One of the most delightful aspects of the ‘new wave’ of cognitive behavioural therapies is the continued adherence to test the effectiveness of therapy in a scientific way. There has been quite a flow of ACT (Acceptance and Commitment Therapy), CCBT (Contextual Cognitive Behavioural Therapy) and allied therapies in the psychological literature, and now it is fast appearing in interdisciplinary journals.
The official publication of the IASP (International Association for the Study of Pain) is the journal Pain. It publishes studies relevant to a broad range of disciplines involved in the study and management of pain. It’s fascinating to see the different articles that make their way to the journal – from basic science to primary prevention/public health campaigns!
This article, Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study is a good example of the type of study on ACT practices that is published in this well-read journal.
Morone, Greco and Weiner write about their pragmatic study to ‘assess the feasibility of recruitment and adherence to an eight-session mindfulness meditation program for community-dwelling older adults with chronic low back pain (CLBP) and to develop initial estimates of treatment effects.’
Now the first point to make is that mindfulness meditation alone does not equate to ACT. It does, however, form a foundation for the practice of ACT, as well as having well-documented effects from simple meditation practice on physiological arousal.
Back to the story – Participants were 37 community-dwelling older adults aged 65 years and older with CLBP of moderate intensity occurring daily or almost every day. Participants were randomized to an 8-week mindfulness-based meditation program or to a wait-list control group. Baseline, 8-week and 3-month follow-up measures of pain, physical function, and quality of life were assessed.
This is an interesting group of participants – I work in a public hospital outpatient centre, and I notice that there are increasing numbers of people in this age group being referred to the service. I’m not sure if this is because medication prescribing has changed, that older adults are reporting chronic pain more readily than 15 – 20 years ago, whether it’s an artifact of having a larger number of people aged 65 in the community, or what it is – but it does have an impact on the type of programmes we provide. In view of the increasing growth in the over 65 year age group in the next 20 years, it is a group that we are going to see more often, and who will require more expenditure in health care especially if disability from chronic pain is not addressed effectively. Whew! that was a long sentence!
So a fairly typical methodology was employed for this study – a wait-list control, and baseline, 8-week and 3-month follow-up measures taken across several domains.
The actual intervention was over eight weeks, and included an introduction to the ‘principles and practices’ of meditation, reading materials, a recording of a ‘body scan’ meditation and a sitting meditation, discussion and problem solving around the habit of meditation, and psychoeducational material on stress, pain and the ‘mind-body’ connection was also provided. A walking meditation was introduced towards the latter part of the eight weeks, and the only major difference from ‘standard’ Mindfulness-Based Stress Reduction Programmes ((Kabat-Zinn, 1982; Kabat-Zinn et al.,1992; Kabat-Zinn, 1990; Kabat-Zinn, 2003.) was the elimination of a full-day silent meditation ‘retreat’ and the yoga component.
Now for the exciting part: what were the results?
Well, the study was a pragmatic and applied one, so the first thing I was interested in was participation rates and adherence. 19 participants were selected for the meditation group, 13 participated, one was lost at followup, leaving 12 completing. In the waiting list group, 18 were initially recruited to this group, 14 eventually participated (after a delay of 8 weeks), and 13 completed.
Allowing that these participants were specially recruited, I’m not sure we can generalise to the group of people who are usually referred to a public hospital service. However, it is interesting that these participants continued to attend what is probably seen as an ‘unusual’ type of therapy for pain.
The authors commented that these participants attended the majority of sessions, engaged in the ‘homework’ activities (meditation practice) during the programme, and reported that they maintained the practice three months later. This is great as it demonstrates that older adults understand the programme, are interested in it, find benefit from it, and as the authors quote a program participant stated it best ‘‘Mindfulness meditation has a quieting effect on me. It gives me a peaceful feeling while doing it and I am able to reduce my back and leg pain by deflecting the pain and by focusing on other parts of my body’’.
It’s also interesting that things like activity planning and exercise were not specifically included in the programme, but activity levels increased.
As expected, acceptance of their situation increased, as did quality of life measures. Pain intensity reduced and ‘global’ health and mental health as measured by the SF36 reduced.
Notable too – people who crossed over from the waiting list group also improved.
The authors are open about several aspects of this study that mean its interpretation needs to be somewhat guarded: it is a small group, a pilot study, between group differences can’t be established due to low power, and the differences between the groups were not entirely controlled for.
However, it’s the beginning of the ‘real world’ type of study that can help us as clinicians think about the people we work with and whether this therapy may be useful.
MORONE, N., GRECO, C., WEINER, D. (2008). Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot studyâ˜†. Pain, 134(3), 310-319. DOI: 10.1016/j.pain.2007.04.038
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