WILLIAM JAMES COLLEGE

Chronic Pain, Mindfulness and Measures of Physical Function: A Systematic Review

William Charles Jackson

MA, William James College, 2015

BFA, Hartt School, University of Hartford, 2005

Submitted in partial fulfillment of the

Requirements for the degree of

Doctor of Psychology

2016
 ProQuest Number: 10188838

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 Copyright 2016

By

William Charles Jackson

ii
 Acknowledgements

Firstly, I would like to express my sincere gratitude to my wife and extended

family for their support of me and our immediate family during the doctoral project

process and my father for his continuous editorial support of my doctoral project. This

project would not have happened without their support. I would like to thank my

supervisor and mentor Dr. Ronald Kulich for his support of my Psy.D. clinical and

research studies and introduction to Ana-Maria Vranceanu who has also made this study

possible with her research design and writing guidance.

Besides my family and mentor, I would like to thank my DP committee: Dr.

Stanley Berman and Dr. David Haddad for their insightful comments, encouragement and

steady and necessary pressure to expand my conceptual view and hone my writing.

A special thanks to Dr. Alberto Malacarne and Amy Lapidow for their support in

the research planning. Also I thank my friends in William James College.

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 Table of Contents

Acknowledgements iii

ABSTRACT vii

CHAPTER ONE: INTRODUCTION 1

CHAPTER TWO: LITERATURE REVIEW 4

Chronic Pain 4

Epidemiological Factors in Chronic Pain 4

Psychological and Physical Sequelae of Chronic Pain 5

Psychological Consequences 6

Physical Consequences 7

Current Treatments – Medical and Psychological Approaches 8

Medical 9

Common Pain Treatment 9

Opioid Treatment 11

Multidisciplinary Treatment 12

Psychological Treatment 15

Cognitive Behavioral Therapy 15

Behavior Therapy 16

Acceptance Based Interventions 17

Mechanisms of Mindfulness 19

Mindfulness Skills Training 22

History of Mindfulness Interventions 22

History of Mindfulness Interventions in Medicine 24

Mindfulness Based Stress Reduction 24

Integrative Approaches 25

Limitations of MST 27

Activity and Chronic Pain 28

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 Assessment of Chronic Pain 30

IMMPACT 30

Use of Quality of Life Measures in Chronic Pain 31

Assessment of Physical Functioning 33

Self-Report Versus Objective Measures 34

Digital Monitoring Devices and Other Objective Measures 35

Systematic Reviews 37

PRISMA 39

Summary 43

CHAPTER THREE: METHODS 45

Preparation of Systematic Review 45

Search Strategy 46

Execution of Systematic Review 46

Search Strategy 46

Selection Criteria/Study Eligibility 48

Data extraction/Quality Assessment 50

CHAPTER FOUR: RESULTS 56

Characteristics of Included Studies 56

Physical Function Outcome Measures 57

Physical function performance based measures 58

Physical Function Self-Report Measures 58

Measures Assessing Physical Function as Part of 59

Quality of Life

Measures Assessing Only Physical Function 59

Results of Self-Reported Measures of Function 61

Results of Performance Measures 62

Alignment with IMMPACT Recommendations 63

Summary of Findings 63

CHAPTER FIVE: DISCUSSION 64

v
 Interpretation of Results 64

Clinical Implications 67

Recommendations for Future Clinical Research 69

Summary and Conclusion 70

References 73

Appendix A: Search Terms 96

Appendix B: Abstract Accepted by America Pain Society for Publication 98

List of Figures

Number Title

1 PRISMA Flow Chart 41

2 PRSIMA 27-Item Checklist 42

3 Search Terms for Four Databases 98

4 Inclusion Exclusion Criteria 47

5 Flow Chart 49

6 Hierarchy of Exclusion Criteria 50

7 10-Item Quality Assessment 54

8 Level of Evidence 55

9 Studies with Objective Measures 71

Table

Number Title

1 Characteristics of Selected Studies 51

vi
 Chronic Pain, Mindfulness and Measures of Physical Function: A Systematic Review

William Charles Jackson

William James College

2016

Chairperson: Stanley Berman

Abstract

The importance of improved physical functioning as a primary outcome in the treatment

of chronic pain is widely accepted. Mindfulness Skills Training (MST) targeting pain

acceptance and engagement in increased activity is becoming increasingly popular for the

treatment of chronic pain. This paper presents the supporting literature review and

systematic review of published randomized control trials (RCTs) using MSTs that also

assess physical functioning (objective or self-report) as primary or secondary outcomes,

describes the instruments used, and summarizes the results. The Preferred Reporting

Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria was used to

identify, select, and assess eligibility of studies for inclusion and follow established

guidelines for best practice of systematic reviews in reporting results. Published reports

of original RCTs were included in the systematic review if they described functional

outcomes after a MST in the chronic pain population, and met methodological quality

according to a list of predefined criteria. Of the 2818 articles identified from the original

search of 4 electronic databases, inclusionary criteria were met by 15 studies published as

of August 10th, 2015, totaling 1,199 patients. All included studies used self-report

measures of physical function, while only 2 studies employed performance based

vii
measures of function. Overall, the quality of the studies was rated as high. We found

inconclusive evidence for small improvements in the subjective self-reported physical

function after MSTs. However, we found strong evidence for the objective performance

physical function, based on results from two high quality studies, which showed no

improvement in function. This review draws attention to the importance of addressing

physical function and assessing it with quality measurements within MSTs for chronic

pain. The use of performance based measures of function and potential strategies to

address physical function in this population are discussed.

viii
 CHAPTER ONE

Introduction

Mindfulness is the nonjudgmental awareness of experiences in the present

moment. It increases well-being and reduces psychiatric and stress-related symptoms.

Mindfulness Skills Training (MST) teaches meditation and mindfulness to

patients with a variety of medical conditions, including pain (Cherkin, 2014; Kenne,

2013; Vranceanu, 2014). Although mindfulness approaches have demonstrated the

capacity to decrease pain levels and contribute to improved quality of life, it is not clear

whether they systematically address improvement in function. A key outcome variable

such as physical function remains based on subjective self-reports of physical function

when there is significant evidence that self-report of physical function is often very

inaccurate (Prince, 2008). Higher quality performance measures are easily accessible and

these objective measurements are supported by current research (Lee, 2014). The

proposed project reviews the existent research literature on the efficacy of Mindfulness

Skills Training (MST) in improving physical function in chronic pain patients. With

supporting information from the following literature review an evidence based systematic

review, assessing the state of current research on functional outcome variables in

mindfulness training in the chronic pain population will be performed.

A literature review typically is a preliminary or sometimes undisciplined way of

exploring available information pertaining to a particular subject matter or clinical

finding. In an evidence based systematic review, however, the clinical research question,

1
inclusion and exclusion criteria, search strategy and criteria for the systematic evaluation

of clinical trials is created a priori (Rys, 2009; Higgins 2008; Khan, 2011). This

systematic approach is maintained in efforts to minimize bias and form an evidence based

answer to the research question defined below. Based on information gathered in the

exploratory literature review, the appropriate inclusion and exclusion criteria for clinical

trials used in the study will be created. To ensure a comprehensive search of existent

literature, a search strategy is systematically developed and four major data bases

searched. The quality of studies that meet the inclusion and exclusion criteria will then be

assessed to determine eligibility for inclusion for quality assessment. The resulting

studies that meet inclusion criteria and quality will then be included in the systematic

review to answer the evidence based review question, “Can we reliably and validly assess

Mindfulness Skills Training’s effect on physical function in chronic pain patients?”

The included literature review will give perspective to the research question by

exploring the use of mindfulness in chronic pain treatment. More specifically, the

literature review will focus on the effects of mindfulness training on chronic pain by

identifying what is known and not yet known about important outcome variables in

mindfulness training and chronic pain management. The broader literature review will

also provide context, clarifying why this research topic is immediately relevant in chronic

pain research and how mindfulness training compares with other chronic pain

interventions. The areas of exploration will be: chronic pain, including physical and

psychological epidemiological factors, current medical and psychological treatment of

chronic pain, the history and current use of mindfulness as a clinical intervention, the

importance of activity and daily function in chronic pain, and research on chronic pain

2
interventions, including special attention to functional outcome measures and the utility

of systematic reviews.

3
 CHAPTER TWO

LITERATURE REVIEW

Chronic Pain

The International Association for the Study of Pain (2012) defines pain as, “An

unpleasant sensory and emotional experience associated with actual or potential tissue

damage, or an experience described in terms of such damage” (p. 1). Chronic pain is

often defined as any pain lasting more than 12 weeks, or pain lasting beyond the normal

medically designated healing or recuperation time from tissue damage (NIH, 2014).

Patients with chronic pain generally suffer from three types of chronic pain, caused either

by tissue damage such as inflammation or infection, neuropathic damage to the

somatosensory system that may never heal, such as chronic regional pain syndrome

(CRPS) or a central sensitization syndrome such as fibromyalgia. Gureje (1998) stated,

“Pain is one of the most common and among the most personally compelling reasons for

seeking medical attention.” (p. 1)

Epidemiological Factors in Chronic Pain

An estimated 100 million adults in the United States suffer from chronic pain

(Institute of Medicine, 2011). Chronic pain is just as prevalent in the rest of the world. In

Europe 19% of the adult population have reported the presence of chronic pain above a 5

on a 10-point numeric rating scale for 6 months or more (Breivik, 2006). In addition, the

World Health Organization reported chronic pain as a public health problem present

throughout the world, with 34% of adults in developing countries and 30% in developed

countries suffering from chronic pain (Gureje, 1998). Jamison (2011) reported, “Chronic

4
[non-cancer] pain is responsible for up to $100 billion [USD] in annual direct and indirect

costs, making it the most financially challenging condition to date” (p. 1). A recent

analysis reported that the estimated cost of pain in the United States in 2008 was between

$560 to $635 billion, including healthcare and lost productivity (Darrell, 2012). As a

consequence of this impact, the National Center for Complementary and Integrative

Health (NCCIH) has designated chronic pain as a national priority area (Research

Funding Priorities, 2015).

Like many chronic illnesses, chronic pain is not a visible illness and therefore

likely more pervasive than perceived by the general public. In a recent survey from the

American Chronic Pain Association, 39% of families interviewed said their loved one

had severe pain, while 70% of the loved ones reported having pain(Pharmaceuticals,

2013). Like many chronic illnesses, as the patients age, the likelihood of chronic pain

also increases. In addition, 32% of adults aged 25 to 34 years and 62% of adults over the

age of 75 report chronic pain (Elliot, 1999). The pervasive problem of chronic pain is

well documented, as are the symptoms that accompany chronic pain.

Psychological and Physical Sequelae of Chronic Pain

Patients with chronic pain often suffer from chronic stress, poor sleep and

psychological comorbidities such as depression and anxiety (Nicholson, 2004). These

psychological comorbidities can lead to an increase in chronic pain symptoms and create

a vicious cycle. Jamison (2011) suggests that chronic back pain negatively impacts every

facet of an individual’s quality of life including, sleep, employment, and social

functioning, with patients reporting depression, anxiety, irritability, sexual dysfunction

5
and decreased energy (p. 1). A complete review of the literature exploring the effects of

chronic pain would be beyond the scope of this paper. However, there are a few key areas

that are important to explore, including psychological symptoms and comorbidities,

quality of life and disability.

Psychological Consequences. More so than with other chronic illnesses, depression

and anxiety are especially present in patients exhibiting chronic pain. In a cross-national,

population-based study, chronic back or neck pain and associated mental disorders

studies have found that anxiety and alcohol disorders, as well as mood disorders,

occurred with greater frequency among persons with chronic back or neck pain

(Demyttenaere, 2007). Whereas the general population has approximately a 5% incidence

rate of depression (Blazer, 1994), it has been reported that a range of 20%- 45% patients

with chronic pain reported symptoms of major depression (Demyttenaere, 2007). A

recent study of patients in primary care settings found that of the nearly one half of

patients with chronic pain, 45% were positive for at least one anxiety disorder (Kroenke,

2013). Comorbid psychiatric conditions of patients can aggravate symptoms, increase

stress and interfere with patient’s accessing available treatment and collaborating

professional care, further exacerbating their physical condition. Although pain is a

multidimensional process, psychological factors may be as important, if not more

important than pathological processes in the experience of pain (den Boer, 2006; Turk,

2002). In addition, the psychological factors of chronic pain have been found to have a

significant impact on physical function (Bawa, 2015) and disability. Across all coping

constructs, pain catastrophizing (Crombez, 2012; Vraceanu, 2014) and pain self-efficacy

(Anderson, 1995; Costal, 2011) have been depicted as the most salient predictors of

6
decreased quality of life and disability among patients with chronic pain. According to

Sullivan (2001), pain catastrophizing is “an exaggerated negative mental set brought to

bear during actual or anticipated painful experience” (p. 53). Pain self-efficacy is the

extent to which a person with pain believes they can successfully adapt to having pain

and continue to accomplish specific or general daily tasks (Wallace, 2006). The two

psychological constructs have been found to have a significant impact on successful

coping and perception of disability.

Physical Consequences. Chronic pain is also associated with decreased quality of

life, impaired functioning, and increased disability (Institute of Medicine, 2011).

Azevedo et al. selected 5,094 participants at random from the Portuguese adult

population and found that the highest disability was found in relation to family, home

life, recreational activities, work and sleep, with 49% of people reporting that their pain

interfered with their job. Physical function - a term that is included in both the definition

of the more objective term impairment and more subjective term disability - refers to a

limitation of physical activity (WHO, 2001). Contrary to folk logic that would assume

that if there is pain there is injury and when there is injury there is disability. However,

when nociception or tissue damage is present, the tissue damage is typically unrelated to

the individual’s level of self-reported disability and pain (Turk, 2006). However, a large

body of research documents that patients with chronic pain have decreased quality of life

(Bernfort, 2015; Kroenke, 2010; Lamé, 2005), and increased disability (Azevedo, 2012;

Garin, 2012; Blyth, 2001), regardless of the location of pain. Patients with chronic pain

also report decrease in activity and functioning (Azevedo, 2012), with pain

catastrophizing being associated with both decreases in physical and psychosocial

7
constructs (Costal, 2011; Lame, 2005). This research shows how intertwined

psychosocial constructs are to the perception of physical disability, as well as how

essential psychological interventions may be in the treatment of physical pain.

Current Treatments – Medical and Psychological Approaches

Patients suffer from neuropathic pain that is defined as, “pain arising as a direct

consequence of a lesion or disease affecting the somatosensory system” (Treede, 2008),

or peripheral pain often described as a central sensitization of the nervous system arising

from some type of hyperalgesia (increased pain). Lee et al. (2011) describes opioid

induced hyperalgesia as “characterized by a paradoxical response whereby a person

receiving opioids for the treatment of pain could actually become more sensitive to

certain painful stimuli” (p. 125). In addition, it is often suggested that this sensitization

occurs through a functional change in neurotransmitters and receptors in the brain,

altering the patient’s pain perception.

Another proposed theory of central sensitization that may occur over a longer

time period is that for an unknown reason, either because of exposure to intense pain,

inflammation or sometimes opioid medication, patients become more sensitive to pain or

report pain with no clear lesion or disease. Research on proposed mechanisms has shown

that the dorsal anterior cingulate cortex (dACC), a pain processing area of the brain, is

atrophied in patients with chronic pain suffering from a central sensitization called

hyperalgesia (Kong, 2008). Whether the patient is diagnosed with a functional disorder,

musculoskeletal or neuropathic condition, determining the etiology of the patient’s

8
condition often defines the care that follows. If the damage is clear, it is possible it can be

effectively addressed and “cured”. However, it is often the case that the cause of pain is

unclear, and the patient and care team must shift their focus from cure to pain

management. Unfortunately, when the diagnosis is unclear, so is the treatment. Whether

it is psychological treatment, physical therapy, surgery or medication, there is

disagreement amongst providers in the same and different disciplines on what constitutes

best care.

Medical. Current medical treatment for chronic pain varies according to

diagnosis. To illustrate the variety of treatments patients can undergo for chronic pain,

common patient experiences will be explored.

Common Pain Treatment. Patients may have a clear textbook pain complaint

that can be addressed with a procedure such as surgery, an injection or other isolated

treatment. Specialists and specialty pain clinics can be very effective for these patients.

Unfortunately, most clinical cases are different from those found in controlled studies or

text book vignettes. Depending on what kind of multidisciplinary clinic a complex pain

patient attends, he or she may receive very different treatment.

Patients with multifocal pain entering a specialty clinic may be referred for one

pain complaint in a specific part of the body, when the issue may be more systemic or

psychological. A patient who enters a dental clinic that focuses on musculoskeletal

conditions with a focus on pain above the shoulders may experience pain in other

locations. In the specialty clinic, focus remains on the pain a patient is having in their

neck, jaw or head because that is the clinic’s specialty. For other pain locations the

9
patient may go to other specialty clinics, missing a more systemic or psychological issue.

The patient receives a dental appliance, exercises, medication, or acupuncture to address

certain neck or jaw pains or a referral to another specialist for a more invasive treatment,

if indicated. The same patient may also be prescribed pain medication or receive

psychotherapeutic support in the clinic, or be referred to psychiatric care, if indicated.

A multidisciplinary pain treatment center that is connected to a very large medical

system with vast resources has the potential to treat many symptoms in one patient.

However, the patient may also get lost in such large systems. As an example, a patient in

such a medical treatment center may have received surgery for an acute problem that led

to lasting chronic pain such as post laminectomy syndrome or surgery for nearly any

other issue that resulted in lasting pain. Patients at these centers may already have many

specialty doctors involved in their care. Although all the doctors may be using the same

electronic heath record system, patient care can become fragmented and patients may

have to wait for months before a surgery, prescription or appointment for one specialist

after the next. Patients can get lost in large systems and become discouraged, adding to

their psychological struggle to find relief.

Care at private multidisciplinary clinics also offer a range of treatments. The team

is likely to be smaller at a private clinic, and therefore the treatment at private

multidisciplinary centers is more limited in procedures. Due to the smaller physical

space, clinicians are more likely to come in contact with one and other. The smaller team

members may have more opportunity to communicate about one patient they are all

seeing. Patients may see a medical doctor for diagnosis and assessment of their pain

condition, a nurse practitioner to adjust their medication, a physical therapist for physical

10
treatment and exercises and a psychotherapist to work on cognitive behavioral coping

skills in one visit under one roof.

Clinics differ in organization and multidisciplinary approach to care. However,

one similar aspect is the need to determine appropriate treatment. In order to determine

appropriate treatment, quality research and assessment of possible interventions needs to

be performed. When the effectiveness of interventions is unclear, decisions on care will

fall to clinician experience, specialty, insurance restrictions and patient preference. In the

chronic pain population many patients come to treatment looking for pain relief via pain

medication. In the wake of pain medication misuse, medication misuse risk assessment

has become a staple component of chronic pain treatment.

Opioid Treatment. In the treatment of chronic pain there can be many

complications with pain medication leading to dependence, risk of addiction, and even

death from overdose. Patients being treated with medication for chronic pain also have to

manage the side effects of pain medication itself. Opioid therapy often has side effects

like nausea, sedation, bowel dysfunction, testosterone deficiency, cardiac arrhythmia,

disordered breathing and opioid dependence (Jamison, 2011). In addition, many doctors

are reluctant to prescribe their patients opioid medication because of the current opioid

epidemic. Olsen (2006) reported that due to increased awareness of pain there has been a

steady increase in the use of opioids medication in the United States (p. 225). There has

also been a steady increase of opioid misuse with many different pain populations,

especially those with chronic back pain (Jamison, 2011). A 2009 literature review by

Rosenblum et al. reported that 43% to 45% of patients with chronic pain met the criteria

for, “aberrant drug-related behavior” (p. 8). This opioid misuse epidemic, as well as

11
ineffective modes of treatment have led the medical and psychological community to

look for alternative modes of treatment, or organization of treatment. A typical regimen

of treatment for a chronic pain patient may include many separate providers including a

primary care physician, surgeon, physical therapist, occupational therapist, psychiatrist

and psychologist. In addition, a patient will have providers who specialize in the patient’s

particular pain condition. More providers do not always mean better care.

Multidisciplinary Treatment. Previous approaches to chronic pain treatment

have been treating one symptom at a time with a different specialist for each pain

location. More recently, physicians in collaboration with psychologists have become

more willing to view the patient through a biopsychosocial lens, taking into consideration

the effects of psychological stress. As an example, patients with fibromyalgia are often

treated for the pain or tender sites individually until they are properly diagnosed. Wolf

(1991) suggests clinicians often have difficulty diagnosing pain conditions. “Pain in the

arm, leg, buttock, or chest for example is often difficult to understand and explain, and

the same symptom can be attributed to many different sources: disk disorders, neuritis,

bursitis, tendonitis, myositis, arthritis, myofascial pain, and psychological disturbance

depending on the provider they see…” (p. 321). Unfortunately, a psychological

disturbance or the affective dimension of pain cannot be separated from the physical

dimension of pain. The International Association for the Study of Pain defines

‘nociception’, as the body’s ability to sense painful stimuli. This process is different for

every person and can be damaged or altered by experience. Some suggest this process has

been altered in patients with fibromyalgia and other pain conditions (Bendtsen, 1997).

Patients with fibromyalgia often display high rates of comorbidities with other stress

12
related, physical and psychological diseases such as migraines, irritable bowel syndrome,

chronic fatigue syndrome, major depression and panic disorder (Hudson, 1992). An aim

in a multidisciplinary approach, focused on managing the pain of fibromyalgia instead of

trying to cure the pain, could target changing the patient’s perception of his or her health.

Instead of relying on procedures to reduce pain at specific pain sites or address other

symptoms one by one, the physician and patient have the opportunity to take a more

holistic view. To do this, the patient and doctor would have to embrace a more complete

bio-psycho-social treatment approach. This more complete approach avoids the inevitable

“Whac-a-Mole” style treatment focused on “curing” one symptom at a time only to

observe another symptom pop up, never really addressing the underlying etiology that

may include both physical and psychological components not well treated in isolation.

Better care in an effective multidisciplinary setting can focus on specific pain sites,

central sensitization and psychological issues. Specifically, helping a patient accept that

pain may never completely go away and manage thoughts and feelings associated with

this understanding may have a significant impact on disability and other factors. In

addition, since there is such high morbidity with chronic stress conditions and other

psychological comorbidity, focus of treatment on addressing the patient’s sources of

stress may be a more effective way to begin managing the pain and accompanying

symptoms of a chronic pain patient. This approach may help patients whose lives become

dominated by an acute focus of trying to find a perfect diagnosis and cure for their

condition, rather than living a quality life with managed pain.

Current research supports a collaborative, interdisciplinary chronic pain

treatment. Lera et al. (2009) recruited 83 women with Fibromyalgia and randomly

13
assigned them to medical treatment group or medical treatment plus CBT group for 15

weeks. The first group used medical treatment (MT) that included medical intervention,

physical training, education, and discussion of the syndrome. The second group treatment

program included cognitive behavioral therapy (CBT) focused on coping with stress,

modifying lifestyles and changing pain behaviors. Both groups were assessed with three

self-report measures. The Fibromyalgia Impact Questionnaire (FIQ) was used to assess

for the specific impact that fibromyalgia symptoms have on quality of life. The Medical

Outcomes Survey Short Form (SF-36) was used to assess general health status and the

Symptom Checklist-90-R (SCL-90-R) was used to evaluate mental health and severity of

psychopathology. In all, sixty-six women (80%) completed treatment. At the end of

treatment and at the six month follow up, there was a significant difference in

fibromyalgia symptoms and general fatigue when comparing MT and MT+CBT groups.

Patients who received CBT on average improved by 8 points on an 80-point scale (FIQ)

and further improved their functional capability and symptoms, where those who only

received MT did not. Using the 36-item health related quality of life measure, the Short

Form Health Survey (SF-36) and the Symptom Checklist-90 (SLC-90-R), it was shown

that the CBT therapy enhanced the effects of medical treatment and reduced the overall

impact of the disease on patient daily functioning.

Working with, with the Cochrane collaboration for systematic reviews, Guzman

et. al (2001) identified 10 trials with a total of 1954 patients comparing rehabilitation

programs for patients with chronic low back pain. Strong evidence was found that an

intensive multidisciplinary bio-psycho-social rehabilitation with functional restoration

approach improved function when compared with inpatient or outpatient non-

14
multidisciplinary approaches. This suggests that including a behavioral component with

an intensive medical treatment can have additive effects for patients with chronic low

back pain. Other systematic reviews assessing the role that psychological factors such as

distress, depression and somatization play in a patient’s ability to return to work and

reengage with life suggest the need for further prospective studies clarifying the

relationship psychological factors have in rehabilitation (Pincus, 2002). It is possible that

the more important component of health is the increase in daily functioning and

engagement in valuable life activities, rather than the reduction of pain.

Psychological Treatment

Cognitive Behavioral Therapy. Cognitive Behavioral Therapy (CBT) is a

combination of behavioral therapy and cognitive therapy focused on the relationships

between thoughts, feelings, behaviors and their effect on overall psychological well-

being. CBT is a skills based, psychoeducational approach with limited sessions focused

on teaching the patient to identify unrealistic or maladaptive thinking. Patients are then

instructed to challenge the unrealistic thinking habits to create more realistic perspective

and therefore change maladaptive behavior as a result of the new perspective. CBT has

been the gold standard of psychological treatment for patients with chronic pain. Some

studies on Cognitive Behavioral Therapy (CBT) have shown it aids in reducing comorbid

psychological symptoms such as distress and pain behavior while increasing physical

functioning (McCracken, 2002). Early systematic reviews of the effects of CBT for pain

have shown moderate effect sizes across several measurements such as pain experience,

15
expression of pain and cognitive coping, but lesser results among key outcomes such as

mood and catastrophizing (Morely, 1999). Early positive outcome results and lack of

alternative behavioral interventions likely led to the wide spread adaptation of CBT in

multidisciplinary treatment. However, more recent systematic reviews have shown that

when CBT is compared with active controls, it has small positive effects on disability and

catastrophizing, but not on pain or mood. When compared to treatment as usual and

waiting list, CBT has small to moderate effects on pain, disability, mood and

catastrophizing, but all effects except for mood are lost at follow up (Williams, 2012). In

addition, there are a significant number of patients who do not benefit at all from CBT

interventions (Turk, 2002; Vlaeyen, 2005). According to some investigations, older

behavioral interventions and newer acceptance-based interventions have actually been

more effective on follow up and able to target key outcome variables with greater patient

satisfaction (Eccleston, 2009; Veehof, 2011; Wetherell, 2011).

Behavior Therapy. A 2009 systematic review from the Cochrane Collaboration

by Eccleston et. al (2009) found that 52 RCTs assessing the effectiveness of

psychological therapies showed behavior therapy had a strong effect on pain, disability

and mood. Behavior therapy for chronic pain focuses on helping the patient to change

behavior related to pain. These programs often take the form of quota-based exercise

programs where the treatment is on increasing activity and decreasing pain contingent

behaviors (e.g. A patient laying down, stopping or avoiding an activity because of pain or

anticipating pain.) (Fordyce, 1968). Of the 52 studies identified, 40 studies met criteria

for quality assessment, and data was extracted. The review focused on the effects of

cognitive behavioral therapy (CBT) and behavior therapy (BT) for management of

16
chronic pain. The pooled data from these studies showed CBT had weak effects at post-

treatment in improving pain when compared with treatment as usual (TAU) and a

cumulative small effect size of 0.19 (CI 95% -0.32, -0.05), weak effects on disability

associated with chronic pain and a cumulative small effect size of 0.08 (CI 95% -0.27,

0.12), and weak effects on altering mood at the end of treatment and at follow up with a

cumulative small effect size of 0.14 (CI 95% -0.32, 0.05). Behavioral therapy that focuses

on increasing activity in chronic pain patients had significantly greater effect when

compared with TAU. The data extracted showed that BT had moderate effects on pain at

post treatment with a medium effect size of .55 (CI 95% -0.90, -0.19), moderate effects

on disability at post treatment with a medium effect size of .46 (CI 95% -1.00, 0.08), and

moderate effects on altering mood at the end of treatment with a medium effect size

of .44 (CI 95%-1.01, 0.13). Although there have not been enough studies to make any

claims as to the effect of BT versus an active control, these results are promising

(Eccelston, 2009). However, in another area of research, newer models of treatment such

as Acceptance and Commitment Therapy (ACT) and Mindfulness Based Stress

Reduction (MBSR) have also shown promise (Veehof, 2011). These approaches have a

significant impact on pain related psychological comorbidities that have been found to

impact disability, mood and other factors (Goyal, 2014).

Acceptance Based Interventions. In a similar fashion to behavior therapy,

instead of over-focus on symptom reduction, acceptance based interventions act by

encouraging patients to spend increasing amounts of time exercising wellness behaviors.

Acceptance and Commitment Therapy (ACT) and mindfulness skills training such as

Mindfulness Based Stress Reduction (MBSR) effectively exercise the patient’s ability to

17
accept and observe experiences, instead of reacting negatively to present moment

sensations (Hayes, 1999; Kabat Zinn, 1982). These interventions then focus on

developing values congruent behavior, thus improving overall wellbeing and

psychological outcomes (Veehof, 2011; Wetherell, 2011; Grabovac, 2011; Hözel 2011).

Although CBT is widely used and sometimes effective, alternative treatments like ACT

and mindfulness skills training such as MBSR have shown to be effective in treating a

patient’s chronic pain, with higher levels of patient satisfaction (Wetherell, 2011). A

2010 meta-analysis and systematic review of acceptance-based interventions for the

treatment of chronic pain found 22 studies, totaling 1235 patients. The results suggested

that although MBSR and ACT were not superior to CBT, they were “good alternatives”,

with a cumulative effect size (Cohen’s d) on pain of .37, comparable to CBT’s .33

(Morely, 1999) and BT’s .55. A more recent systematic review and meta-analysis of

meditation programs for psychological stress and well-being published in JAMA Internal

Medicine suggested that as models of meditation programs improve, it is likely the

effectiveness of those programs will also rise (Goyal, 2014). A recent overview of

systematic reviews on mindfulness interventions in healthcare showed mindfulness had a

small to moderate effects on several important pain related outcomes, including

depressive symptoms (d=0.37), anxiety (d=0.49), stress (d=0.51), quality of life (d=0.39),

and physical functioning (d=0.27) (Gotnik, 2015). Several well designed studies have

also shown sustained impact at follow up for anxiety (Miller, 1995), depression (Morgan,

2003), mood (Carlson, 2001), stress (Carlson, 2007), sleep (Ong, 2009), quality of life

(Grossman, 2004) and other commonly assessed health outcomes variables (Gotink,

2015). Although there has been significant progress in assessing mindfulness outcomes

18
and models of treatment, effect sizes for key chronic pain outcome variables remain small

in the chronic pain population - pain (d=0.16) and physical functioning (d=0.22) (Bawa,

2015).

Mechanisms of mindfulness. Part of creating more effective programs for the

treatment of chronic pain is making clear the change mechanisms involved in meditation

programs and other therapies. In an attempt to understand the difference in meditation

techniques, Bawa et al.’s (2015) systematic review and meta-analysis compared

outcomes in patients with chronic pain after Mindfulness Based Stress Reduction

(MBSR), Transcendental Meditation (TM) and mantra based meditation (MBM)

programs. It was clear that when mindfulness based meditation programs were compared

with other meditation systems, mindfulness based meditation had superior results across

most domains and populations studied. Notably though, CBT or medication was just as

effective in several domains (Goyal, 2014). So what makes one meditation more effective

than another?

A recent investigation looked into the mechanisms underlying MST in an attempt

to understand how meditation changes the brain, body and behavior. Hözel et al.’s (2011)

investigation and review of current research sought to integrate the existing literature into

a theoretical framework which suggested that there are 4 categories where mindfulness

exerts its effects: (1) attention regulation, (2) body awareness, (3) emotion regulation and

(4) change in perception of self (p. 538).

Studies on attention regulation found that meditators had enhanced performance

in measures assessing the brain’s attention network. This means that meditators were

19
more effective at sustaining attention and orienting their attention. They were able to

maintain their attention over longer periods of time with less attentional fatigue than non-

meditators. Studies on body awareness found that participants were more aware of their

body sensations but the awareness was not a hypervigilant attention or somatization, but a

non-reactive awareness. In addition, participants were better able to verbalize body

sensations and express emotional feelings verbally. Findings on the effects of

mindfulness on emotion regulation revealed an increase in positive appraisal of thoughts,

feelings and situations (i.e. non-judgmentally, with acceptance). In general, there was

found to be less internal reactivity to sensations. Although changes in perception of self

can be a hard variable to measure accurately, meditators reported they had more

detachment from a static sense of self. They were able to accept a wider view of

themselves in reference to emotions experienced, habitual reactions and personality traits.

In short, Hözel’s and other recent research has shown that MST correlates with

improved performance of executive attention as measured by the Attention Network Test

and Stroop Interference Test (Chan, 2007; Moore, 2009). These are psychological tests

commonly used to measure one’s ability to maintain attention and filter out distraction.

These and other studies revealed that there is substantial fMRI data supporting the

assertion that mindfulness has a measurable impact on key parts of the brain, notably the

Prefrontal Cortex (PFC). The PFC is often referred to as the “CEO of the brain” as it is

able to direct many of the other resources of the brain to specific tasks, including

managing emotions. Mindfulness practice has also been shown to increase body

awareness via narrative reports and pre and post measures of mindfulness, notably,

fMRIs showing increased activity in related brain structures. One such study by Creswell

20
et al. (2007) studied reactions in the brains of participants who reported a higher level of

dispositional mindfulness versus participants who reported a lower level of dispositional

mindfulness. Participants were shown faces of people in distress. Although many of the

same areas of the brain related to a healthy emotional response to seeing another human

being in distress were activated in both groups, the mindfulness group showed more

activation in the PFC. This suggests the mindful participants had a stronger ability to

inhibit the emotional response. In terms of emotion regulation, mindfulness has been

correlated with reduction in a host of negative affective symptoms, increases in positive

appraisal and non-reactivity to inner experiences. Lastly, mindfulness has been show to

change an individual’s “static perception “of oneself by detaching from conceptual

understandings and focusing on a more contextual, present moment perspective (Hözel,

2011).

It is these types of scientific explorations that move meditation from a mystical or

religious practice that requires faith or blind trust into understandable and more widely

accepted intervention techniques. Having a clear understanding of the operative

mechanisms allows for a better understanding of the processes that add to the

effectiveness of an intervention. The ability to identify which aspects of an intervention

are arbitrary or contraindicated is enhanced. Specifically, with mindfulness based

meditation practice, it is important to understand that this practice developed out of many

different cultural and religious traditions. Without research documenting the parsing out

the active ingredients of mindfulness interventions, it would be difficult to segregate the

cultural and historical influences from the effective practices that can be applied to a wide

audience of patients and practitioners.

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 Mindfulness Skills Training. Over the last decade, Mindfulness Skills Training

(MST) such as Mindfulness Based Stress Reduction (MBSR) (Kabat-Zinn, 1982) and

Mindfulness Based Cognitive Therapy (MBCT) (Teasdale, 2000) programs have been

found successful in improving pain related outcomes across patient population

demographics over a variety of chronic pain conditions. These programs effectively teach

patients mindfulness meditation skills, while focusing on acceptance rather than control

of pain sensations and pain related thoughts and behaviors (Wetherell, 2011).

History of mindfulness interventions. What nearly all acceptance-based

interventions have in common is an element of mindfulness (Baer, 2003). Though

unpalatable for some, especially to those averse to religion, mindfulness has a foundation

in Buddhist meditation. Many papers, studies and treatments do not cite the appropriate

antecedents to today’s effective therapeutic treatments. If the methods of meditation are

identified, it is with limited appreciation of the enduring tradition and depth of

understanding contained in these systematic practices. As a simple example, researchers

may appreciate that a Buddhist monk is able to develop the ability to generate an intense

positive affect after many hours of sitting meditation, but neglect to recognize the

associated supportive environment in which they live. Researchers may be unaware of

consistent daily practice during interpersonal interactions that come from a life

commitment to keep vows that are designed to exercise mindfulness continuously.

Instead, they may focus solely on number of hours spent in formal meditation (Lutz,

2009). Although new to the field of psychology (Kabat-Zinn, 1982), mindfulness based

meditation is not new. Mindfulness skills training is a word of mouth intervention that

has been able to stay relevant and effective since the 6th century B.C.E., transcending

22
time and cultures (Horner, 1957). In order to further understand the mechanisms involved

in the cultivation of mindfulness, it may be useful to bring to light some basic cultural

influences that have aided in the development and proliferation of these practices.

Theravada Buddhism is the oldest known tradition of Buddhism following

teachings from the tipitaka (Pali: ti, "three," + pitaka, "baskets") dating back to the 3rd

century (Bodhi, 2005). These are the earliest written documents of the oral tradition from

the time of the historical Buddha, Siddharta Gotama. These practices have been kept

alive both in a written form and in the form of meditative practices that have been passed

down in a lineage from teacher to student since the time of the Buddha (Bodhi, 2005).

From these traditional practices have come other branches of Buddhist meditation in

South Asia, Northern India, Nepal, China, Japan, Korea and more recently in the United

States, Europe and much of the developed world. Each branch of Buddhism has

developed with clear cultural influences, but nonetheless maintaining core practices

focused on the cultivation of mindfulness. This information is relevant because there are

many techniques and practices being studied in the scientific realm. Each religious

branch has adapted the simple concept of cultivating mindfulness that supports the needs

and culture for the community in which it served. From those practices have developed

different meditative practices specific to the culture. In China, Mahayana Buddhism

flourished, in Japan and Korea, Zen Buddhism, in Tibet, Vajrayana and Sri Lanka, Burma

and Thailand, Theravada Buddhism.

Presently, in American approaches to mindfulness based meditation, it is clear

that the approach is evolving to an evidence supported practice that focuses on cognition,

attention, acceptance and emotional regulation. Not until recently has the impact of

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different meditation techniques on chronic illness been evaluated, as is currently

happening in western adaptations of mindfulness practice (Goyal, 2014).

History of mindfulness interventions in medicine. In the early 1970’s, Herbert

Benson MD, a cardiologist, started doing research with yogis who claimed that they were

able to control their respiratory rate, blood pressure and other previously believed

autonomic processes that were not able to be manipulated intentionally. These were

transcendental meditation practitioners who used a variety of meditation practices.

Benson’s research showed that yogis with varying levels of practice were able to trigger

their parasympathetic nervous system, lowering their oxygen intake, blood pressure and

other vital signs. Benson called this intentional triggering of the parasympathetic nervous

system “The Relaxation Response.” Preliminary results of his research were published in

a 1972 article (Benson, 1974) and, later book titled, The Relaxation Response (Benson,

1992). Benson currently has a large multidisciplinary treatment center, The Benson

Henry Institute for Mind-Body Medicine attached to the Massachusetts General Hospital.

However, it was not until recently that Benson was even taken seriously as a researcher.

History has it that, Benson was at first denied tenure at Harvard because his efforts were

was considered fringe research. He had difficulty convincing his colleagues of its

importance (Andresen, 2000).

Mindfulness Based Stress Reduction. In the late 1970’s Jon Kabat-Zinn

developed a new model of mindfulness practice at UMass Medical Center. It continues as

one of the most influential mindfulness training programs in the country as the Center for

Mindfulness in Worcester. Intensive Mindfulness Based Stress Reduction training and 8-

week mindfulness courses based on this training have been found to be effective in

24
treating a large spectrum of psychological disorders, and stress related illnesses (Baer,

2003). As already explored above, MBSR has shown that this approach is effective in

treating chronic pain (Baer, 2003; Veehof, 2011; Goyal, 2014), anxiety (Kabat-Zinn,

1992; Miller, 1995) and increasing quality of life (Goyal, 2014).

Kabat-Zinn’s pioneering work in extracting the heart of Buddhist practice from

the esoteric cultural elements of the Buddhist religions has been essential to developing a

pragmatic approach to the cultivation of mindfulness in the non-secular realms of western

medicine. In developing a non-secular approach founded on the heart of the practice,

Kabat-Zinn has avoided many of the pitfalls that could arise from blending religion with

medicine. By skillfully naming his intervention Mindfulness Based Stress Reduction,

maintaining the essential mental exercises and removing the religious aspects of the

practice, he was able to bridge medical and contemplative traditions while making these

mental practices more palatable to the general American public. Jon Kabat-Zinn defined

mindfulness in terms that were approachable as, “the awareness that emerges through

paying attention on purpose, in the present moment, and nonjudgmentally to the

unfolding of experience moment by moment” (Kabat-Zinn, 2003, p. 145). In addition, he

avoided cultural aspects such as vows, chanting and esoteric practices that may conflict

with the American Christian and scientific culture. Opposed to a temple or church, Jon

Kabat-Zinn started teaching these practices in a medical hospital setting, which is

arguably the most respected area for health information dissemination in current

American culture.

Integrative Approaches. With the popularization of these practices other

established interventions co-opted many of the components of mindfulness. In Baer’s

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(2003) conceptual and empirical review, she explored several psychotherapeutic

mindfulness based interventions, including Mindfulness Based Stress Reduction (Kabat-

Zinn, 1982) and Mindfulness Based Cognitive Therapy (Teasdale, 2000). She also

reviewed other well-known interventions that incorporate mindfulness – Dialectical

Behavior Therapy (DBT) (Linehan, 1993), Acceptance and Commitment Therapy ACT

(Hayes, 1999) and Relapse Prevention (RP) (Witkiewitz, 2005). Baer also reviewed

literature showing preliminary results of early studies where mindfulness was effectively

combined with previous therapeutic techniques to enhance current models of treatment. It

has been suggested more recently that mindfulness interventions could work well in

tandem with other behavioral interventions (Veehof, 2011).

Perhaps the best current example of an integrative approach is the work of

Teasdale, Williams and Segal (2000) who effectively brought together cognitive

behavioral therapy (CBT) and mindfulness in what they call Mindfulness Based

Cognitive Therapy (MBCT). MBCT is another manualized group skills-training program.

It is based on the integration of Cognitive Behavioral Therapy components and the 8

week Mindfulness Based Stress Reduction program (Teasdale, 2000). Preliminary

research has shown this approach to be particularly effective in reducing relapse in

patients who have had a major depressive episode (Teasdale, 2000; Coelho, 2013). There

is also a recent multidisciplinary combination of mindfulness based therapy and Physical

Therapy to treat patients with chronic pain called Mindfulness Based Functional Therapy

(MBFT) (Schütze, 2014). These two approaches are promising for two reasons. First,

awareness is building that mindfulness skills training is an easy adjunctive treatment to

already effective interventions to help enhance outcomes. Second, there is growing

26
awareness that mindfulness, like other interventions, has clear limitations. The idea of

mindfulness being a cure all treatment, effective with all types of illnesses runs the risk of

it being synonymous with snake oil. This view of mindfulness as a potential cure all is

even more dangerous than neglecting its potential benefits.

Limitations of MST. Mindfulness Skills Trainings (MST) are effective in

improving outcomes in chronic pain patients but do not directly address physical

function. Over the last decade Mindfulness Skills Training (MST) programs, particularly

Mindfulness Based Stress Reduction (MBSR), have been found to be successful in

improving pain outcomes across patients with a variety of chronic pain conditions

(Goyal, 2014). These programs effectively teach patients mindfulness meditation skills

while focusing on acceptance rather than control of pain sensations and pain related

thoughts (Wetherell, 2011). However, they face several limitations. First, MBSR

programs are typically 8-12 weeks long, which may place both time and financial

burdens on patients, particularly those with low income (Morledge, 2013). In other

words, asking patients in significant pain who are often on living on a disability wage

($1000 to $1200 per month) (Salkever, 2014) to invest the time and money in an 8 week

course of treatment that is often priced above $545 (Center for Mindfulness, 2014) and

not covered by insurance is a significant barrier to treatment. There is evidence that

within MST programs patients experience significant benefit as soon as the fourth week

of mindfulness training (Baer, 2012; Fjorback, 2011), suggesting that shorter

interventions may provide a more optimal treatment plan and be cost effective in this

population. There is a lack of evidence showing that an intervention shorter than 4 weeks

has any significant impact on symptoms. Although they demonstrate improvements in

27
self-reported pain and increased quality of life, most mindfulness approaches are limited

by a failure to address improvement in objective physical functioning.

Activity and Chronic Pain

Prior research has not been focused on measuring objective function in chronic pain

patients. The United States Department of Public Health’s research has shown a clear

relationship between daily endurance-based activity such as a 30-minute brisk walk or a

15-minute run and several health related outcomes such as mortality, cardiovascular

diseases, and cancer (United States, 1996). Studies on chronic low back and neck and

shoulder pain have shown 2 to 3 hours of exercise a week can reduce the risk of chronic

pain (van den Heuvel, 2005). Geraets et al. (2005) studied the effects of a graded exercise

program on patients (n=176) with chronic shoulder pain. Patients were placed in two

groups, a behavioral therapy graded exercise group (n=87) where patients were asked to

increase their exercise each week and a usual care group (n=89). The focus of the

behavioral therapy graded exercise approach was to encourage patients to engage in,

“their own preferred shoulder activities in daily life at home or at work, irrespective of

the pain experience” (p. 88). The usual care group maintained treatment as usual

according to current standard of care. The mean differences between groups in the

performance of shoulder related activities related to the patient’s main complaints reach a

statistically significant effect (d =0.30). The patients in the graded exercise group were

able to increase exercise and reduce symptoms simultaneously. The patients in the usual

care group did not increase exercise and showed no reduction in symptoms. To some

patients and doctors this is a counter intuitive approach to pain treatment because our

natural human inclination is to rest when we are in pain.

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 When working with patients who have chronic pain, deconditioning can be a

significant risk factor for further pain conditions (Turk, 2006). Aerobic exercise has been

shown to be the mainstay of chronic pain treatment for multiple conditions including low

back pain, fibromyalgia, and chronic myofascial conditions, with walking being the most

commonly prescribed (Nijs, 2012). In a systematic review on exercise for treating

fibromyalgia, Busch et al. (2003) found strong evidence supporting the use of exercise

therapy in treating patients with fibromyalgia. In a broad search of literature and journal

databases, they found 16 studies totaling 724 participants. Four of the articles were high

quality aerobic training studies that reported a 17.1% increase in aerobic performance

versus a .5% increase in control groups, a 28.1% increase in tender point pain tolerance

versus a 7% increase in control groups and an 11.4% decrease in pain versus a 1.6%

decrease in control groups. Exercise is an effective treatment for various chronic pain

disorders, including fibromyalgia, chronic neck pain, osteoarthritis, rheumatoid arthritis,

chronic low back pain (Nijs, 2012), spondylolysis, spondylolisthesis (O'Sullivan, 1997),

chronic soft tissue shoulder disorders and chronic lateral epicondylitis (Mior, 2001).

Like many people, patients with chronic pain often have difficulty distinguishing

between hurt and harm. It can be easily concluded that because the activity hurts, the

activity is causing more harm. However, it is often the case that although painful at first,

increased activity is likely to reduce pain, increase strength and believed to prevent the

increase of pain in the future (Turk, 2006).

When exercise is quota-based (i.e., not contingent on pain level), results are even

more promising (Eccleston, 2009; Richards, 2013; Kent, 2012; Rainville, 2004). A

randomized trial by Lindstrom (1992) compared the progress of (n=103) patients placed

29
in either an activity group (n=51) or a control group (n=51). The approach was an

operant-conditioning graded quota-based exercise program (i.e. patients were rewarded

for reaching certain activity goals). Their progress was measured over a 3-year period by

the amount of sick time taken from work or school. The activity group was absent for a

significantly lower average amount of time (12.1 weeks) versus the control group (19.6

weeks). This trial’s results, along with evidence from numerous other studies, suggests

that increasing chronic pain patient’s physical function, no matter the diagnosis, is

essential to improving quality of life and reducing disability (Nijs, 2012).

Assessment of Chronic Pain

IMMPACT

The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials

(IMMPACT) is an international committee of chronic pain experts who came together to

develop a consensus on recommendations for chronic pain research (Dworkin, 2005). In

2003, IMMPACT convened to identify a standard set of important core outcome

variables that would, “facilitate comparison and pooling of data” (Turk, 2003, p. 338). In

2003, IMMPACT identified 6 outcome domains considered important for chronic pain

research: pain, physical functioning, emotional functioning, participant ratings of global

improvement, symptoms and adverse events, and participant disposition (including

adherence to treatment regimen and reasons for premature withdrawal from a trial) (Turk,

2003). The recommendation was made by IMMPACT consensus that researchers use

more than one measurement for each domain. For the domain of physical functioning it

30
was suggested that both a generic measure of physical function and a disease specific

measure of physical function be used. A generic measure is a measure that can be easily

compared to other disease populations. A disease specific measure is used to catch

disease specific impact on physical function that may not be captured by the generic

measure.

Use of Quality of Life measures in Chronic Pain

In efforts to capture the effects of a particular intervention on a patient’s overall

health, including psychosocial functioning and physical functioning, quality of life

measures (QOL) and health related quality of life measures (HQOL) have been used to

address several domains. The Short Form Medical Outcomes Scale (SF-36) is a

commonly used generic QOL measure that addresses multiple domains. It is utilized as a

quality of life and an independent measure of function. This 36-item scale is designed to

assess general health related quality of life. The SF-36 is a multiscale health survey

validated for many populations that measures eight health concepts: including limitations

in physical activities because of health problems; limitations in social activities because

of physical or emotional problems; limitations in usual role activities because of physical

health problems; bodily pain; general mental health (psychological distress and well-

being); limitations in usual role activities because of emotional problems; vitality (energy

and fatigue); and perceived general health (Ware, 1992).

In the field of pain other QoL measures are used as disease specific quality of life

measures. These disease specific measures are used to assess the specific impact of a

31
disease over several domains. As an example, the Fibromyalgia Impact Questionnaire

(FIQ) is a validated disease specific 20-item self-report HRQoL measure used to assess

physical function, overall well-being and frequent fibromyalgia symptoms (pain, fatigue,

stiffness and mood) (Bennett, 2005). The Inflammatory Bowel Disease Questionnaire

(IBDQ) is another disease specific validated 32-item self-report HRQoL measure for

patients with irritable bowel syndrome. In the IBDQ the questions are divided into 4

domains (bowel, emotional, systemic, and social) and a mean score can be calculated for

each domain to assess impact on daily function (Guyatt, 1989). Both of these measures

focus on capturing important quality of life measures thought to be important to measure

the specific impact of the disease and impact of treatment on the disease.

Of the six domains that IMMPACT deemed as important for the assessment of the

chronic pain and the impact of a given therapeutic intervention, pain, emotional

functioning, participant ratings of global improvement, symptoms and adverse events,

participant disposition are by nature subjective domains. They require the patient to

express their subjective experience in order to assess the impact of disease or

intervention. Physical function has also been treated in the same fashion, but with current

advances in technology physical function can be treated more objectively. However, in

2005, IMMPACT went further than recommending assessment domains and identified

specific measures for the six domains including assessments for physical function

(Dworkin, 2005). All measures suggested were self-report measures.

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Assessment of Physical Functioning

Physical functioning and one’s ability to engage in activities of daily living is an

essential component to health and well-being. Unfortunately, this perspective has been

lightly addressed in chronic pain and mindfulness based interventions. While some

mindfulness skills training studies address suggested IMMPACT domains with self-

reported physical functioning as an outcome variable, more objective performance

measures of functioning are largely unaddressed in the research literature. A recent

systematic review of RCTs of meditation interventions showed that out of 18,753 studies,

of the 47 MST investigations with sufficient comparison conditions, only 11 measured

self-reported QoL and none measured physical function independently with self-report or

more objective performance measures (Goyal, 2014). A more recent study showed that

out of 2,463 studies identified, only 5 studies reported on the effects that mindfulness

training has on the chronic pain population’s physical function. The results showed a

small effect (heges g = .22) (Bawa, 2015). Another meta-analysis of MST on the broader

category of health related outcomes showed five well controlled RCTs included measures

such as the Short Form 36 Health Survey and the Medical Symptom Checklist showed

significant improvements but none measured objective function (Grossman, 2004). Even

in a recent Mindfulness Based Functional Therapy protocol with an integrated

physiotherapy component and several self-reported functioning questionnaires that

included a pre objective functional assessment, a post objective functioning assessment

was not included (Schütze, 2014). Although none of these studies focused on assessment

of physical functioning the results from these studies show a scant attention to physical

functioning outcome measures.

33
Self-Report Versus Objective Measurements

An objective measurement as defined by The Program Committee of the Institute

for Objective Measurement is, “The repetition of a unit amount that maintains its size,

within an allowable range of error… no matter who or what relevant person or thing is

being measured” (Definition of objective measurement, 2000). In contrast, subjective

measures’ unit of measurement changes from person to person. As an example, a

common question asked in the measurement of physical function in chronic pain is,

“How much does your pain interfere with your ability to participate in general

activities?” (BPI) (Cleeland, 1994) Then the patient is asked to rate 1 through 10, ten

being high interference, and one being low. This is a subjective question because the

value of the unit is determined subjectively by the patient. This could be heavily

influenced by mood or any number of factors that may affect perception or reporting. In

an objective measurement the unit of measure is determine a priori. As an example, in the

objective measurement of physical function a unit of measure could be steps. How many

steps an individual took on a particular day can used to assess level of physical function.

There is little disagreement on what constitutes a step. Objective measurements are

preferred when possible because they are accurate, standardized, less subjective and can

be easily compared.

When possible, it is preferable for clinicians and scientists to measure something

directly rather than take someone’s word for it (i.e. self-report). Human beings are

notorious for poor memory recall. This is no exception when working with self-report

measures. A recent systematic review by Prince et al. (2008) looked at direct

measurement of physical function versus self-report measures for assessing physical

34
function in adults. Out of 4,463 potential articles data from 187 studies met criteria. The

studies showed a moderate to low correlation of self-reported activity to direct

measurement of activity. In reporting, no clear pattern emerged for mean differences. In

other words, people did not regularly over report or under report. The self-reports were

often inaccurate by as much as 37% to 78% for males and 58% to 113% for females

(Prince, 2008). This level of inaccuracy is difficult to accept where other more objective

measures are available that are not intrusive and do not require a clinical assessment. One

direct measurement that was also employed in this study is an accelerometer which is a

digital monitoring device that is commercially available and a more accurate objective

measurement.

Digital Monitoring Devices and Other Objective Measures

New advances in technology and inexpensive commercially available digital

monitoring devices now provide the opportunity to make biological measurements more

convenient, accurate and cost effective for patients. Pedometers have been used for years

as an aid to track and increase activity for a variety of patients. The use of pedometers is

associated with significant increase in physical activity and decrease in body mass and

blood pressure (Bravata, 2007). Piezoelectric accelerometers have been used to measure

proper acceleration (“g-force”) in several different fields of industry since the early

1940’s (Walter, 2007). Accelerometers already have several clinical applications

including validating self-report measures, assessing physical function via expended

energy (EE) in different populations, as novel way for clinicians to track physical activity

and a potential motivator for behavior, treatment alliance and adherence (Appelboom,

35
2014; Cadmus-Bertram 2015; Kurti, 2013). Although pedometers and accelerometers

have been around for a long time, adherence to their use has been problematic due to

their bulkiness lack of real time feedback though smartphones and popular fashion

appeal. In addition, there has been a lack of standardized method of reporting the vast

amount of data captured by previous generations of accelerometers making comparison

across studies problematic (Lee, 2014). With the miniaturization of these devices and the

advent of low energy Bluetooth 4.0 peripheral devices such as digital monitoring devices,

patients can track their activity and receive real time feedback on the smartphones. They

can compare to previous days, weeks or friends’ activity in friendly competition through

online forums. Consumer activity trackers such as the FitBit use a tri-axis piezoelectric

accelerometer and sophisticated algorithms to measure the number of steps one takes

while wearing these devices, with only a 10.1% error rate (Lee, 2014). In addtion, at

$19.99 (Amazon as of August, 2015), recent models have become relatively inexpensive.

Even though these consumer-based activity trackers are inexpensive, convenient and

accurate, “the widespread integration of this technology into medical practice remains

limited” (Appelboom, 2014). Utilizing digital monitoring devices looks like a logical

next step in assessment of physical function. Further investigation of the field of physical

function assessment in chronic pain seems to suggest that a systematic review assessing

the utilization of the current tools used to measure physical function would be timely.

Other validated objective measures are availible for the assessment of physical

functioning. The Six-Minute Walk Test (6MWT) is an objective measurement of physical

function where the patient is asked to walk for 6 minutes and the distance is then

measured. The six-minute walk test has been validated for healthy (Gibbons, 2001) and

36
frail elders (Balke, 1963), spinal injuries (van Hedel, 2005), fibromyalgia (King, 2002)

and several other populations. The Short Physical Performance Battery (SPPB) assesses

patient’s standing balance, gait speed and ability to rise from a chair. The SPPB is an

objective measurement of physical function that is performed by a trained lay observer

and takes approximately 10 – 15min. to administer (Guralnik, 1994). Although these and

other objective assessment tools are available they may be underutilized.

To date there is yet to be study that assesses measurement of function in chronic

pain according to the IMMPACT guidelines for chronic pain research. In addition,

although IMMPACT makes a good first step towards developing appropriate guidelines

for the assessment of function in chronic pain, the guidelines currently fall short by only

considering self-report measurements rather than more objective performance assessment

measures. It is unclear whether or not the field of chronic pain has followed IMMPACT’s

efforts to find common assessments, or further by including performance measures of

physical functioning.

Systematic Reviews

In the past 20 years of their existence The Cochrane Collaboration has become a

global network of researchers, professionals, patients and leader in using high quality

information to make health decisions (About Us, 2016). With a focus on cultivating a

rigorous methodology for performing systematic reviews they have become a steady

source of support for quality systematic reviews. Evidence based health care, medicine

and clinical practice depends on systematic reviews (Moher, 2009)). A systematic review

37
is defined as, “A high-level overview of primary research on a particular research

question that tries to identify, select, synthesize and appraise all high quality research

evidence relevant to that question in order to answer it” (Higgins, p. 1.2.2, 2008). The

process of performing a systematic review goes through 8 basic steps. Uman (2011)

explores the 8 steps to preforming a systematic review and meta-analysis. The first step

in performing a systematic review is to formulate a research question/hypothesis. This

gives direction to the review and will help inform the review title. Second, the researcher

will define inclusion and exclusion criteria for studies to be included in the review based

on four components: population, intervention, study design and outcomes. The third step

is to create search terms and a search strategy to identify relevant articles that address the

research question within the defined inclusion and exclusion criteria for studies. Because

each digital database searched has a different method for identifying articles (i.e. search

language and categorization of study topic and content) it is important to consult an

experienced librarian. It is often suggested that at least 3 digital databases are searched

(Khan, 2011). The fourth step is to eliminate studies that have been identified through the

database search as not meeting inclusion criteria created before the search. This includes

removing duplicate studies, reading all abstracts of identified studies and removing

irrelevant studies. Part two of this step is reading the full articles of those studies that may

meet criteria and removing any studies that still do not meet criteria after the full article

has been reviewed. The fifth step is to extract important information such as demographic

data and information particular to your research question created in step one. If one is

performing a meta-analysis, effect sizes and other quantitative information should be

extracted in order to pool information. The sixth step is to assess study quality. This is an

38
essential step to rate the quality of the findings from each of the studies one includes in

the systematic review. This ensures that poor quality studies do not have the same

influence as well designed studies. The seventh step is to analyze and interpret the results

of the study. Important trends in the qualitative and quantitative data gathered begin to

present themselves. The last step is the dissemination of information. This is most often

accomplished by publishing the review in a peer reviewed journal or using a service such

as the Cochrane Database of Systematic Reviews to ensure the review is regularly

updated (Uman, 2011).

With the consolidation of information that goes into creating a systematic review,

it is not a surprise that these reviews currently have a large impact on the field of

medicine and medical decision making. They are considered the highest level of evidence

based study for the reporting on therapeutic outcomes (Burns, 2011). However, it is

important to note that the impact of systematic reviews on clinical decision making is not

long lived because they need to be regularly updated (Viswanathan, 2012).

PRISMA

Sacks et al. (1987) evaluated 86 meta-analyses and scored them to assess the quality

and potential impact of the results and suggestions. At this point meta-analyses were still

a new type of study without clear guidelines for reporting. Sacks study found only 24

meta-analyses met acceptable study design and reporting. This evaluation revealed that

there were several methodological proesses that could be improved. In 1996, with a clear

need to enhance the quality of a new type of study that attempted to analyze and combine

39
results of studies pertaining to a particular subject area, the Quality of Reporting of Meta-

Analyses (QUOROM) committee was convened. This was the first attempt to create a

consensus group statement for improving the quality of reporting Meta-Analyses. The

QUOROM committee was an international group of clinicans, statisticians and editors.

The resulting QUOROM checklist was an attempt to provide guidelines for adressing the

methodological shortfalls of previous reviews (Moher, 1999). In an effort to further the

quality of meta-analyses and develop guidelines for systematic reviews, the Preferred

Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was

created from a three day meeing of 29 participants, including review authors,

methodologists, clinicans, medical editors and readers. In efforts to make way for

advances and methodology and create a comprehensive quality assuarance rubric for

those reporting on systematic reviews, the participants developed the PRISMA statement,

which includes a 27-item checklist and a four-phase flow diagram (Figure 1 and Figure 2)

(Moher, 2009). The following systematic review adheres to the PRISMA rubric for

performing and reporting on systematic reviews.

40
Figure 1. Included in the PRISMA statement is the flow chart of the process of search, exclusion
and inclusion for quality assessment (Moher, 2009).

41
Figure 2. Included in the PRISMA statement is the 27-item checklist. The checklist provides a
detailed list of PRISMA reporting criteria for reporting on a systematic review (Moher, 2009).

42
 Summary

The World Health Organization and the National Center for Complementary and

Integrative Health (NCCIH) have identified chronic pain treatment priorities (Gureje,

1998; Research Funding Priorities, 2015). New directions and collaborations in medical

treatment have moved towards multidisciplinary treatment that includes psychotherapy

(Guzman, 2001). Acceptance based techniques including MST have been shown to be

just as effective as current gold standards of psychological treatment (Veehof, 2011;

Goyal, 2014). Studies above have shown that 8 week MSTs have been effective in

treating chronic pain and common related comorbidities which likely compound the

perceived pain of patients. (Baer, 2003; Veehof, 2011; Goyal, 2014; Teasedale, 2000;

Kabat-Zinn, 1992; Miller, 1995), With MST having clear limitations in treating chronic

pain, pairing mindfulness skills with a component of increased activity is indicated.

Exercise and increasing patient activity have also been shown to be effective treatments

for chronic pain patients. (Rainville, 2004; Nijs, 2012; Mior, 2001; Turk, 2006;

O’Sullivan, 1997) No studies found have yet focused on the assessment functional

measures for mindfulness based interventions. The above literature review of chronic

pain, current treatments, and measurements confirms that there is support for mindfulness

based interventions in chronic pain treatment. However, there is limited data on the

effects of mindfulness training on physical functioning. A systematic review that clearly

focuses on the measurements being used to assess function in the field of chronic pain

and mindfulness interventions will help give a clearer picture as to the actual effects

mindfulness has on physical functioning and what recommendations can be given for

future research. The remainder of this paper constitutes a systematic review meant to

43
answer the question, “Can we reliably and validly assess Mindfulness Skills Training’s

effect on physical function in chronic pain patients?”

44
 CHAPTER THREE

METHODS

This methods section will not follow the same methods format used for individual

studies focusing on interventions of a specific sample of participants. As described above,

in a systematic review the subjects being studied are studies. The studies need to be

examined differently than a group of individuals (i.e. type of study, quality…). The

following is an industry standard example of the methodology for reporting a systematic

review process according to PRISMA. In addtion, as explained above, the process for

performing a systematic review is very specfic and differs significantly from a normal

review of literature and this should become more evident in the methods section below.

Preparation for Systematic Review

The guidelines were follow for performing a systematic review as laid out in

Khan’s 2011 book Systematic reviews to support evidence-based medicine (Khan, 2011)

and the Cochrane Handbook for Systematic Reviews of Interventions (Higgins, 2008).

Ana-Maria Vranceanu, an experienced researcher in clinical interventions with

experience conducting systematic reviews, served as a consultant. The reason for using

both Khan’s method and that from the Cochrane Collaboration is that the methods given

in both approaches are complementary. Khan’s method gives a general outline, laying out

industry standards and basic components of a systematic review. The Cochrane

Collaboration gives a more detailed and specific methodology that is high in quality and

sufficiently thorough and complex to merit peer review.

45
 Search Strategy. The clinical research question, inclusion and exclusion criteria,

search strategy and criteria for the systematic evaluation of clinical trials will be created a

priori in accordance with industry standard (Rys, 2009; Higgins 2008; Khan, 2011). This

systematic approach is maintained in efforts to minimize bias and form an evidence based

answer to the research question defined below. Inclusion and exclusion criteria for

potential studies is predefined in the four domains of study design, population,

intervention and outcomes (Khan, 2011; Higgins, 2008). To ensure a comprehensive

search of existent literature, a search strategy is systematically developed and major data

bases searched. The data of studies that meet the inclusion and exclusion criteria will be

extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA) criteria (Moher, 2009) (Figure 1 and Figure 2). The resulting studies that meet

criteria and quality will then be included in the study review to answer the evidence

based review question, “Can we reliably and validly assess Mindfulness Skills Training’s

effect on physical function in chronic pain patients?”

Execution of Systematic Review

Search Strategy. Reports of original research studies investigating the effects of

MSTs on physical function in the chronic pain population were identified for the review.

Articles published in peer-reviewed journals as of August 10th 2015 were identified via

searches of four electronic databases - PubMed, PsychINFO, EMBASE and Web of

Science (See Figure 3 in Appendix A). Search criteria included population, intervention,

study design and physical function terms in accordance with the inclusion and exclusion

criteria (Figure 3 and Figure 4). Two scientific librarians with expertise in complex

electronic database searches were consulted to develop a comprehensive search for

46
individual databases. A total of 2818 study abstracts were retrieved. There were 706

duplicate studies, and 353 studies were removed. One study was eliminated because no

abstract was available. 2464 studies remained for screening by abstract, after removing

duplicates (Figure 5).

Question Inclusion Criteria Exclusion Criteria

Component
The Population Adult Patients with Chronic Pain
The Interventions Mindfulness Based Intervention
(Including, mindfulness based
cognitive therapy (MBCT),
mindfulness based stress reduction
(MBSR), mindfulness based functional
therapy (MBFT) or other mindfulness
skills training)
The Outcomes Pre and Post measure of physical
function (limitation of daily activities)
 performance measure
 self-report
The Study Design Experimental Study with control group 
including: RCT and CCT
 (18+) Patients without
chronic pain
 Acute pain conditions
 Mix populations (i.e.
chronic illness (e.g.
chronic pain patients and
chronic illness patients
without chronic pain)
 No mindfulness
intervention
 Regular meditation was
not expected
 Intervention was less than
3 weeks
 No daily practice expected
 Measure of physical
function
 No pre and post measure
No control group

Figure 4. Inclusion and exclusion criteria for studies to be included and excluded during literature
search. Studies that met the four criteria were included in the quality assessment.

Selection Criteria/Study Eligibility. A detailed inclusion and exclusion criteria

was defined by the authors a priori (Figure 4). There were 2,449 studies that did not meet

inclusion criteria. The initial screening of abstracts identified that 1,100 studies did not

47
use an adult non-cancer chronic pain population. 1,102 studies did not meet the criteria

for an acceptable mindfulness intervention. There were 189 studies classified as reviews,

protocols, commentary or “other.” As a result, a total of 58 articles were retrieved in full.

After reviewing the full articles, 43 additional articles were excluded according to

original inclusion and exclusion criteria. Three articles were removed because the full

article was not retrievable, 4 studies did not meet population criteria, 3 studies did not

meet intervention criteria, 29 studies had no measure of physical function and 4 studies

met criteria for population and intervention, but were not RCTs. A total of 15 articles

were included in the final analysis (Figure 5).

48
` PubMed EMBASE PsychINFO Web of Science

N= 655 N=1257 N= 52 N= 854

Articles

N= 2818

Duplicates

N= 353

Abstracts collected

N=2464

Full-text articles assessed for eligibility

N=58

Studies included in qualitative

analysis

N=15

Figure 5. The flow chart of this systematic review shows the process of search, exclusion of
studies and inclusion of studies for quality assessment and extraction of data.

49
Data Extractions/Quality Assessment. Abstracts were evaluated independently for

eligibility by two reviewers (W.C.J. and A.M.). Any citation considered potentially

relevant by each reviewer was retrieved in full text form in order to determine whether it

was eligible to be included in the review for quality assessment. All disagreements were

resolved upon discussion and review of the articles. Because many studies could have

been excluded for more than one reason, a hierarchy of exclusion criteria was used to

enhance interrater reliability (Figure 6). A log of excluded studies along with reasons for

their rejection is available upon request. Interrater reliability of abstracts was 93%, and

assessed using 15 studies.

Criteria Order of Exclusion

Population 1st

Intervention 2nd

Outcome 3rd

Study design 4th

Reviews and “other” 5th

Meets Criteria 6th

Figure 6. Hierarchy of exclusion aided in the exclusion of studies by level of importance. This
hierarchy help to identify exclusion criteria and organize and track the reason for exclusion as
many studies fit more than one criteria.

Full articles were retrieved and reviewed independently by the two investigators

(W.C.J. and A-M.V.) for eligibility for inclusion in the group assessed for quality. Data

was extracted on study design, population, age, type of intervention, duration of

50
 treatment, control condition, sample size and results of measure of function (Table 1.). A

standardized 10-item checklist of predetermined criteria shown in Figure 7 was used to

assess the methodological quality of each individual study. The checklist is adapted from

a previously established criteria list for systematic reviews (Kuijpers, 2004; Scholten-

Peeters, 2003), and modified for the chronic pain population. Quality assessment for each

individual study was done as follows.

Table 1

Characteristics of Selected Studies

Author Study Quality Population Mean Intervention Sessions Control n= Summary of

design Score age & condition Functional
Duration Measures
Astin, 2003 RCT High Fibromyalgia 48 MBSR + 8 6MWT: No
(9/10) Qigong sessions Education 128 improvements
2.5hr in both groups

FIQ: Both
groups
significantly
improved; no
significant
difference
between
groups

Brown, 2013 RCT (8/10) Musculoskeletal -- Mindfulness 8 weeks TAU 28 SF-36 (PCS):
Pain based Pain No
Management improvement
Cash, 2015 RCT (8/10) Fibromyalgia -- MBSR 8 weeks Waitlist 91 FIQ (PFS):
Improvement
not significant
Esmer, 2010 RCT (8/10) Failed back 55 MBSR 8 weeks Waitlist 25 RMDQ:
surgery 1.5 - Significant
syndrome 2.5hrs between
groups

51
Author Study Quality Population Mean Intervention Sessions Control n= Summary of
design Score age & condition Functional
Duration Measures

Fjorback, RCT (8/10) Somatization, 40 MBSR 8 weeks CBT & 119 SF-36 (PCS):
2013 functional 3.5hrs TAU Both groups
somatic significantly
improved; no
significant
difference
between
groups
Gardner-Nix, RCT (7/10) Chronic Pain 52 MBSR 12 weeks Waitlist 119 SF-36 v2
2014 (PCS):
Improvement
not significant
Goldenberg, RCT (8/10) Fibromyalgia 47 SR-CBT 10 weeks Waitlist 120 FIQ:
1994 2hrs Significant
Improvement
la Cour, 2015 RCT (8/10) Chronic Pain 48 MBSR 8 weeks Waitlist 109 SF-36 (PCS):
2.5 hours Improvement
not significant

Morone, RCT (10/10) Chronic low 75 MBSR 8weeks Waitlist 37 SPPB: No

2008 back pain 1.5hrs significant
differences
between the
two groups
SF-36 (PCS):
Improvement
not significant
SF-36 (PFS):
Significance
between
groups
RMDQ:
Improvement
not significant
Morone, RCT (9/10) Chronic Low 76 MBSR 8 weeks Education 35 RMDQ:
2009 Back Pain 1.5hrs Improvements
in both
groups, no
statistical
significant
difference
Plews-Ogan, 3 arm (7/10) Chronic 47 MBSR 8 week Massage 30 SF-12 (PCS):
2005 RT Musculoskeletal 2.5 hrs & TAU No
pain improvements

52
Author Study Quality Population Mean Intervention Sessions Control n= Summary of
design Score age & condition Functional
Duration Measures

Schmidt, 3 arm (9/10) Fibromyalgia 52 MBSR 8 week Active 177 FIQ:

2011 RCT Control Improvements
& in the MBSR
Waitlist group, but no
significant
difference
between
groups
Weissbecker, RCT (8/10) Fibromyalgia 18+ MBSR 8 week Waitlist 91 FIQ (PFS):
2002 2.5hr No significant
between
group
difference
Wells, 2014 RCT (9/10) Migraines 46 MBSR 8week TAU 19 MIDAS:
Significant
Improvement
Zangi, 2011 RCT (8/10) Inflammatory 54 VTP – 10 Routine 71 NRS (of self-
rheumatic joint MBGI session Care care ability):
disease + booster Significant
treatment
effects

Note. RCT: randomized control trial; Quality rating was based on a predefined 10 point criteria
(Figure 7); MBSR: Mindfulness Based Stress Reduction; MT: Mindfulness training; MORE:
Mindfulness-Oriented Recovery Enhancement; SR-CBT: Stress Reduction Cognitive Behavioral
Therapy; VTP – MBGI: Vitality Training Program Mindfulness Based Group Intervention;
TAU: Treatment as usual; 6MWT: Six minute walk test; FIQ, Fibromyalgia Impact
Questionnaire; SF-36(PCS): Physical component scale of 36-Item Short-Form Health Survey;
FIQ(PFS): Physical function scale of FIQ; RMDQ: Roland Morris Disability Questionnaire;
SPPB: Short Physical Performance Battery; SF-36(PFS): Physical Functioning Scale component
scale of 36-item Short-Form Health Survey; MIDAS: The Migraine Disability Assessment;
NRS: 10 point Numeric Rating Scale.

53
 A Socio-demographic and medical data described (e.g., age, race, employment,
education)

B Process of data collection clearly described (e.g., interviews, questionnaires,

accelerometer)

C Type of chronic pain described (e.g. low back pain, fibromyalgia)

D Results are compared between 2 or more groups (e.g., healthy populations, between
patient groups, etc.)

E Participation and response rate reported and more than 75 %

F Differences between responders/non-responders are presented when they exist

G Results are described for objective and subjective measures of physical functional

H Standard statistics (mean, median, ranges, SD) are present for the main study
variables

I Patients and/or their parents signed an informed consent prior to study participation,
and this was explicitly stated in the manuscript

J Selection of participants is adequately described

Figure 7. The 10-item quality assessment aided in categorizing the studies as to their level of
evidence. The checklist is adapted from a previously established criteria list for systematic
reviews (Kuijpers, 2004; Scholten-Peeters, 2003), and modified for the chronic pain population.

Each item that fulfilled the appropriate criterion was assigned one point. If an item

did not fulfill the criterion, or was not sufficiently addressed in the study, zero points

were awarded. The maximum score was 10, corresponding to 100 %. Studies that scored

54
70 % or more, corresponding to a score >=7, were considered ‘‘high quality.” Studies

that scored between 50 and 70 % were considered of ‘‘moderate quality.’’ Studies that

scored <50 % were considered of ‘‘low quality’’ (score =<4). Findings regarding

functional assessment and outcomes were summarized according to level of evidence

(Kuijpers, 2004) (Figure 8). Consistent with previously determined criteria (Ariens,

2000), and prior systematic reviews (Vranceanu, 2013, 2015), level of evidence is

considered ‘‘strong’’ when findings are consistent in at least 2 high quality studies,

‘‘moderate’’ if consistent in one high quality study and at least one moderate or low

quality study, ‘‘weak’’ if present in one high quality study or at least 3 or more low

quality studies, ‘‘inconclusive’’ if findings are inconsistent or less than 3 low quality

studies are available, and “no evidence’’ when no data is present (Figure 8).

Strong Consistent findings (C70 %) in at least 2 high quality studies

Moderate Consistent findings (C70 %) in one quality study and at least one moderate or
low quality study

Weak Findings in one high quality study or consistent findings (C70 %)in at least 3 or
more low quality studies

Inconclusive Inconsistent findings, or less than 3 low quality studies available

No evidence No data present

Figure 8. This criteria was adapted from a previous sesytematic review (Ariens, 2000). All
studies included in quality assessment were categorized as to their level of evidence.

55
 CHAPTER FOUR

RESULTS

Characteristics of Included Studies

A total of 15 studies were included in the final analysis (see Table 1.) All studies

were randomized controlled trials published between 1994 and 2015. Studies were

conducted in several countries, including 10 in the USA (Astin, 2013; Cash, 2015;

Esmer, 2010; Gardener-Nix, 2014; Goldenberg, 1994; Morone, 2008; Mororne, 2009;

Plews-Ogan, 2005; Weissbecker, 2002 and Wells 2014), 1 in the UK (Brown, 2013), 2 in

Denmark (Fjorback, 2013; la Cour, 2015), 1 in Germany (Schmidt, 2011) and 1 in

Norway (Zangi, 2011). In addition, several different chronic pain populations were used.

Of the 15 studies, the following includes a breakdown of subject populations per study:

5: fibromyalgia (Astin, 2003; Cash, 2015; Goldenberg, 1994; Schmidt, 2011;

Weissbecker 2002), 2: mixed “chronic pain” (Gardener-Nix, 2014; la Cour, 2015), 3:

chronic back pain (Esmer, 2010; Morone, 2008; Morone, 2009), 2: unspecified

musculoskeletal pain (Brown, 2013; Plews-Ogan, 2005), 1: migraine (Wells, 2014), 1:

somatization and functional somatic disorders (Fjorback, 2013), 1: inflammatory

rheumatic joint disease (Zangi, 2011) (Table 1.). All studies used validated self-report

tools that were language specific to the study population.

56
 All studies included were considered high quality, with scores of 100% (1 study),

90% (4 studies), 80% (8 studies) and 70% (2 studies) (Table 1). Studies did fall short

methodologically in several criteria (A-J) presented in Figure 7. Specifically, the results

of performance based and subjective physical function measures were described (G) in

only two studies (Astin, 2003; Morone, 2008) because only these studies included a

performance based measure of physical function. Although most studies addressed some

aspect of patient demographics (A), two studies did not (Brown, 2013 and Cash, 2015).

Four of the studies included did not reach a participation response rate of 75% or above

(E) (Astin, 2003; Esmer, 2010 and Gardener-Nix, 2014). Four studies did not report

differences between responders and non-responders (F) (Garland, 2014; Plews-Ogan,

2003; Wessbecker, 2002 and Wells, 2014).

Physical Function Outcome Measures

Measures of physical function were specified as such if the authors stated they

were either a self-reported or a performance based measure that assessed a physical

limitation, or capability, of engaging in or performing daily activities. Prior studies have

identified a significant discrepancy in self-reported physical function and performance

measures of physical function (Prince, 2008; Latham, 2008; Brach, 2002)). Therefore,

results were organized to highlight the discrepancy in outcomes related to measurement

tools used. The considered the content of the measurement tools utilized in the included

studies was also considered. Below is a description of measures used to clarify content of

individual measures.

57
 Physical function performance based measures. The measures listed below tested

for function, using physical performance criteria during real time physical exertion of a

participant. In line with other objective measurements the units of measure such as

distance, time or ability to rise from a chair were determined a priori and were not based

on subjective reporting of the participant. Using the predefined criteria, the physical

function was assessed by a clinician or trained observer.

1. The Six-Minute Walk Test (6MWT) was used in one study (Astin, 2003). The six-

minute walk test measures the distance a patient can walk at a maximum speed

during a 6-minute interval. The six-minute walk test has been validated for

healthy (Gibbons, 2001) and frail elders (Balke, 1963), spinal injury (van Hedel,

2005), fibromyalgia (King, 2002) and several other populations.

2. The Short Physical Performance Battery (SPPB) was used in one study (Monroe,

2008). The SPPB battery assesses patient’s standing balance, gait speed and

ability to rise from a chair. The test is performed by a trained lay observer and

takes approximately 10 – 15 minutes to administer (Guralnik, 1994).

Physical Function Self-Report Measures. The measures in this category assessed

physical function, in addition to psychological function (e.g., quality of life measures), or

assessed only physical function. These were generic measures (i.e. measures that can be

utilized across disease populations) and disease specific measures (i.e. measures

assessing the impact of a specific disease) (Turk, 2003).

58
Measures assessing physical function as part of quality of life.

1. The Physical Component Scale of the Short Form Health Survey (SF-12)

(Generic) was used in one study (Plews-Ogan, 2005). The SF-12 is an abbreviated

version of the SF-36, which measures physical and mental health. The SF-12

includes several questions assessing ability to accomplish activities of daily living

(ADLs) and psychosocial assessment. The physical component score (PCS) of the

SF-12 uses the same questions as the original SF-12, but uses a weighted scoring

to better assess for physical functioning (Ware, 1996).

2. The Fibromyalgia Impact Questionnaire (FIQ) (Disease specific) was used in 3

studies (Astin, 2003; Goldenberg, 1994 and Schmidt, 2011). The FIQ is a

validated 20-item self-report HRQoL measure used to assess physical function,

overall well-being and frequent fibromyalgia symptoms (pain, fatigue, stiffness

and mood).

Measures assessing only physical function.

1. The Physical Component Scale of the SF-36 & SF-36 v2 (Generic) was used

in 5 studies (Brown, 2013; Fjorback, 2013; Gardener-Nix, 2014 (v2); la Cour,

2015 and Morone, 2008). The SF-36 measure addresses multiple domains. It
59
 is utilized both as a quality of life measure and an independent measure of

function. This 36-item scale is designed to assess general health related

quality of life. The SF-36 is a multiscale health survey validated for many

populations that measures eight health concepts - limitations in physical

activities because of health problems, limitations in social activities because

of physical or emotional problems, limitations in usual role activities because

of physical health problems), bodily pain, general mental health

(psychological distress and well-being), limitations in usual role activities

because of emotional problems, vitality (energy and fatigue), and perceived

general health (Ware, 1992). The PCS has 21 items assessing limitations in

physical functioning, and is validated for use alone, or as part of the SF-36

scale (Ware, 2000; Ware, 1992).

2. The Physical Functioning Scale of the SF-36 (PFS)(Generic) was used in 1

study (Morone, 2008). The PFS has 10 items assessing limitations in physical

functioning and is validated for use alone or as part of the SF-36 scale (Ware,

1994).

3. The Numeric Rating Scale (NRS) (Generic) was used to assess perceived

ability to engage in self-care, on a scale from 0 to 10 scale (where 10 was very

good) (Zangi, 2011).

4. The Roland and Morris Disability Questionnaire (RMDQ) (Disease specific)

was used in 3 studies (Esmer, 2010; Morone, 2008 and Morone, 2009). The

RMDQ is a validated 24-item questionnaire that assesses disability related to

low back pain.

60
 5. The Migraine Disability Assessment (MIDAS) (Disease specific) was used in

1 study (Wells, 2014). The MIDAS is a validated 7-item questionnaire that

assesses migraine related disability. The questionnaire includes 5 disability

related questions and 2 question related to headache frequency and intensity

of headache pain (Stewart, 2001).

6. Fibromyalgia Impact Questionnaire- physical functioning scale (PFS)

(Disease specific) is a validated measure of the impact of fibromyalgia

symptoms on physical functioning used in two studies (Cash, 2015 and

Weissbecker, 2002). The measure is an 11 item self-report 4-point Likert scale

where 0 is “always able to do” and 3 is “never able to do” (Bennett, 2005).

Results of Self-Reported Measures of Function. All 15 studies had at least one

measure addressing self-reported physical function either at the conclusion of treatment

or follow up. Seven studies (47%) reported at least one measure with a significant

improvement in self-reported physical function at the end of treatment or follow up

(Astin, 2003; Esmer, 2010; Fjorback, 2013; Goldenberg, 1994; Morone, 2008; Wells,

2014 and Zangi, 2011). Because all included studies were considered “high quality,” this

finding suggests there is strong evidence for mindfulness intervention’s effect on self-

reported measures of physical function. An additional 7 studies (47%) showed possible

improvement, yet did not reach significance (Cash, 2015; Gardener-Nix, 2014; la Cour,

2015; Morone, 2008; Morone, 2009; Schmidt, 2011; Weissbecker, 2002). Three studies

(20%) (Astin, 2003; Brown, 2013; Plews-Ogan, 2005) had at least one measure that

61
showed no improvement, suggesting there is also strong evidence for no improvement,

leaving the results of self-report measures inconclusive.

Further analysis of the results of self-report measures showed that four high

quality studies used a measure to assess physical function as part of a broader quality of

life measure (Astin, 2003; Goldenberg, 1994; Plews-Ogan, 2005 and Schmidt, 2011). Of

these four studies, three used the FIQ to report on physical functioning (Astin, 2003;

Goldenberg, 1994 and Schmidt 2011). Plews-Ogan (2015) used the SF-12 PCS, a quality

of life measure that is weighted to represent physical functioning. Of all the studies that

used a QOL measure to assess physical functioning, two reported a significant

improvement in self-reported physical function (Astin, 2003 (FIQ) and Goldenberg, 1994

(FIQ)), and two (Plews-Ogan, 2005) (SF-12) and Schmidt 2011 (FIQ)) showed no

significant improvement at the conclusion of the intervention group or follow up. Results

of the studies that used a QOL measures are conflicting, suggesting there is inconclusive

evidence on the impact of mindfulness on self-reported physical functioning, although the

impact of mindfulness on overall measures of functioning, i.e., measures that also address

emotional and social factors may have been the actual phenomena being measured in the

QOL studies.

Results of Performance Measures. Two studies included both a measure of self-

reported physical function and a performance measure of physical function (Astin, 2003

and Morone, 2008). Contrary to the self-report findings, the two objective performance

measures of physical function used showed no improvement in physical function (Astin,

2003, Morone, 2008). Since there were two high quality studies that used objective

performance measures, results suggest there is strong evidence from objective

62
performance measures that conflicts with the finding that mindfulness training has a

significant impact on self-reported physical function.

Alignment with IMMPACT Recommendations. IMMPACT guidelines suggest

that studies evaluating an intervention’s effect on physical function should include both a

generic measure of function (i.e. a measurement that can be compared with other health

populations) and a disease specific measure (i.e. a measurement that captures disease

specific impacts). Only two studies used both a generic measure and a disease specific

measure (Table 1).

Summary of Findings

Twelve studies used self-reported physical function specific measures to assess

physical functioning. Five studies reported a significant improvement in self-reported

function (Esmer, 2010; Fjorback, 2013; Morone, 2008; Wells, 2014 and Zangi, 2011).

Three studies reported no impact on self-reported physical functioning (Cash, 2015; la

Cour, 2015 and Weissbecker 2002). Results of the physical function specific measures

suggest there is inconclusive evidence of the effect mindfulness has on physical

functioning.

63
 CHAPTER FIVE

DISCUSSION

As evidenced by the large number studies extracted for this review (2818),

mindfulness approaches clearly have a major presence in the research and clinical pain

literature. Although it would be expected that a psychological approach would primarily

target psychosocial outcome variables, the absence of attention to physical functioning

was surprising given its critical importance in the field of chronic pain management.

Less than 1% of mindfulness interventions considered employing self-report measures of

physical function.

Interpretation of Results

As discussed earlier, IMMPACT recommendations for chronic pain research

suggest the assessment of an intervention, includes addressing 6 categories - pain,

physical functioning, emotional functioning, participant ratings of global improvement,

symptoms and adverse events, and participant disposition (including adherence to

treatment regimen and reasons for premature withdrawal from a trial) (Turk, 2003).

However, specific recommendations for the assessment of physical function are self-

report measures, several of which include questions pertaining to mental health

(Dworkin, 2005). This is relevant because when questions pertaining to mental health are

included, it becomes unclear what phenomena are actually being measured. The measures

suggested by IMMPACT that include only questions pertaining to physical activities are

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

64
(Bellamy, 1988), the RMDI described earlier and the SF-36 (PCS) that is also described

earlier. IMMPACT also suggests two self-report measures that include psychosocial

items. The measures that include psychosocial items and questions pertaining to physical

function are, the West Haven-Yale Multidimensional Pain Inventory (MPI) (Kerns,

1985), and The Brief Pain Inventory (BPI) (Cleeland, 1994). It is surprising that

IMMPACT made no recommendation concerning more objective performance measures.

As we see with the results from this systematic review, it makes a difference whether

objective performance measures or subjective self-report measure are used to assess for

physical functioning.

Perhaps even more surprising, in the current study only two investigations used

measures that addressed objective change in physical functioning. Both were rated as

high quality investigations, and mindfulness had no effect on physical functioning. Astin

et al., 2003 used the 6-minute walk test (6MWT) and Morone et al., 2008 used the Short

Physical Performance Battery (SPPB). Both measures had widespread use across

multiple other pain studies, each with sufficient validity and reliability across a range of

populations (Gibbons, 2001; van Hedel, 2005; Guralnik, 2000; Vasunilashorn, 2009).

Both studies appeared well controlled, and interventions utilized lasted up to 8 weeks

with previously published mindfulness approaches. Each was published in journals with

relatively high impact factors, and subjects were chronic low back and fibromyalgia

diagnoses, both clinically relevant populations. The drop-out rate of (25%) was relatively

high for the fibromyalgia study, a possible impact on outcome. Nonetheless, the data do

not support a conclusion that mindfulness approaches have impact on objective measures

of function.

65
 Critics of objective measures may say that the objective performance measures

such as the 6MWT or the SPPB may not give a full picture of physical functioning. They

may suggest that when these performance measures are taken it is only a brief view in a

person’s week. It may be suggested that whether a person can walk for 6 minutes is not

predictive of whether they can drive a car or do other physical activities. However, the

research states otherwise.

While objective measures of function can be subject to some of the same biases

and methodological problems of self-report measures, objective measure typically are

superior with respect to predictive validity. When possible, it is preferable for clinicians

and scientists to measure something directly rather than take someone’s word for it (i.e.

self-report). As stated earlier, an objective measurement is defined as, “The repetition of

a unit amount that maintains its size, within an allowable range of error… no matter who

or what relevant person or thing is being measured” (Definition of objective

measurement, 2000). In contrast, the unit of measure for subjective measures changes

from person to person. A recent systematic review by Prince et al. (2008) showed self-

reports can be inaccurate by as much as 37% to 78% for males and 58% to 113% for

females (Prince, 2008). This level of inaccuracy is difficult to accept where other more

objective measures are available that are not intrusive and do not require a clinical

assessment. Previous recommendations by IMMPACT to include self-reported

measurements of physical function, may no longer be adequate when accurate, low cost

and minimally invasive objective assessment of physical function (i.e. accelerometer) is

available (Lee, 2014).

66
 Earlier reviews suggest that physical functioning be added to self-report measures

in pain (Simmonds 1998; Turk, 2003; Dworkin, 2005). Although some studies included

in the current review did attempt to assess physical function, four of these studies may

have confounded their findings on physical functioning by assessing function as part of a

QOL measure. Two studies using a quality of life measure, FIQ, did show change in self-

reported over function. However, the data was inconsistent with respect to outcomes for

two other studies utilizing the FIQ and SF-12 (PCS) as measures of function. Results for

measures physical function that did not include psychosocial items were similarly

inconclusive with studies showing both significant impact and no impact of mindfulness

interventions on self-reported physical functioning. While it was unclear in the 15

manuscripts, it can be assumed that the experimenters did target function in their

programs, or possibly reinforced the subject’s self-report of improved function. It is also

possible that the psychometric quality of some physical functioning measures that did not

include psychosocial items were poor in contrast to the measures that did include

psychosocial items, as the latter have a long history of empirical support in the research

literature. (Kerns, 1985; Cleeland, 1994).

Clinical Implications

Mindfulness approaches are typically delivered to the patient as stand-alone

clinical services such as 8 week courses (Gotink, 2015), while other behavioral

techniques like operant or recent acceptance techniques are more commonly integrated

into rehabilitation medicine or multidisciplinary pain treatment settings (Gatchel, 2014).

67
The latter typically focus on addressing disability, pain behavior, and underscore the

importance of improved physical functioning and return to work. In contrast, the largest

clinical programs in mindfulness training stand largely in isolation, running stand-alone

8-week mindfulness and mind-body courses, that contrast with a more integrated

approach found in functional restoration programs or other interdisciplinary care.

Bringing mindfulness interventions into the fold of mainstream interdisciplinary care may

help to focus outcomes on more clinically relevant endpoints.

Mindfulness goals are conceptually close to the objectives of acceptance

approaches, providing an opportunity to target and measure physical functioning as an

important outcome variable. It’s reasonable to consider the “acceptance” of pain, while

targeting improved function despite pain employing mindfulness techniques. Garland et

al. 2014 suggest several criteria where mindfulness research has shown promise in

mediating effects of chronic pain, including attenuating emotionally aversive appraisals

of pain sensations, reducing attention fixation on pain, bolstering positive emotion and

savoring natural rewards, and enhancing cognitive control over habitual behavioral

responses (Garland, 2014, p. 609). However, integrating these treatment approaches into

interdisciplinary care and translating the cognitive effects into increased physical function

may require additional steps.

One factor that is important to address is the clinical utility of these measures. For

research purposes the priority is to find the most accurate and specific measures possible.

When working with a patient, it is important to balance this need with good care and

efficiency of time and money. A self-report questionnaire can be filled out in a waiting

room or with non-clinical staff that has limited training. However, the 6MWT or the

68
SPPB may require more clinical time or trained staff, therefore using more resources

giving these measurements less clinical utility. An ideal measure may be one that does

not require more resources, but can address both the breadth of assessing function over

time and having an objective framework.

Recommendations for Future Clinical Research

Despite their superiority, objective measures of function are often burdensome

for the patient and clinician, requiring more time and expense than brief self-report

measures. Nonetheless, new technology may ease the burden, increase adherence, and

provide opportunities to measure objective physical functioning change in a non-clinical

environment (Appelboom, 2014). While integration in a multidisciplinary team is always

optimal for care of the patient with chronic pain, a stand-alone mindfulness or other

behavioral service can easily employ digital monitoring devices with a patient in a group

or individual setting. These devices increasingly used in treatments studies for

osteoarthritis (Feehan et al., 2014), Insomnia (Goodie, 2014), and other conditions

commonly targeted by mindfulness approaches with adherence rates as high as 95%

(Cadmus-Bertram, 2015) and an error rate as low as 10.1% (Lee, 2014).

There is increased focus on mindfulness approaches in the management of

chronic pain conditions and strong evidence supporting physical function as an important

outcome measure chronic pain. Research and clinical programs now have an opportunity

to target physical function within mindfulness training programs and systematically

measure functional outcomes. Where barriers can be overcome, efforts to employ

objective measures should always be considered. With improving technology,

69
opportunities to employ interactive measures that both reinforce function and measure

objective improvement are now increasingly available. Previous recommendations for

chronic pain research suggesting self-report of physical function for assessment of

physical function may no longer be adequate. Further integration of mindfulness training

into interdisciplinary care where physical function is more directly targeted as an

important outcome variable may be conducive to creating a more comprehensive

treatment approach. To properly assess the effectiveness and impact of mindfulness based

interventions, physical function must be considered as a primary or secondary outcome

measure. In order to measure physical function properly, both self-report and objective

measures of function should be considered. If in fact the effectiveness of mindfulness

training is limited to psychosocial factors, the impact of a targeted intervention to address

physical functioning paired with mindfulness should be assessed.

Summary and Conclusion

The initial purpose of this study was to address whether or not we can reliably

assess the effects of mindfulness training on physical functioning in chronic pain. The

findings of this study suggest that there are research tools available to reliably assess the

effects an intervention has on physical functioning in chronic pain patients. Although

consensus groups like IMMPACT give suggestions for research that rely primarily on

subjective self-reporting, other means of measurement, such as physical functioning

performance measures and new advances in technology such as commercially available

70
digital monitoring devices like the Fitbit, provide accurate and cost effective alternate

methods of measuring physical functioning.

Following the guidance of experienced researchers, suggested methods from

Khan et al. 2011 and the Cochrane Collaboration (Higgins, 2008), the process of the

systematic review performed as part of this paper was at the level of industry standards.

Following consultation with experienced academic research librarians, a wide, inclusive

and systematic search of the literature was conducted. Adhering to PRISMA guidelines

for reporting on systematic reviews all data relevant to the research question was

collected and reported.

Articles Excluded
2802

Studies Using an
Objective Measure
2

Assessed for Physical

Function
15

Figure 9. There is a clear gap in mindfulness research in chronic pain. Functional measures for
the most part have not been considered. Out of the many studies identified only 2 met criteria for
mindfulness intervention and chronic pain population and had objective measure of function.

71
 Although physical functioning has been identified in the field of chronic pain

research as an important endpoint, with the exception of 15 studies, physical functioning

has been all but neglected in the literature. The studies that used objective measures were

even fewer, with only 2 studies including objective measures of physical functioning

(Figure 9). The studies that did include self-reported measures of functioning were often

inconclusive in their findings. The objective measures of physical functioning in the 2

out of 2818 studies found mindfulness to have no significant impact of physical

functioning. However, with the a very limited number of studies including objective

measures or a combination of objective and subjective measures it is not possible at this

time to draw any firm conclusions about the effects mindfulness has on physical function.

Findings from this study show that the effects of mindfulness training on physical

functioning in chronic pain has not been thoroughly assessed. Although previous methods

of measuring objective physical function may have been more cumbersome and less cost

effective, new accurate and cost effective methods are available and should be utilized

when possible. Future research on the effects of mindfulness training on chronic pain

should include both self-report and objective measurements of physical functioning.

72
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 APPENDIX A: Search Terms

Database Search Terms

PubMed (((((((((((((((((((((((exp pain[MeSH Terms]) OR pain[Text Word]) OR exp chronic

pain[MeSH Terms]) OR "chronic illness"[Text Word]) OR exp chronic disease[MeSH
Terms]) OR "chronic disease"[Text Word]) OR somatoform[Text Word]) OR exp
headache disorders[MeSH Terms]) OR headache*[Text Word]) OR migraine*[Text
Word]) OR fibromyalgia[MeSH Terms]) OR fibromyalgia[Text Word]) OR exp
arthritis[MeSH Terms]) OR arthriti*[Text Word]) OR myalgi*[Text Word]) OR
neuralgi*[Text Word]) OR exp musculoskeletal pain[MeSH Terms]) OR
musculoskeletal[Text Word]) OR nociceptive[Text Word]))) AND ((((((((((((((((((((exp
motor skills[MeSH Terms]) OR motor[Text Word]) OR exp psychomotor
performance[MeSH Terms]) OR exp athletic performance[MeSH Terms]) OR
dexterity[Text Word]) OR exp rehabilitation[MeSH Terms]) OR "daily activities"[Text
Word]) OR "daily living"[Text Word]) OR mobility[Text Word]) OR exp motor
activity[MeSH Terms]) OR exp movement[MeSH Terms]) OR locomotion[Text
Word]) OR exp exercise[MeSH Terms]) OR exp physical therapy modalities[MeSH
Terms]) OR exp physical fitness[MeSH Terms]) OR walk*[Text Word]) OR
function*[Text Word]) OR fitness[Text Word])))) AND ((((((((((((exp
mindfulness[MeSH Terms]) OR exp mind body therapies[MeSH Terms]) OR
mindfulness[Text Word]) OR "mind body"[Text Word]) OR relaxation[Text Word])
OR meditation[Text Word]) OR zen[Text Word]) OR vipassana[Text Word]) OR
samatha[Text Word]) OR shamatha[Text Word])))) AND ((((((((((((clinical trials,
randomized[MeSH Terms]) OR randomized) OR "clinical trial*") OR "control* trial")
OR "randomized control* trial") OR review) OR "meta analysis") OR "meta synthesis")
OR controlled clinical trials, randomized[MeSH Terms]))) OR "Clinical
Trial*"[Publication Type])

Web of (RCT OR "clinical trial*" OR randomized OR "control* trial" OR "systematic review"

Science OR "meta analysis" OR "meta synthesis") AND (mindfulness OR "mind body" OR
relaxation OR meditation OR zen OR vipassana OR samatha OR shamatha) AND
(motor OR psychomotor OR athletic OR dexterity OR rehabilitation OR activit* OR
mobili* OR locomotion OR exercise OR physical OR walk* OR function* OR fitness)
AND (pain OR "chronic pain" OR "chronic illness" OR "chronic disease" OR
somatoform OR headache* OR migraine* OR fibromyalgia OR arthriti* OR myalgi*
OR neuralgi* OR musculoskeletal OR nociceptive)

96
 PsychINFO ((SU.EXACT.EXPLODE("Mindfulness") OR SU.EXACT.EXPLODE("Mind Body
(via Therapy") OR ab((mindfulness OR "mind-body")) OR ti((mindfulness OR "mind-
Proquest) body"))) AND (SU.EXACT.EXPLODE("Pain") OR ab(pain) OR ti(pain))) AND
((SU.EXACT.EXPLODE("Pain") OR ab((pain OR "chronic illness")) OR ti((pain OR
"chronic illness")) OR (SU.EXACT.EXPLODE("Chronic Illness") OR
SU.EXACT.EXPLODE("Chronic Mental Illness")) OR ab(("chronic mental" OR
"chronic fatigue")) OR ti(("chronic mental" OR "chronic fatigue")) OR
SU.EXACT.EXPLODE("Chronic Fatigue Syndrome") OR
SU.EXACT.EXPLODE("Chronic Stress") OR ab(("chronic stress" OR somatoform))
OR ti(("chronic stress" OR somatoform))) OR (SU.EXACT.EXPLODE("arthritis") OR
ti((headache* OR migraine*)) OR ab((migraine* OR headache*)) OR ab((fibromyalgia
OR arthritis*)) OR ti((fibromyalgia OR arthritis*)) OR ab((myalgia* OR
musculoskeletal)) OR ti((neuralgia* OR musculoskeletal)))) AND
(((SU.EXACT.EXPLODE("Physical Agility") OR SU.EXACT.EXPLODE("Aerobic
Exercise") OR SU.EXACT.EXPLODE("Movement Therapy") OR
SU.EXACT.EXPLODE("Motor Skills") OR SU.EXACT.EXPLODE("Perceptual
Motor Processes") OR SU.EXACT.EXPLODE("Athletic Performance") OR
SU.EXACT.EXPLODE("Locomotion") OR SU.EXACT.EXPLODE("Activities of
Daily Living") OR SU.EXACT.EXPLODE("Exercise")) OR ab((agility OR dexterity))
OR ti((agility OR dexterity)) OR ab((psychomotor OR mobility)) OR ti((psychomotor
OR mobility)) OR ab(("daily living" OR "daily activities")) OR ti(("daily living" OR
"daily activities")) OR ab(("motor skills" OR locomotion)) OR ti(("motor skills" OR
locomotion)) OR ab((exercise OR "physical fitness")) OR ti((exercise OR "Physical
fitness"))) OR (SU.EXACT.EXPLODE("Physical Fitness") OR
SU.EXACT.EXPLODE("Physical Mobility")))

EMBASE ('clinical trial controlled' OR 'randomized controlled study' OR 'controlled study' OR

'systematic review' OR 'meta analysis' OR 'meta synthesis') AND ('mindfulness' OR
'mind body therapies' OR 'relaxation training' OR 'meditation' OR 'zen' OR 'vipassana'
OR 'samatha' OR 'shamatha') AND ('motor' OR 'psychomotor' OR 'athletic' OR
'dexterity task' OR 'rehabilitation' OR 'activity' OR 'mobility' OR 'locomotion' OR
'exercise' OR 'walking' OR 'functional' OR 'fitness physical') AND ('pain' OR 'chronic
pain' OR 'chronic disease' OR 'psychogenic pain' OR 'headache' OR 'migraine' OR
'fibromyalgia' OR 'arthritis' OR 'myalgia' OR 'neuralgia' OR 'musculoskeletal' OR
'nociceptive pain')

Figure 3. List of search terms used for the four data bases searched. List was generated with the
help of an academic medical research librarian at Tufts University School of Dental Medicine in
accordance with best practices. As each data base has a different organization of articles and
parameters for accurate inquiry and results, search terms were tailored to allow the most inclusive
parameters while maintaining parsimony.

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 Appendix B: Abstract of Article Accepted by American Pain Society for Publication

Abstract

Introduction: The importance of improved physical function as a primary outcome in

the treatment of chronic pain is widely accepted. Mindfulness skills training (MSTs)

programs targeting pain acceptance and engagement in activity are becoming

increasingly popular for the treatment of chronic pain.

Methods: We conducted a systematic review of published randomized control trials

(RCTs) using MSTs that assessed physical function (performance based or self-report) as

primary or secondary outcomes, described how physical function was conceptualized and

assessed, and summarized results with regard to physical function. We used the Preferred

Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria (Moher,

2009) to identify, select, and assess eligibility of studies for inclusion and followed

established guidelines for best practice of systematic reviews in reporting results (Moore,

2010). Published reports of original RCTs were included if they described physical

function outcomes after a MST in the chronic pain population, and met methodological

quality according to a list of predefined criteria.

Results: Of the 2818 articles identified from the original search of 4 electronic databases,

inclusionary criteria were met by 15 studies published as of August 10th, 2015, totaling

1,199 patients. All included studies used self-report measures of physical function, while

only 2 studies employed performance based measures of function. Overall, the quality of

the studies was rated as high. We found inconclusive evidence for small improvements in

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the subjective self-reported physical function after MSTs. However, we found strong

evidence for the objective performance physical function, based on results from two high

quality studies, which showed no improvement in function.

Discussion: This review draws attention to the importance of addressing physical

function and assessing it with quality measurements within MSTs for chronic pain. The

use of performance based measures of function and potential strategies to address

physical function in this population are discussed.

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