Mechanisms of Mindfulness Meditation, Cognitive Therapy, and Mindfulness-based Cognitive Therapy for Chronic Low Back Pain

Abstract

Objectives: This study evaluated theoretically derived mechanisms and common therapeutic factors to test their role in accounting for pain-related outcome change during group-delivered cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain. Methods: A secondary analysis of a pilot randomized controlled trial was used to explore the primary mechanisms of pretreatment to posttreatment changes in pain control beliefs, mindful observing, and pain catastrophizing, and the secondary common factor mechanisms of therapeutic alliance, group cohesion, and amount of at-home skill practice during treatment. The primary outcome was pain interference; pain intensity was a secondary outcome. Results: Large effect size changes in the 3 primary mechanisms and the outcome variables were found across the conditions. Across all 3 treatment conditions, change in pain control beliefs and pain catastrophizing were significantly associated with improved pain interference, but not pain intensity. Therapeutic alliance was significantly associated with pain intensity improvement and change in the therapy-specific mechanisms across the 3 conditions. Mindful observing, group cohesion, and amount of at-home practice were not significantly associated with changes in the outcomes. Discussion: Cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain were all associated with significant changes in the primary mechanisms to a similar degree. Change in perceived pain control and pain catastrophizing emerged as potential “meta-mechanisms” that might be a shared pathway that contributes to improved pain-related outcomes across treatments. Further, strong working alliance may represent a critical therapeutic process that both promotes and interacts with therapeutic techniques to influence outcome.

Cognition and Pain: A Review

“…Pain catastrophizing is a maladaptive change, and patients often view pain as uncontrollable, permanent, and destructive. CBT is a vital treatment modality for this class of chronic pain patients (Day et al, 2020;Gilliam et al, 2020). Evidence in fibromyalgia patients suggests the clinical benefits of CBT in reducing pain catastrophizing (Lazaridou et al, 2017).…”

“…Mindfulness meditation and mindfulness-based cognitive therapy have shown therapeutic benefit and improved sensitivity to opioid-based treatment in patients with chronic lower back pain (Zgierska et al, 2016;Day et al, 2019Day et al, , 2020. Mindfulnessbased practices focus on altering the pain catastrophizing, which is an essential component of non-pharmacological therapies for chronic pain.…”

“…Mindfulnessbased practices focus on altering the pain catastrophizing, which is an essential component of non-pharmacological therapies for chronic pain. It alters the cognitive content, processing, and negative affectivity, thus leading to a shift critical for any treatment efficacy (Day et al, 2020). Other theoretical models hypothesize that mindful meditation can restructure the pain-related cognitive content, making adaptive changes necessary to counter pain perception.…”

“…Studies have shown an increase in the EC levels even after short-term meditation practice, providing evidence of the analgesic potential of mindbody therapies (Sadhasivam et al, 2020). Understanding and individualizing the treatment and matching it to the patient's requirement can improve treatment response, adherence, and outcomes (Day et al, 2020;Zetterqvist et al, 2020). Considering at-home practices and online modules can improve reach and compliance with mindfulness-based therapies (Day et al, 2020;Zetterqvist et al, 2020).…”

Move to health-a holistic approach to the management of chronic low back pain: an intervention and implementation protocol developed for a pragmatic clinical trial

“…Spirituality can contribute to a sense of value, resilience, meaning and purpose, and can play a role in pain-related beliefs and coping responses of patients with chronic pain [ 75 ]. Mindfulness, or intentional and nonjudgmental awareness of present experience, can reduce pain and enhance function for individuals with chronic LBP likely through enhanced sense of control over pain and reduced catastrophizing [ 76 , 77 ]. Additional personal habits and maladaptive stress responses such as smoking can also increase risk for persistence of chronic LBP [ 78 ].…”