acceptability of an MBSR-based intervention for patients with chronic pain in a ‘real-world’ primary care setting, with the intent of implementing and studying further such programmes within this setting. As a secondary objective, the study sought to evaluate whether participation in this newly implemented MBSR-based treatment group was associated with reductions in pain disability, subjective ratings of pain, and psychological distress related to pain, and increases in activity level and willingness to experience pain. Improved management of chronic pain in primary care is critical for improving patient care and efficient use of health-care resources.
Methods
Intervention
An eight-week group treatment programme was developed based on MBSR principles and implemented in a primary care clinic in Winnipeg, Manitoba. The clinic is a regionally funded multi-disciplinary setting that is part of Shared Mental Health Care, a collaborative care programme consisting of ~20 clinics. Two experienced mental health counsellors trained in MBSR co-delivered the programme across two groups in 2011. These counsellors are integrated into the primary care team. Each weekly 2-h session involved two meditations, each ~30 min in length, and an inquiry process during which time participants were invited to share their experiences, challenges, and growth. Patients were provided with CDs of the meditations and encouraged to practice the meditations on at least five days weekly. Handouts were also provided and patients were encouraged to record their observations on challenges and growth between sessions. Patients attended a 2-h orientation session the week before the programme commenced (or met with a group facilitator at a different time) to determine appropriate fit to the programme, describe the commitment required for participation (ie, regular attendance as defined as a minimum of six sessions, completion of exercises between sessions), and clarify expectations.
Participants
Patients living with chronic pain (eg, lower back pain, fibromyalgia, arthritis) were referred to the MBSR group by health-care providers from the Shared Mental Health Care programme. The first group included 18 patients (3 joining after week 1) and the second group included 8 patients. Of the 26 patients, 4 were male and 22 were female, all were Caucasian. Patients ranged in age from 33 to 71 years and there was broad socio-economic representation. In all, 17 of the 26 patients completed evaluation measures at the end of programme. Unique to this area of research, all interested patients, regardless of type or severity of chronic pain, were invited to participate in the programme. No patients were excluded.
Measures
Outcome measures were administered during the orientation meeting and at the end of the final programme session. Although administered by the programme facilitators, responses were viewed only by the first author. These measures included the: Kessler Psychological Distress Scale (K10), Pain Disability Index (PDI), Visual Analogue Pain Intensity Scale, and the Chronic Pain Acceptance Questionnaire – Revised (CPAQ-R). The K10 is a 10-item scale that asks respondents to rate the frequency of anxiety and depression symptoms over the past four weeks on a five-point Likert scale (1=all of the time; 5=none of the time). The total score was used (range 10–50). The PDI asks respondents to rate the degree of impact that pain has across seven life activities: family and home responsibilities, recreation, social activity, occupation, sexual behaviour, self-care, and life-support activities, along an 11-point scale (0=no disability; 10=worst disability). Subscale (range 0–10) and total scores (range 0–70) were used. The Visual Analogue Pain Intensity Scale asks respondents to mark their perceived current intensity of pain along an 11 cm horizontal line with ends representing the range from ‘no pain’ to ‘worst possible pain’. This measure is scored by measuring the millimetres from the ‘no pain’ end of the line (range 0–110). The CPAQ-R includes two factors: activity engagement and pain willingness, as measured on 20 items along a seven-point Likert scale (0=never true; 6=always true). The two factor score was used (range 0–60 for each factor). Research has demonstrated these measures to be both reliable and valid (Pollard, Reference Pollard1984; Tait et al., Reference Tait, Chibnall and Krause1990; Chibnall and Tait, Reference Chibnall and Tait1994; Andrews and Slade, Reference Andrews and Slade2001; McCrackena et al., Reference McCrackena, Vowlesb and Ecclestona2004; Kahl and Cleland, Reference Kahl and Cleland2005).
In addition, the Client Satisfaction Questionnaire (CSQ8), an eight-item measure that evaluates satisfaction along a four-point Likert scale, was administered after the programme. Post programme, participants were also asked to report their level of confidence that the programme helped them manage their chronic pain condition (four-point Likert scale: 1=very confident; 4=very unconfident), what they liked best about the programme, and what they would change about the programme to make it better. Attendance data were also collected.
Results
Participant satisfaction
Patients attended on average 5.5 of 8 sessions. Of the 26 patients, 15 completed six or more sessions (58%). When participants were asked to report their level of confidence that the MBSR programme helped them manage their chronic pain condition, all but one participant reported that they were very confident or somewhat confident (ie, 9 out of 17 very and 7 out of 17 somewhat confident).
Using the CSQ8, of the 17 respondents, a high level of satisfaction was reported with this programme (average of 3.49 out of 4 for the eight-item total); only one participant had an average satisfaction level below 3 out of 4. In terms of what participants liked best about this programme, respondents’ comments related to four different themes: programme facilitators, group experience, skills gained, and general comments about the programme as a whole. When asked what they would change about the programme to make it better, responses related to five different themes: duration/frequency, timing, offering an ongoing group, group discussion, and nothing.
Patient outcomes
Using SPSS, the first analysis involved independent sample t-tests to compare the similarity of the two programme groups at baseline on the dependent measures. A significant difference was found on the PDI self-care category, such that at baseline, Group 1 reported a significantly higher level of disability related to this area (5.56±2.38) as compared with Group 2 (2.63±2.39) (t(24)=2.90, P=0.008). No other differences were found and the remaining analyses combined the two groups.
Next, an attrition analysis investigated for differences in baseline characteristics between the participants who attended six or more sessions (ie, completers) to participants who attended five or fewer sessions (ie, non-completers). The only significant difference was on subjective rating of current pain, with completers reporting a lower baseline level of pain (61.80±25.04 mm) as compared with non-completers (81.64±8.90 mm) (t(18.48)=2.83, P=0.011).
Subsequently, the effectiveness of the MBSR programme on the outcomes of interest were assessed through 12 paired samples’ t-tests. To avoid α inflation owing to multiple t-tests, a P-value of 0.01 was used to determine significant improvement; with this more stringent criterion, five t-tests were significant. Specifically, significant improvements were found for level of pain disability related to recreation and overall total disability, level of psychological distress, level of engagement in life activities, and willingness to experience pain. When considering effect sizes for this programme, the following changes from baseline to post programme were associated with large effect sizes (ie, r⩾0.50): level of pain disability related to family/home responsibilities, recreation, occupation, and overall total disability score; participants’ subjective rating of current pain; level of psychological distress; level of engagement in life activities; and willingness to experience pain (see Table 1 for statistics).
Paired samples t-tests: comparison of scores before and after programme
PDI=Pain Disability Index.
* Significant at the P-value of 0.01.
Discussion
This pilot study demonstrated a brief MBSR-based treatment programme to be both feasible and acceptable for patients with chronic pain in a primary care setting. The findings also suggest that this treatment approach led to benefits for patients. Despite the modest attendance rate and short length of programme, participation was associated with significant and/or clinically relevant improvements (as defined by a P-value of 0.01 and/or large effect sizes) in level of pain disability, psychological distress, engagement in life activities, willingness to experience pain, and subjective rating of current pain.
Limitations of this pilot study include the non-experimental design, small sample size, predominant female sample, higher than ideal attrition rate, self-report nature of the findings, and lack of follow-up data. In addition, it would have been useful to collect more information about the participants and implementation of the programme (eg, fidelity of programme delivery, number of patients referred versus started in programme). An absence of a control group prevents us from concluding that it was the intervention, and more specifically, mindfulness skills, that resulted in improved outcomes for participants, rather than regression to the mean, placebo, or some other effect. Notwithstanding this significant limitation, the magnitude and pattern of changes suggest that the intervention did contribute to participant improvements. Research generally demonstrates larger impacts for patients with greater symptoms. Although patients with lower levels of pain at baseline were more likely to complete the treatment in this study, clinically important changes were still found. Prior research has demonstrated the benefits of this type of approach in other contexts, yet to our knowledge, this study contributes further to the literature by demonstrating the feasibility and likely utility of this treatment approach for a heterogeneous group of patients with chronic pain within the primary care context. Further strengths of this study are the naturalistic nature of the study design and the use of an external evaluator.
In addition to confirming the benefits of this programme in a more rigorous study design, it would be worthwhile for future research to explore the cost-effectiveness of this type of programme within a primary care setting, such as the potential for this treatment programme to reduce physician and other health-care visits. Future research on the acceptability and feasibility of such treatment programmes from the primary care provider perspective is also warranted. Finally, it would be valuable to pursue implementation research exploring how MBSR or mindfulness programmes can be adapted and delivered within shorter time frames for diverse groups of patients within the primary care context.
Acknowledgements
The authors acknowledgements are extended to Sheila Korban and Clarence Ens, co-facilitators of the MBSR programme.
