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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=sbeh20 Download by: [Universiteit Twente.] Date: 22 March 2016, At: 05:41 Cognitive Behaviour Therapy ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: http://www.tandfonline.com/loi/sbeh20 Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review M. M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs To cite this article: M. M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs (2016) Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta- analytic review, Cognitive Behaviour Therapy, 45:1, 5-31, DOI: 10.1080/16506073.2015.1098724 To link to this article: http://dx.doi.org/10.1080/16506073.2015.1098724 Published online: 28 Jan 2016. Submit your article to this journal Article views: 313 View related articles View Crossmark data
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Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=sbeh20
Download by: [Universiteit Twente.] Date: 22 March 2016, At: 05:41
Cognitive Behaviour Therapy
ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: http://www.tandfonline.com/loi/sbeh20
Acceptance- and mindfulness-based interventionsfor the treatment of chronic pain: a meta-analyticreview
M. M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs
To cite this article: M. M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs (2016)Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review, Cognitive Behaviour Therapy, 45:1, 5-31, DOI: 10.1080/16506073.2015.1098724
To link to this article: http://dx.doi.org/10.1080/16506073.2015.1098724
Published online: 28 Jan 2016.
Submit your article to this journal
Article views: 313
View related articles
View Crossmark data
Cognitive Behaviour therapy, 2016voL. 45, no. 1, 5–31http://dx.doi.org/10.1080/16506073.2015.1098724
© 2016 Swedish association for Behaviour therapy
Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review
M. M. Veehofa,b , H. R. Trompettera , E. T. Bohlmeijera and K. M. G. Schreursa,c aDepartment of psychology, health & technology, university of twente, enschede, the netherlands; bDepartment of occupational therapy, Medische Spectrum twente, enschede, the netherlands; croessingh research & Development, enschede, the netherlands
Introduction
Chronic pain is a major health problem with a large impact on the emotional, physical and social functioning of patients as well as society (Breivik, Eisenberg, O’Brien, & Openminds,
ABSTRACTThe number of acceptance- and mindfulness-based interventions for chronic pain, such as acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT), increased in recent years. Therefore an update is warranted of our former systematic review and meta-analysis of studies that reported effects on the mental and physical health of chronic pain patients. Pubmed, EMBASE, PsycInfo and Cochrane were searched for eligible studies. Current meta-analysis only included randomized controlled trials (RCTs). Studies were rated for quality. Mean quality did not improve in recent years. Pooled standardized mean differences using the random-effect model were calculated to represent the average intervention effect and, to perform subgroup analyses. Outcome measures were pain intensity, depression, anxiety, pain interference, disability and quality of life. Included were twenty-five RCTs totaling 1285 patients with chronic pain, in which we compared acceptance- and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Effect sizes ranged from small (on all outcome measures except anxiety and pain interference) to moderate (on anxiety and pain interference) at post-treatment and from small (on pain intensity and disability) to large (on pain interference) at follow-up. ACT showed significantly higher effects on depression and anxiety than MBSR and MBCT. Studies’ quality, attrition rate, type of pain and control group, did not moderate the effects of acceptance- and mindfulness-based interventions. Current acceptance- and mindfulness-based interventions, while not superior to traditional cognitive behavioral treatments, can be good alternatives.
KEYWORDSMindfulness; acceptance and commitment therapy; meta-analysis; chronic pain; acceptance
ARTICLE HISTORYreceived 16 april 2015 accepted 18 September 2015
CONTACT K. M. g. Schreurs [email protected] Department of psychology, health & technology, university of twente, Drienerlolaan 5, 7522 nB enschede
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2013). Unfortunately, none of the most commonly used pharmacological, medical or sur-gical treatments are, by themselves, sufficiently able to remove pain, or to substantially enhance physical and emotional functioning (Turk, Wilson, & Cahana, 2011). This calls for the inclusion of psychosocial factors in addressing chronic pain and pain-related disabilities. Among psychological treatments, cognitive behavioral treatments (CBTs) have accumu-lated the most evidence in the research literature. However, as is the case for biomedical treatment solutions, effect sizes of CBTs are modest (Williams, Eccleston, & Morley, 2012).
The modest effects of both biomedical interventions and CBTs on pain removal and control are not surprising given the complex nature of chronic pain. They only shallowly reflect the large advances that have been made over the last decades in our understanding and treatment of chronic pain. They do, however, also point out a present necessity to negotiate with patients’ realistic expectations from treatments. In general total pain relief is an unrealistic goal and treatments should focus on improving function (Turk et al., 2011). Acceptance and Commitment Therapy (ACT) emphasizes the necessity of pain acceptance in order to improve function. ACT is based on the relational frame theory and focusses on psychological flexibility as the ultimate goal of treatment. Psychological flexibility refers to the capacity to change or maintain one’s behavior in open contact with thoughts and feelings and, with attention to the opportunities of the current situation in order to realize valued life goals (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). In the context of chronic pain, psychological flexibility means that painful sensations, feelings, and thoughts are accepted, that attention is focused on the opportunities of the current situations rather than on ruminating about the lost past or catastrophizing about the future, and that behavior is focused on realizing valued goals instead of pain control (McCracken & Vowles, 2014). In ACT, psychological flexibility is attained by acquiring six psychological skills: accept-ance, cognitive defusion, present moment awareness, contact with self-as context, values formulation and committed actions (Hayes, Strosahl, & Wilson, 2012). These skills can be divided in two overlapping processes, i.e. mindfulness and acceptance on the one hand and commitment and behavior change on the other hand (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). In ACT mindfulness exercises in the form of meditation are advisable but not a precept.
Formal meditation is the central technique in mindfulness based stress reduction (MBSR) (Kabat-Zinn, 1990) and mindfulness-based cognitive therapy (MBCT) (Segal, Williams, & Teasdale, 2002). Mindfulness is defined as intentional and non-judgmental awareness (Kabat-Zinn, 1990). It can be conceptualized as a multifaceted construct, consisting of the facets: observe, describe, act with awareness, nonjudge and nonreact. These last two facets are strongly related to acceptance (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). Although ACT, MBSR and MBCT can be differentiated theoretically, they share an under-lying focus on the concepts of acceptance and mindfulness. In the systematic review and meta-analysis with studies published before January 2009, we concluded that acceptance and mindfulness-based therapies in chronic pain produced small effects that are similar to CBT (Veehof, Oskam, Schreurs, & Bohlmeijer, 2011). Since our last analysis, the num-ber of studies on acceptance- and mindfulness-based studies has expanded considerably. Systematic reviews that qualitatively assess the efficacy of ACT, MBSR and MBCT generally find beneficial effects in chronic pain conditions (Lakhan & Schofield, 2013; McCracken & Vowles, 2014). The rapid increase of acceptance- and mindfulness-based studies in chronic pain allowed for a more rigorous assessment of their effectiveness. The aim of the present
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study, therefore, was to conduct a meta-analysis to assess the effectiveness of acceptance- and mindfulness-based treatments for chronic pain patients across randomized controlled studies.
Methods
A protocol based on the Cochrane Manual for Systematic Reviews of Interventions was used.
Search strategy
We included studies identified in our previous meta-analysis (Veehof et al., 2011) (up to December 2008), and updated this list of studies by conducting a new search (from January 2009 to December 2013) in the four electronic databases: PubMed, EMBASE, PsycInfo, and the Cochrane Central Register of Controlled Trials. The databases were searched for English language studies using the same terms as in our previous search: ‘mindfulness’ or ‘vipassana’ or ‘meditation’ or ‘mindfulness-based stress reduction’ or ‘MBSR’ or ‘mindfulness-based cognitive therapy’ or ‘MBCT’ or ‘acceptance-based’ or ‘acceptance based’ or ‘acceptance and commitment’, in combination with ‘chronic pain’ or specific chronic pain conditions including ‘fibromyalgia’ or ‘chronic low back pain’ or ‘whiplash associated disorder’ or ‘WAD’ or ‘repetitive strain injury’ or ‘RSI’ or ‘dystrophy’. Given recent developments in diagnosing specific chronic pain conditions, we added the following terms: ‘complaints arm neck shoulder’ or ‘CANS’ ‘complex regional pain syndrome’ or ‘CRPS’. Furthermore, the reference lists of newly included studies as well as systematic reviews were examined for additional eligible studies.
Selection procedure and eligibility criteria
Inclusion criteria were the same as the ones in our previous review, except that all studies had to have a randomised controlled design (Veehof et al., 2011). The new search initially yielded 1393 titles (PubMed: 927, EMBASE: 222, PsycInfo: 151, Cochrane: 93). After removal of duplicates, two reviewers (MV and KS) independently selected potentially eligible studies on the basis of title and abstract. Systematic reviews were initially included in this phase. The inter-rater reliability was satisfactory (κ = .79) (Everitt, 1992), and disagreements were resolved by consensus.
A total of 163 studies (including 76 systematic reviews) were identified as being poten-tially eligible for inclusion in the study, and we subsequently requested the full-text articles. The final selection was then made by two reviewers (MV and KS). The inter-rater reliability was very good with a κ value of .93 (Everitt, 1992). Studies were included if they reported on the effectiveness of a standardized acceptance- (ACT) or mindfulness (MBSR/MBCT)-based treatment program in patients with chronic pain or chronic pain related conditions. Given the increasing number of (randomized) controlled studies published in this field in recent years, only randomized controlled studies were included. Both published and unpub-lished (e.g. dissertations) studies were included. Studies were excluded if (1) mindfulness or acceptance was just one of several modalities provided simultaneously to the treatment group, (2) the intervention consisted of a single treatment session, (3) insufficient data was reported (and could not be obtained) to calculate standardized mean differences (SMDs),
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or (4) absence of appropriate outcome measures (pain, depression, anxiety, pain interfer-ence, disability or quality of life). Systematic reviews were only examined for additional potentially eligible studies and were not definitely included.
Data extraction
Data extraction was performed using a standardized data abstraction form created for the study. Data were extracted on participant characteristics, intervention type, control group and attrition rate. In agreement with the Clinical Importance of Treatment Outcomes in Chronic Pain Clinical Trials recommendations (Dworkin et al., 2005), our outcome meas-ures were pain intensity, depression, anxiety, disability, pain interference, and quality of life.
Quality assessment
Methodological quality of included studies was independently assessed by two review-ers (MV and KS) using a 8-point scale, based on criteria by the Cochrane Collaboration (Higgins & Altman, 2008) and the validated Jadad scale (Jadad, 1996) tailored for the included studies (see Table 1). The inter-rater reliability was satisfactory (κ = .78) (Everitt, 1992), and disagreements were resolved by consensus. When seven or more criteria were met, the quality of the study was assessed as high. The study quality was assessed as medium when four, five or six criteria were met and low when three or less criteria were met.
Data analysis
Primary goal was to compare the effects of acceptance- and mindfulness-based interven-tions with no treatment or an attention control condition. Therefore, for our main analyses, we only included studies with a waitlist, a (medical) treatment as usual [(M)TAU] or, an education/support group as a control condition. Secondary goal was to compare effects of acceptance- and mindfulness-based treatments with an active treatment like CBT, multi-disciplinary treatment (MDT) or relaxation therapy.
We used RevMan software version 5.2 for calculating (pooled) SMDs to test heterogeneity and to perform subgroup analyses. SMDs were calculated at post-treatment and follow-up using post-treatment and follow-up scores respectively with standard deviations from the experimental group and the control group. Given the presence of statistical heterogeneity between the studies (tested with the χ2 test and I2-statistic), pooled SMDs were calculated using the random-effects model representing the average intervention effect. Cohen (Cohen, 1977) has described effect sizes .2, .5, and .8 as small, moderate, and large, respectively.
In our main analysis, subgroup analyses were performed for all outcome measures by comparing pooled SMDs for significant differences between subgroups. Since these analy-ses were exploratory, no hypotheses were formulated beforehand. Subgroups were created based on (1) quality score (divided by low, medium and high quality as mentioned ear-lier), (2) control group [waitlist or (M)TAU vs. education/support], (3) intervention type (ACT vs. mindfulness-based), (4) type of pain (categorized as chronic pain without further specification, fibromyalgia, specific site pain, or rheumatoid arthritis), and (5) attrition rate (higher or lower than 25%).
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To assess for publication bias, we performed a funnel plot for all outcome measures by plotting the pooled SMD at post-treatment against its standard error (as a measure of study size). When publication bias is absent, the studies are expected to be distributed symmet-rically around the pooled effect size. Bias can be expected when the plot shows a higher concentration of studies on one side of the pooled SMD than on the other.
Results
A flow chart of the selection procedure is shown in Figure 1. A total of 87 studies were identified as being potentially eligible for inclusion in the study. The full-text versions of these studies were independently assessed by two reviewers (MV and KS). Of the 87 arti-cles, 67 were excluded for the following reasons: no acceptance- and mindfulness-based intervention (Coleman, 2011; Cramer et al., 2013; Curtis, Osadchuk, & Katz, 2011; Elinoff, Lynn, Ochiai, & Hallquist, 2009; Elomaa, Williams, & Kalso, 2009; Evans et al., 2011; Friedberg et al., 2013; Hirschfeld et al., 2013; Hsu et al., 2010; Liu et al., 2012; Paoloni et al., 2013; Rasmussen, Mikkelsen, Haugen, Pripp, & Forre, 2009; Rasmussen et al., 2012; Sawynok, Hiew, & Marcon, 2013; Stinson et al., 2010; Tekur, Chametcha, Hongasandra, & Raghuram, 2010; Tekur, Nagarathna, Chametcha, Hankey, & Nagendra, 2012; Vincent, Hill, Kruk, Cha, & Bauer, 2010), mindfulness or acceptance is not the main component of the intervention (Carbonell-Baeza et al., 2011; Carson, Carson, Jones, Mist, & Bennett, 2012; Carson et al., 2010; Cassidy, Atherton, Robertson, Walsh, & Gillett, 2012; Smeeding, Bradshaw, Kumpfer, Trevithick, & Stoddard, 2011), no intervention study (Morone et al., 2012), only CFS no chronic pain (Rimes & Wingrove, 2013), no control group (Abbey & Nanke, 2013; Baer, Carmody, & Hunsinger, 2012; Duggan et al., 2015; Fox, Flynn, & Allen, 2011; Gauntlett-Gilbert, Connell, Clinch, & McCracken, 2013; Hawtin & Sullivan, 2011;
Table 1. Methodological quality criteria.a
aScores are summed, 1 point for each fulfilled criterion, range 0–8.
1. allocation to conditions was based on randomization according to the text 1/02. the randomization scheme was described and appropriate, e.g. using a computer, random number
table1/0
3. a drop-out analysis was conducted (comparing drop-outs and completers at baseline on outcome measures), or there were no drop-outs
1
reasons of attrition were reported, but no analysis was conducted 04. intention to treat analysis was performed, or there were no drop-outs 1/05. at least one of the trainers was experienced or trained in teaching Mindfulness or aCt 1
Specific experience or training was not reported 06. patient’s pain was diagnosed by a physician or rheumatologist, or patients were referred from a pain
clinic where diagnosis was prior to admission1
recruitment through the media, or diagnosis based on a scale and self-report, or diagnosis not mentioned
0
7. the study had a minimal level of statistical power to find significant effects of the treatment, and included 50 or more persons in the comparison analysis between treatment and control group. (this allows the study to find standardized effect sizes of .80 and larger, assuming a statistical power of .80 and α of .05.)
1
Sample smaller than 50, or the total the sample was bigger than 50, but the results were only reported divided by different studies
0
8. treatment integrity was checked during the study by supervision of the therapists during treatment, or by recording the treatment sessions, or by systematic screening of protocol adherence by a standardized measurement instrument
1
treatment integrity was not checked, or integrity was supervised by one of the therapists, or they tried to keep the intervention sound by intensive consultation
0
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Hennard, 2011; Ilgen et al., 2011; Jelin, Granum, & Eide, 2012; Kristjánsdóttir et al., 2011; Ljotsson et al., 2013; Lunde & Nordhus, 2009; Lush et al., 2009; Mathias, Parry-Jones, & Huws, 2013; McCracken & Gutiérrez-Martínez, 2011; McCracken & Jones, 2012; Oberg,
87 full-text articles assessed for eligibility
76 full-text (systematic) reviews assessed for additional references
20 studies fulfilled selection criteria
67 full-text articles excluded for several
reasons (see text)
no additional relevant studies found
8 studies from previous meta-analysis fulfilled selection criteria
28 studies included in current meta-analysis
1393 records identified through database
searching
1133 records excluded
1393 records screened for relevance (title /
abstract)
163 records identified as relevant after
removal of duplicates
260 records identified as relevant
Figure 1. Flow chart of the selection procedure.
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COGnITIVE BEHAVIOuR THERAPy 11
Rempe, & Bradley, 2013; Rosenzweig et al., 2010; Vernon, 2011; Vowles & McCracken, 2010; Vowles, McCracken, & O’Brien, 2011; Vowles, Witkiewitz, Sowden, & Ashworth, 2014), no randomization (Cusens, Duggan, Thorne, & Burch, 2010; Vowles, Wetherell, & Sorrell, 2009), sample contained subjects other than pain patients (Branstetter-Rost, Cushing, & Douleh, 2009; Fjorback et al., 2012, 2013; Hartmann & Vlieger, 2012; Sampalli, Berlasso, Fox, & Petter, 2009), no appropriate outcome measure(s) (Cathcart, Barone, Immink, & Proeve, 2013; Cathcart, Vedova, Immink, Proeve, & Hayball, 2013; Garland & Howard, 2013; McCracken, Sato, & Taylor, 2013; Vago & Nakamura, 2011), 100% attrition in the control group (Jastrowski Mano et al., 2013), duplicate study data (Jensen et al., 2012; Wicksell, Olsson, & Hayes, 2010, 2011), insufficient quantitative data or none at all (Esmer, Blum, Rulf, & Pier, 2010; Olsson et al., 2013; S. Y. Wong, 2009), single treatment session (Martin, 2012). As a result, 20 new studies were included. Together with the eight randomized con-trolled studies included in our previous meta-analysis, we definitely included 28 studies. Our main analyses consists of 25 studies comparing acceptance- and mindfulness-based interventions with waitlist, (M)TAU or, education/support groups. Two of these 25 studies also used an active intervention as control (Schmidt et al., 2011; Zautra et al., 2008). Three studies only made a comparison with an active intervention (Thorsell et al., 2011; Wetherell et al., 2011; Wicksell, Melin, Lekander, & Olsson, 2009). So, five studies were included for our secondary analyses, comparing acceptance- and mindfulness-based interventions with active treatment.
Characteristics of included studies
Characteristics of the selected studies are presented in Table 2. The 25 studies included in the main analyses evaluated 1285 subjects. In general, the participants were adults with a mean age between 35 and 60 years. In two studies (Morone, Greco, & Weiner, 2008; Morone, Rollman, Moore, Li, & Weiner, 2009) the mean age of the participants was higher (> 70 years). In all studies the majority of the participants were female. Nine studies referred to patients with chronic pain without further specification and, one to patients with mus-culoskeletal pain Seven studies included patients with fibromyalgia, six with specific-site pain (e.g. chronic low back pain, chronic headache), and two with rheumatoid arthritis. Study sizes ranged from a small pilot study of 14 subjects to a large-scale study involving 112 subjects, with an average of 51 subjects. In ten studies the attrition rate (in one or both groups) was higher than 25% (range 26.7% to 67.3%). Eleven studies used a MBSR (-based) program, nine an ACT(-based) program, two a MBCT(-based) program, and one a combination of MBCT and MBSR. Two studies used other mindfulness-based programs: Mindfulness-based Pain Management (MBPM) and Four Step Mindfulness-based Therapy (FSMT). Most mindfulness-based programs (MBSR, MBCT, MBPM, FSMT) consisted of eight weekly group sessions, each session ranging in length from 1.5 to 2.5 h. In one MBSR study a self-help program was used. A self-help program was also used in two ACT stud-ies. In the seven other ACT studies, four to twelve weekly sessions were held, each session ranging in length from 1.0 to 2.5 h. In two of these studies, the sessions were held with individual patients. In the other five studies, the sessions were group-based. Ten studies used a waitlist as the comparison group, eight used an education/support group, and seven used a (M)TAU as the control group. The majority (n = 14) of the studies scored ‘medium’
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Tabl
e 2.
Cha
ract
eris
tics o
f inc
lude
d st
udie
s.
Auth
or
follo
w-u
pQ
ualit
y sc
ore
Pain
Mea
n ag
e (S
D
or ra
nge)
Mal
e %
Inte
r-ve
ntio
nG
roup
si
ze
Sess
ions
: nu
mbe
r, du
ratio
nCo
ntro
l gro
upn
Att
ritio
n ra
te %
(fo
l-lo
w-u
p)O
utco
me
mea
sure
s
Com
paris
on w
ith e
duca
tion/
supp
ort,
(M)T
AU o
r wai
tlist
as c
ontr
ol g
roup
astin
et a
l., 2
003
16 w
5Fi
brom
yalg
iat:
47.
7 (1
0.6)
i: 1.
6M
BSr
+
Qig
ong
10–2
08,
2.5
hed
ucat
ion/
supp
ort
i: 32
t: 3
9.0
(49.
0)pa
in: S
F-36
C: .0
C: 3
3D
epre
ssio
n: B
Di
QoL
: FiQ
Brow
n &
Jone
s, 20
13–
2M
uscu
-lo
-ske
leta
l pa
in
i: 48
(10)
i: 20
.0M
BpM
Max
15
8, 2
.5 h
tau
i: 15
i: 25
.0pa
in: M
pQ (s
enso
ry p
ain)
C: 4
5 (1
2)C:
30.8
C: 1
3C:
35.
0D
isab
ility
: SF-
36 p
CSBu
hrm
an e
t al.,
201
36
m
expe
rimen
tal
grou
p on
ly
5Ch
roni
c pa
ini:
48.8
(9
.5)
i: 44
.7aC
tSe
lf-he
lp
(onl
ine)
7ed
ucat
ion/
supp
ort
i: 38
i: 15
.8pa
in: M
pi
C: 4
9.3
(11.
3)C:
36.
8C:
38C:
23.7
Dep
ress
ion:
haD
S
anxi
ety:
haD
Sin
terf
eren
ce: M
piQ
oL: Q
oLi
Cath
cart
, gal
atis
, im
min
k, p
roev
e, &
pe
tkov
, 201
4
–2
Chro
nic
tens
ion-
type
he
adac
he
i: 45
.8
(13.
1)i:
43.0
MBC
t/M
BSr
6, 2
hW
aitli
sti:
22i:
20.7
pain
: 0–5
scal
e
C: 4
5.3
(14.
2)C:
31.
5C:
19
C: 3
4.5
Dah
l, W
ilson
, &
nils
son,
200
46
m4
Chro
nic
pain
i:
36.7
(1
2.5)
i: 9.
1aC
t in
divi
d-ua
l4,
1 h
Mta
ui:
110
pain
: nrS
C: 4
4.4
(13.
6)
C: 1
2.5
C: 8
0Q
oL: L
SQ
Dav
is &
Zau
tra,
201
3–
5Fi
brom
yalg
iat:
46.
1t:
2.0
MBS
rSe
lf-he
lp12
(6 w
)ed
ucat
ion/
supp
ort
i: 19
i: 51
.3pa
in: n
rS
C: 2
5C:
37.
5g
arla
nd, M
anus
ov,
Froe
liger
, Kel
ly &
W
illia
ms,
2013
3 m
7Ch
roni
c pa
ini:
49.3
(1
3.7)
i: 30
MBC
t +
po
sitiv
e ps
ycho
l-og
y
8–12
8, 2
hed
ucat
ion/
i: 31
i:4
5.6
(59.
6)pa
in: B
pi
C: 4
7.4
(13.
6)C:
34
supp
ort
C: 3
8 C:
34.
4 (5
1.7)
Dep
ress
ion:
C-S
oSi
inte
rfer
ence
: Bpi
-SF
John
ston
, Fos
ter,
Shen
nan,
Sta
rkey
, &
John
son,
201
0
–2
Chro
nic
pain
t: m
edia
n 43
t: 3
7.5
aCt
Self-
help
6W
aitli
sti:
6i:
50.0
pain
: SF-
MpQ
C: 8
C: 3
3.3
Dep
ress
ion:
CM
Di a
nxie
ty: B
aiQ
oL: Q
oLi
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COGnITIVE BEHAVIOuR THERAPy 13
Luci
ano
et a
l., 2
014
6 m
7Fi
brom
yalg
iai:
48.9
(5
.9)
i: 3.
9aC
t10
–15
8, 2
.5 h
Wai
tlist
i: 51
i: 9.
8 (1
1.8)
pain
: vaS
C: 4
8.3
(5.7
)C:
5,7
C: 5
3C:
5.7
(1
1.3)
Dep
ress
ion:
haD
S
anxi
ety:
haD
SQ
oL: F
iQM
awan
i, 20
09–
2Ch
roni
c pa
in
i: 46
.2
(12.
1)i:
16.0
MBS
r4–
88,
2 h
educ
atio
n/i:
14i:
51.7
pain
: MpQ
pri
C: 4
4.7
(13.
2)C:
31.
0su
ppor
t C:
14
C: 5
6.3
McC
rack
en e
t al.,
20
133
m6
Chro
nic
pain
t: 5
8.0
(12.
8)t:
31.
5aC
t12
–13
4, 4
hta
ui:
28i:
16.2
(2
4.3)
pain
: nrS
C: 2
6C:
25.
0 (2
2.2)
Dep
ress
ion:
ph
Q-9
Dis
abili
ty: r
MD
QM
oron
e et
al.,
200
8–
3Ch
roni
c lo
w
back
pai
ni:7
4.1
(6.1
)t:
43.
2M
BSr
8, 1
.5 h
Wai
tlist
i: 19
i: 31
.6pa
in: M
pQ-S
F
C: 7
5.6
(5.0
)C:
18
C: 5
.6D
isab
ility
: SF-
36 p
CS
QoL
: SF-
36 g
hM
oron
e et
al.,
200
92
m4
Chro
nic
low
ba
ck p
ain
i: 78
(7.1
)i:
31.2
MBS
r8,
1.5
hed
ucat
ion/
i: 16
i: 20
.0
(20.
0)pa
in: M
pQ-S
F cu
rren
t pai
n sc
ore
C: 7
3 (6
.2)
C: 4
2.1
supp
ort
C: 1
9C:
5.0
(5.0
)D
isab
ility
: rM
DQ
Mo’
tam
edi e
t al.,
201
2–
5pr
imar
y ch
roni
c he
adac
he
i:34.
2 (7
.4)
t: .0
aCt
158,
1.5
hM
tau
i: 15
i:26.
7pa
in: M
pQ se
nsor
y di
men
sion
C: 3
7.9
(8.7
)C:
15
C:0
Dis
abili
ty: M
iDaS
nas
h-M
c Fe
ron,
200
6–
4Ch
roni
c he
adac
hei:
50
(14.
6)
i: .0
MBS
r20
8, 1
.5 h
tau
i: 19
i: 5
pain
: SF-
36
C: 5
1 (1
2.2)
C: 3
5.0
C: 1
8C:
10D
isab
ility
: SF-
36 p
F
parr
a-D
elga
do &
La
torr
e-po
stig
o, 2
013
3 m
4Fi
brom
yalg
iai:
53.1
(1
0.5)
t: .0
MBC
t17
8, 2
.5 h
tau
i: 15
i: 11
.8
(11.
8)D
epre
ssio
n: B
Di
C: 5
2.7
(10.
6)C:
16
C: .0
Q
oL: F
iQ
plum
b vi
lard
aga,
20
12–
4Ch
roni
c pa
int:
52.
3 (1
3.0)
t: 2
5.0
aCt
156,
2 h
Wai
tlist
i: 11
i: 26
.7pa
in: p
ir
C: 9
C:
30.
8D
epre
ssio
n: D
aSS
Dis
abili
ty: p
Di
QoL
: Qo
LS (Con
tinue
d)
Dow
nloa
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Tw
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.] a
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201
6
14 M. M. VEEHOf ET Al.
Auth
or
follo
w-u
pQ
ualit
y sc
ore
Pain
Mea
n ag
e (S
D
or ra
nge)
Mal
e %
Inte
r-ve
ntio
nG
roup
si
ze
Sess
ions
: nu
mbe
r, du
ratio
nCo
ntro
l gro
upn
Att
ritio
n ra
te %
(fo
l-lo
w-u
p)O
utco
me
mea
sure
spr
adha
n et
al.,
200
74
m7
rheu
mat
oid
arth
ritis
i: 56
(9)
i: 16
.0M
BSr
13–1
88,
2.5
hW
aitli
sti:
28i:
9.7
(9.7
)D
epre
ssio
n: S
CL-9
0
C: 5
3 (1
1)C:
9.0
C: 3
2C:
0 (6
.3)
Schm
idt e
t al.,
201
18
w6
Fibr
omya
lgia
i: 53
.4
(8.7
) t:
.0M
BSr
Max
12
8, 2
.5 h
Wai
tlist
i: 53
i:15.
1 (1
1.3)
pain
: ppS
(sen
sory
pai
n)
C: 5
2.3
(10.
9)C:
59
C: 1
1.9
(5.1
)D
epre
ssio
n: C
eS-D
QoL
: FiQ
Seph
ton
et a
l., 2
007
2 m
6Fi
brom
yalg
iai:
48.4
(8
.9)
t: .0
MBS
r25
8, 2
.5 h
Wai
tlist
i: 51
28.6
(38.
5)D
epre
ssio
n: B
Di
C:47
.6
(11.
5)C:
39
Wic
ksel
l, ah
lqvi
st,
Brin
g, M
elin
, &
ols
son,
200
8
4 m
6W
hipl
ash-
as-
soci
ated
di
sord
ers
i: 48
.2
(7.8
) i:
18.2
aCt
indi
vid-
ual
10, 1
hW
aitli
st +
tau
i: 11
i: .0
(9.1
)pa
in: v
aS
C: 5
5.1
(11.
2)C:
30.
0C:
9C:
10.
0 (.0
)D
epre
ssio
n: h
aDS
anxi
ety:
haD
SD
isab
ility
: pD
iin
terf
eren
ce: v
aSQ
oL: S
WLS
Wic
ksel
l et a
l., 2
013
3–4
m6
Fibr
omya
lgia
t: 4
5.1
(6.6
)t:
0aC
t6
12, 1
.5 h
Wai
tlist
i: 20
i: 13
.0
(17.
4)pa
in: n
rS
C:16
C: 5
.9
(17.
6)D
epre
ssio
n: B
Di
anxi
ety:
Sta
i sta
teD
isab
ility
: SF-
36 p
CSQ
oL: F
iQC.
M. W
ong,
200
9–
7Ch
roni
c pa
ini:
48.3
(8
.2)
i: 47
.4FS
Mt
10–1
28,
2 h
tau
i: 38
i: 32
.0pa
in: n
rS
C: 4
0.1
(12.
9)C:
41.
2C:
27
C: 4
4.9
Dep
ress
ion:
BD
i
inte
rfer
ence
: Mpi
Won
g et
al.,
2011
;3
m, 6
m7
Chro
nic
pain
i: 48
.7
(7.8
)M
BSr
8, 2
.5 h
educ
atio
n/su
ppor
ti:
51i:
13.7
(2
1.6,
19.
6)pa
in: n
rS
C: 4
7.1
(7.8
)C:
48
C: 4
.2
Dep
ress
ion:
CeS
-D
(6.3
, 6.3
)an
xiet
y: S
tai s
tate
Dis
abili
ty: S
F-12
pCS
Zaut
ra e
t al.,
200
8–
7rh
eum
atoi
d ar
thrit
isi:
57.3
(1
5.3)
i:46.
3M
BSr
6–10
8ed
ucat
ion/
supp
ort
i: 41
i: 8.
3 pa
in: n
rS
C: 5
2.4
(13.
0)C
23.3
C: 3
0C:
2.3
D
epre
ssio
n: o
wn
scal
e
Tabl
e 2.
(Con
tinue
d).
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6
COGnITIVE BEHAVIOuR THERAPy 15
Com
paris
on w
ith C
BT
Zaut
ra e
t al.,
200
8;–
7rh
eum
atoi
d ar
thrit
isi:
57.3
(1
5.3)
i:46.
3M
BSr
6–10
8CB
t i:
41i:
8.3
pain
: nrS
C: 5
6.1
(13.
5)C:
40.0
C: 3
5C:
4.0
D
epre
ssio
n: o
wn
scal
e
Wet
here
ll et
al.,
201
1;6
m8
Chro
nic
pain
t: 5
4.9
(12.
5)t:
49.
1aC
t6
8, 1
.5 h
CBt
i:57
i: 24
.6pa
in: B
pi-S
F
C: 5
7C:
26.
3D
epre
ssio
n: B
Di
Dis
abili
ty: S
F-12
pCS
inte
rfer
ence
: Bpi
-SF
Com
paris
on w
ith M
DT/r
elax
atio
n
Wic
ksel
l et a
l., 2
009
3.5
m, 6
.5 m
5Lo
ngst
and-
ing
idio
path
-ic
pai
n
t: 1
4.8
(2.4
)t:
21.
9aC
tin
divi
d-ua
l10
, 1 h
MD
ti:
16i:
6.3
(12.
5,
18.8
)pa
in: v
aS
C:16
C: 1
2.5
(31.
3, 3
1.3)
Dep
ress
ion:
CeS
-D
Dis
abili
ty: S
F-36
pCS
inte
rfer
ence
: Mpi
and
Bpi
Schm
idt e
t al.,
201
1;
8 w
6Fi
brom
yalg
iai:
53.4
(8
.7)
t: .0
MBS
rM
ax 1
28,
2.5
hre
laxa
tion
i: 53
i:15.
1 (1
1.3)
pain
: ppS
(sen
sory
pai
n)
C: 5
1.9
(9.2
)C:
56
C: 8
.9
(12.
5)D
epre
ssio
n: C
eS-D
QoL
: FiQ
thor
sell
et a
l., 2
011
6 m
, 6
Chro
nic
pain
t: 4
6.0
(12.
3)t:
35.
6aC
tin
divi
d-ua
l9
rela
xatio
ni:
52i:
46.2
(4
8.1,
67.
3)pa
in: n
rS
12 m
C: 3
8C:
28.
9 (3
1.6,
60.
5)D
epre
ssio
n: h
aDS
anxi
ety
: haD
SD
isab
ility
: ÖM
pQ
not
es: a
Ct: a
ccep
tanc
e an
d co
mm
itmen
t the
rapy
; C: c
ontr
ol g
roup
; CBt
: cog
nitiv
e be
havi
oura
l the
rapy
; FSM
t: fo
ur st
ep m
indf
ulne
ss-b
ased
ther
apy;
h: h
ours
; i: i
nter
vent
ion
grou
p; m
: mon
ths;
MBC
t:
min
dful
ness
-bas
ed c
ogni
tive
ther
apy;
MBp
M: m
indf
ulne
ss-b
ased
pai
n m
anag
emen
t; M
BSr:
min
dful
ness
-bas
ed st
ress
redu
ctio
n; M
Dt:
mul
tidis
cipl
inar
y tr
eatm
ent;
(M)t
au: (
med
ical
) tre
atm
ent a
s us
ual;
SD: s
tand
ard
devi
atio
n; t
: tot
al g
roup
; w: w
eeks
.o
utco
me
mea
sure
s: B
ai: B
eck
anxi
ety
inve
ntor
y; B
Di:
Beck
Dep
ress
ion
inve
ntor
y; B
pi: B
rief p
ain
inve
ntor
y; C
eS-D
: Cen
ter
for
epid
emio
logi
c St
udie
s D
epre
ssio
n Sc
ale;
CM
Di:
Chic
ago
Mul
ti-sc
ale
Dep
ress
ion
inve
ntor
y; C
-So
Si: C
alga
ry S
ympt
oms
of S
tres
s in
vent
ory;
DaS
S: D
epre
ssio
n an
xiet
y an
d St
ress
Sca
le; F
iQ: F
ibro
mya
lgia
impa
ct Q
uest
ionn
aire
; haD
S: h
ospi
tal a
nxie
ty a
nd D
epre
ssio
n Sc
ale;
LSQ
: Life
Sat
isfa
ctio
n Q
uest
ionn
aire
; MiD
aS: M
igra
ine
Dis
abili
ty a
sses
smen
t Sc
ale;
Mpi
: Mul
tidim
ensi
onal
pai
n in
vent
ory;
MpQ
: Mcg
ill p
ain
Que
stio
nnai
re; n
rS: n
umer
ical
rat
ing
Scal
e;
ÖM
pQ: Ö
rebr
o M
uscu
losk
elet
al p
ain
Que
stio
nnai
re; p
Di:
pain
Dis
abili
ty in
dex;
ph
Q-9
: pat
ient
hea
lth Q
uest
ionn
aire
-9; p
ir: p
ain
inte
nsity
rat
ing;
ppS
: pai
n pe
rcep
tion
Scal
e; p
ri: p
ain
ratin
g in
dex
(MpQ
); Q
oL: Q
ualit
y of
Life
pro
file
for t
he C
hron
ical
ly il
l; Q
oLi
: Qua
lity
of L
ife in
vent
ory;
Qo
LS: Q
ualit
y o
f Life
Sca
le; r
MD
Q: r
olan
d an
d M
orris
Dis
abili
ty Q
uest
ionn
aire
; SCL
-90:
90-
item
Sym
ptom
Ch
eckl
ist;
SF-1
2/SF
-36:
12/
36-it
em S
hort
-For
m h
ealth
Sur
vey;
SF-
36 g
h/p
CS/p
F: S
F-36
gen
eral
hea
lth/p
hysi
cal C
ompo
nent
Sum
mar
y/ph
ysic
al F
unct
ioni
ng; S
tai:
Stai
t-tra
it an
xiet
y in
vent
ory;
SW
LS: S
atis
fact
ion
With
Life
Sca
le; v
aS: v
isua
l ana
logu
e Sc
ale;
WSa
S: W
ork
and
Soci
al a
djus
tmen
t Sca
le.
n =
sam
ple
size
of p
ost-
trea
tmen
t ana
lyse
s, lo
wes
t sam
ple
size
in c
ase
sam
ple
size
s diff
ered
am
ong
outc
ome
mea
sure
s.
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6
16 M. M. VEEHOf ET Al.
on the quality criteria, six scored ‘high’ and five scored ‘low.’ None of the 25 studies met all the quality criteria.1
Characteristics of the three additional studies that only used an active control group are given in Table 2.
Publication bias
Some indication for publication bias was found for the outcome measure of depression. The funnel plot for depression is presented in Figure 2, and shows asymmetrically distributed studies in the bottom of the figure, which displays smaller studies. This might be due to the fact that smaller studies are more likely to be published if they have larger-than-average effects (Borenstein, 2005). The funnel plots for the other outcome measures were sym-metrically distributed around the pooled SMD, which is an indication for the absence of publication bias.
Post-treatment effects
Twenty-two studies assessed the effects at post-treatment on pain intensity, 16 on depres-sion, six on anxiety, four on pain interference, 10 on disability, and 11 on quality of life. Pooled SMDs and the results of the tests for heterogeneity and overall effect are presented in Table 3. Small effects were found for pain intensity, depression, disability, and quality of life with mean SMDs of respectively .24 (95% CI = .06, .42), .43 (95% CI = .18, .68), .40 (95% CI = .01, .79), and .44 (95% CI = −.05, .93). A moderate effect was found for anxiety and pain interference with mean SMD of respectively .51 (95% CI = .10, .92) and .62 (95% CI = .21, 1.03). All effects were statistically significant, except for the effect on quality of life (p = .08). Statistical heterogeneity between the studies was caused by the studies of Luciano et al. (2014) (for pain, depression, anxiety and quality of life) and Mo’tamedi, Rezaiemaram, and
Figure 2. Funnel plot for depression.
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COGnITIVE BEHAVIOuR THERAPy 17
Table 3. effects at post-treatment and follow-up.
Outcome measures Time n Studies
Heteroge-neity
Pooled SMD (95% CI)
Test for over-all effect
pain post-treat-ment
22 astin et al., 2003; Brown & Jones, 2013; Buhrman et al., 2013; Cath-cart et al., 2014; Dahl et al., 2004; Davis & Zautra, 2013; garland & Fredrickson, 2013; Johnston et al., 2010; Luciano et al., 2014; Mawani, 2009; McCracken et al., 2013; Morone et al., 2008, 2009; Mo’tamedi et al., 2012; nash-Mc Feron, 2006; plumb vilardaga, 2012; Schmidt et al., 2011; Wick-sell et al., 2008, 2013; C. M. Wong, 2009; Wong et al., 2011; Zautra et al., 2008
χ2 = 41.53, df = 21
(p = .005); I2 = 49%
.24 (.06, .42) Z = 2.68 (p = .007)
Follow-up 10 astin et al., 2003; Dahl et al., 2004; garland & Fredrickson, 2013; Luciano et al., 2014; McCracken et al., 2013; Morone et al., 2009; Schmidt et al., 2011; Wicksell et al., 2008, 2013; Wong et al., 2011
χ2 = 20.93, df = 9
(p = .01); I2 = 57%
.41 (.14, .68) Z = 3.02 (p = .003)
Depression post-treat-ment
16 astin et al., 2003; Buhrman et al., 2013; garland & Fredrickson, 2013; Johnston et al., 2010; Luciano et al., 2014; McCracken et al., 2013; parra-Delgado & Latorre-postigo, 2013; plumb vilardaga, 2012; pradhan et al., 2007; Schmidt et al., 2011; Sephton et al., 2007; Wicksell et al., 2008, 2013; C. M. Wong, 2009; Wong et al., 2011; Zautra et al., 2008
χ2 = 52.30, df = 15
(p < .00001); I2 = 71%
.43 (. 180, .68) Z = 3.38 (p = .0007)
Follow-up 10 astin et al., 2003; Luciano et al., 2014; McCracken et al., 2013; parra-Delgado & Latorre-posti-go, 2013; pradhan et al., 2007; Schmidt et al., 2011; Sephton et al., 2007; Wicksell et al., 2008, 2013; Wong et al., 2011
χ2 = 30.65, df = 9
(p = .0003); I2 = 71%
.50 (.19, .80) Z = 3.22 (p = .001)
anxiety post-treat-ment
6 Buhrman et al., 2013, Johnston et al., 2010; Luciano et al., 2014; Wicksell et al., 2008, 2013; Wong et al., 2011
χ2 = 15.13, df = 5
(p = .01); I2 = 67%
.51 (.10, .92) Z = 2.42 (p= .02)
Follow-up 4 Luciano et al., 2014; Wicksell et al., 2008, 2013; Wong et al., 2011
χ2 = 12.07, df = 3
(p = .007); I2 = 75%
.57 (.00, 1.14) Z = 1.97 (p = .05)
pain inter-ference
post-treat-ment
4 Buhrman et al., 2013; garland & Fredrickson, 2013; Wicksell et al., 2008; C. M. Wong, 2009
χ2 = 6.50, df = 3
(p = .09); I2 = 54%
.62 (.21, 1.03) Z = 2.94 (p = .003)
Follow-up 2 garland & Fredrickson, 2013; Wicksell et al., 2008
χ2 = .58, df = 1
(p = .44); I2 = 0%
1.05 (.55, 1.56) Z = 4.09 (p < .0001)
Disability post-treat-ment
10 Brown & Jones, 2013; McCracken et al., 2013; Morone et al., 2008, 2009; Mo’tamedi et al., 2012; nash-Mc Feron, 2006; plumb vilardaga, 2012; Wicksell et al., 2008, 2013; Wong et al., 2011
χ2 = 30.12, df = 9
(p = .0004); I2 = 70%
.40 (.01, .79) Z = 2.01 (p = .04)
(Continued)
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Tavallaie (2012) (for disability). Both studies, which were respectively of high and medium quality, found large beneficial effects of acceptance- and mindfulness-based interventions.
Follow-up effects
Thirteen studies assessed long-term effects. Follow-up periods ranged from 2 months to 6 months after completing treatment. Wong et al. (2011) reported follow-up results at both 3 and 6 months. In this case, we included the longest follow-up period. Ten studies assessed the effects on pain intensity, 10 on depression, four on anxiety, two on pain interference, five on disability, and seven on quality of life. Pooled SMDs and the results of the tests for heterogeneity and overall effect are presented in Table 3. The effect on pain increased but remained small with a mean SMD of .41 (95% CI = .14, .68). The effects on depression and quality of life (slightly) increased and became moderate with mean SMDs of respectively . 53 (95% CI = .24, .82) and .66 (95% CI = .06, 1.26). The effect on pain interference increased and became large with a mean SMD of 1.05 (95% CI = .55, 1.56). The effects on anxiety and disability remained moderate with mean SMDs of respectively .59 (95% CI = .14, 1.04) and .39 (95% CI = .11, .67). All effects were statistically significant.
Subgroup analyses
Results of the subgroup analyses are presented in Table 4. Significant differences in mean SMDs were found between some subgroups. ACT interventions reported a statistically significant higher mean effect on depression (SMD .82 vs. .18) and anxiety (SMD .64 vs. −.01) than mindfulness-based interventions. Furthermore, studies using a (M)TAU group as the control group (SMD .85) showed a higher mean effect on anxiety than studies using an education/support group as an active control group (SDM .07). Finally, medium quality studies (SMD .17) showed a lower mean effect on quality of life than the low (SMD 1.01) and high (2.33) quality studies.
Outcome measures Time n Studies
Heteroge-neity
Pooled SMD (95% CI)
Test for over-all effect
Follow-up 5 [68, 74, 85, 110, 111, 117] Mc-Cracken et al., 2013; Morone et al., 2009; Wicksell et al., 2008, 2013; Wong et al., 2011
χ2 = 4.54, df = 4
(p = .34); I2 = 12%
.39 (.11, .67) Z = 2.71 (p = .007)
Quality of life
post-treat-ment
11 astin et al., 2003; Buhrman et al., 2013; Dahl et al., 2004; Johnston et al., 2010; Luciano et al., 2014; Morone et al., 2008; parra-Delga-do & Latorre-postigo, 2013; plumb vilardaga, 2012; Schmidt et al., 2011; Wicksell et al., 2008, 2013
χ2 = 68.44, df = 10
(p < .00001); I2 = 85%
.44 (−.05, .93) Z = 1.77 (p = .08)
Follow-up 7 astin et al., 2003; Dahl et al., 2004; Luciano et al., 2014; parra-Del-gado & Latorre-postigo, 2013; Schmidt et al., 2011; Wicksell et al., 2008, 2013
χ2 = 41.41, df = 6
(p < .00001); I2 = 86%
.66 (.06, 1.26) Z = 2.16 (p = .03)
notes: SMD, standardized mean difference; 95% Ci, 95% confidence interval; df, degrees of freedom; n.a., not applicable.
Table 3. (Continued).
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Table 4. Subgroup analyses on outcome measures at post-treatment.
Outcome measure Criteria Subgroup n SMD [95% CI] Test for subgroup differences
pain Quality Low 5 .27(−.06, .60) χ2 = 1.33, df = 2 (p = .52), I2 = 0%Medium 12 .13 (−.06, .32)high 5 .39 (−.08, .85)
intervention aCt 9 .38 (.00, .76) χ2 = 1.23, df = 1 (p = .27), I2 = 18.8%Mindfulness 13 .15 (−.01, .30)
Control group education/support 8 .13 (−.08, .34) χ2 = 1.11, df = 1 (p = .29), I2 = 9.8%(M)tau/waitlist 14 .31 (.06, .57)
pain type Chronic pain 10 .19 (.01, .38) χ2 = .15, df = 3 (p = .98), I2 = 0%Fibromyalgia 5 .23 (−.34, .80)Specific-site pain 6 .27 (−.06, .59)rheumatoid arthritis 1 .22 (−.26, .69)
attrition rate <25% 11 .38 (.12, .63) χ2 = 3.16, df = 1 (p = .08), I2 = 68.3%>25% 11 .08 (−.14, .29)
Depression Quality Low quality 1 .60 (−.49, 1.70) χ2 = .34, df = 2 (p = .84), I2 = 0%Medium quality 9 .34 (.16, .51)high quality 6 .45 (−.13, 1.02)
intervention aCt 7 .82 (.30, 1.33) χ2 = 5.36, df = 1 (p = .02), I2 = 81.3%Mindfulness 9 .18 (.03, .34)
Control group education/support 5 .21 (.00, .41) χ2 = 2.66, df = 1 (p = .10), I2 = 62.4%(M)tau/waitlist 11 .56 (.19, .93)
pain type Chronic pain 7 .35 (.15, .55) χ2 = 6.56, df = 3 (p = .09), I2 = 54.3%Fibromyalgia 6 .54 (−.02, 1.11)Specific-site pain 1 1.09 (.13, 2.05)rheumatoid arthritis 2 .00 (−.34, .34)
attrition rate <25% 10 .46 (.07, .84) χ2 = .20, df = 1 (p = .66), I2 = 0%>25% 6 .36 (.13, .58)
anxiety Quality Low quality 1 1.40 (.17, 2.62) χ2 = 2.74, df = 2 (p = .25), I2 = 27.1%Medium quality 3 .33 (−.02, .67)high quality 2 .47 (−.48, 1.42)
intervention aCt 5 .64 (.24, 1.05) χ2 = 5.09, df = 1 (p = .02), I2 = 80.4%Mindfulness 1 −.01 (−.40, .38)
Control group education/support 2 .07 (−.23, .37) χ2 = 12.42, df = 1 (p = .0004), I2 = 91.9%(M)tau/waitlist 4 .85 (.53, 1.16)
pain type Chronic pain 3 .25 (−.25, .76) χ2 = 2.76, df = 2 (p = .25), I2 = 27.7%Fibromyalgia 2 .81 (.39, 1.23)Specific-site pain 1 .62 (−.29, 1.53)rheumatoid arthritis 0
attrition rate <25% 5 .43 (.01, .84) χ2 = 2.16, df = 1 (p = .14), I2 = 53.82%>25% 1 1.40 (.17, 2.62)
Disability Quality Low quality 2 .41 (.05, .77) χ2 = 1.81, df = 2 (p = .41), I2 = 0%Medium quality 7 .57 (.00, 1.14)high quality 1 .35 (−.04, .75)
intervention aCt 5 .75 (−.10, 1.61) χ2 = 1.42, df = 1 (p = .23), I2 = 29.7%Mindfulness 5 .21 (−.05, .47)
Control group education/support 2 .34 (−.01, .68) χ2 = .12, df = 1 (p = .73), I2 = 0%(M)tau/waitlist 8 .45 (−.09, .98)
pain type Chronic pain 4 .22 (−.13, .56) χ2 = 3.65, df = 2 (p = .16), I2 = 45.2%Fibromyalgia 1 −.19 (−.85, . 47)Specific-site pain 5 .81 (.03, 1.59)rheumatoid arthritis 0
attrition rate <25% 7 .36 (.13, .58) χ2 = .14, df = 1 (p = .70), I2 = 0%>25% 4 .59 (.60, 1.78)
Quality of life Quality Low quality 1 1.01 (−.14, 2.16) χ2 = 61.50, df = 2 (p < .00001), I2 = 96.7%
Medium quality 9 .17 (−.02, .37)high quality 1 2.30 (1.80, 2.80)
intervention aCt 6 .77 (−.13, 1.67) χ2 = 1.74, df = 1 (p = .19), I2 = 42.4%Mindfulness 5 .14 (−.10, .39)
Control group education/support 2 .08 (−.25, .41) χ2 = 1.57, df = 1 (p = .21), I2 = 36.2%(M)tau/waitlist 9 .53 (−.09, 1.16)
pain type Chronic pain 4 .03 (−.46, .52) χ2 = 2.13, df = 2 (p = .35), I2 = 5.9%Fibromyalgia 5 .67 (−.19, 1.52)Specific-site pain 2 .52 (−.28, 1.32)rheumatoid arthritis 0
attrition rate <25% 7 .60 (−.09, 1.28) χ2 = 1.35, df = 1 (p = .25), I2 = 26.0%>25% 4 .11 (−.32, .54)
(Continued)
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Comparison with active treatments
In two of the 25 studies, a comparison was made with both a waitlist or education/support group and an active intervention such as CBT (Zautra et al., 2008) or relaxation (Schmidt et al., 2011). Three additional studies made only a comparison with an active intervention like CBT (Wetherell et al., 2011), MDT (Wicksell et al., 2009) or relaxation (Thorsell et al., 2011). The results of these studies were pooled in a meta-analysis to compare the effects of acceptance- and mindfulness-based interventions with the effects of other active treatments. Pooled SMDs and the results of the tests for heterogeneity and overall effect are presented in Table 5. Small effects were found on depression, pain interference and disability, in favour of CBT compared to acceptance- and mindfulness-based interventions. Moderate to large effects were found on pain, depression, pain interference, disability and quality of life in favour of acceptance- and mindfulness-based interventions compared to MDT/relaxation. None of these differences in pooled SMDs were significantly different.
Discussion
Main findings
The increased number of studies on the effectiveness of acceptance- and mindfulness-based interventions for people with chronic pain enabled a more robust assessment of their effects on the physical and mental health of patients. Twenty-five randomized controlled trials (RCTs) were included in this meta-analysis. At post treatment, small effects were found for pain intensity, depression, disability and quality of life; and moderate effects for anxiety and pain-interference. These results confirm the findings of the former meta-analysis (Veehof et al., 2011). The larger effect size for pain interference is congruent with acceptance- and mindfulness-based treatment models, mainly because pain interference, as opposed to pain intensity, is a more proximate indicator of the aim of acceptance- and mindfulness-based interventions, i.e. for patients to go along with life even in the face of pain. Disabilities caused by chronic pain as experienced by patients also depend on the degree to which the patients allow pain sensations to interfere with their daily life. Increased acceptance of pain sensations instead of fighting them, may be related to a larger decrease of pain interference.
Outcome measure Criteria Subgroup n SMD [95% CI] Test for subgroup differences
pain interfer-ence
Quality Low quality 0 χ2 = .03, df = 1 (p = .86), I2 = 0%
Medium quality 2 .64 (.23, 1.06)high quality 2 .56 (.28, 1.40)
intervention aCt 2 .64 (−.23, 1.06) χ2 = .03, df = 1 (p = .86), I2 = 0%Mindfulness 2 .56 (−.28, 1.40)
Control group education/support 2 .76 (−.34, 1.18) χ2 = .34, df = 1 (p = .56), I2 = 0%(M)tau/waitlist 2 .48 [−.37, 1.32)
pain type Chronic pain 3 .56 (.09, 1.03) χ2 = .72, df = 1 (p = .40), I2 = 0%Fibromyalgia 0Specific-site pain 1 1.02 (.07, 1.96)rheumatoid arthritis 0
attrition rate <25% 2 .64 (.23, 1.06) χ2 = .03, df = 1 (p = .86), I2 = 0%>25% 2 .56 (−.28, 1.40)
notes: SMD, standardized mean difference; 95% Ci, 95% confidence interval; aCt, acceptance and commitment therapy; (M)tau, (medical) treatment as usual.
Table 4. Subgroup analyses on outcome measures at post-treatment.
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Only four studies, however, included pain interference as an outcome measure. To ensure conformity, comparability and especially, consistency with theory, we advise for future acceptance- and mindfulness-based intervention trials to apply pain interference or pain disabilities as the primary outcome.
At two to six months after treatment, the effect sizes for depression, anxiety and quality of life were moderate. The effect size for pain interference was large. These (in general) larger effects at follow-up indicate that patients, even in the presence of enduring pain, in the long term manage to apply the principles of acceptance- and mindfulness-based treatments in their daily lives.
The effect sizes for pain intensity were small, both at post-treatment and follow-up. This confirms the findings of a recent systematic review of mindfulness-based interventions and ACT in mixed samples (Reiner, Tibi, & Lipsitz, 2013). Given the chronic nature of pain, it is doubtful whether psychological treatments can achieve larger effects on pain intensity. Pain control and reduction are not the primary aims of acceptance- and mindfulness-based interventions, but some impact on pain intensity may be reached because mindfulness skills have been found to influence brain mechanisms that may alter the pain experience (Zeidan et al., 2011). In addition, acceptance- and mindfulness-based interventions can have indirect effects on pain intensity since increased acceptance may buffer the degree to which pain sensations are experienced as stressful events to be immediately avoided (Shapiro, Carlson, Astin, & Freedman, 2006).
Subgroup analyses showed that the effect sizes of ACT were higher in comparison to MBSR and MBCT for all outcome measures and significantly higher for depression and anxiety. The difference on depression remained after excluding an ACT study that found
Table 5. Comparison of acceptance-based treatments with CBt and MDt/relaxation at post-treatment.
note: SMD, standardized mean difference; 95% Ci, 95% confidence interval; df, degrees of freedom; n.a., not applicable.
Outcome measures n Studies Heterogeneity
Pooled SMD (95% CI)
Test for overall effect
Comparison with CBT
pain 2 Wetherell et al., 2011; Zautra et al., 2008
χ2 = 6.04, df = 1 (p = .01); I2 = 83%
−.02 (−.74, .70) Z = .05 (p = .96)
Depression 2 Wetherell et al., 2011; Zautra et al., 2008
χ2 = 1.29, df = 1 (p = .26); I2 = 22%
−.25 (−.58, .08) Z = 1.48 (p = .14)
anxiety 0pain interference 1 Wetherell et al., 2011 n.a. −.23 (−.60, .14) Z = 1.24 (p = .21)Disability 1 [109] n.a. −.22 (−.58, .15) Z = 1.15 (p = .25)Quality of life 0
Comparison with MDT/relaxation
pain 3 Schmidt et al., 2011; thorsell et al., 2011; Wicksell et al., 2009
χ2 = 27.09, df = 2 (p < .00001);
I2 = 93%
.94 (−.16, 2.04) Z = 1.68 (p = .09)
Depression 3 Schmidt et al., 2011; thorsell et al., 2011; Wicksell et al., 2009
χ2 = 51.94, df = 2 (p < .00001);
I2 = 96%
.83 (−.70, 2.37) Z = 1.06 (p = .29)
anxiety 1 thorsell et al., 2011 n.a. .00 (−.42, .42) Z = .00 (p = 1.00)pain interference 1 Wicksell et al., 2009 n.a. .69 (−.03, 1.41) Z = 1.89 (p = .06)Disability 2 thorsell et al., 2011;
Wicksell et al., 2009χ2 = 49.90, df = 1
(p < .00001); I2 = 98%
2.54 (−1.20, 6.29) Z = 1.33 (p = .18)
Quality of life 2 Schmidt et al., 2011; thorsell et al., 2011
χ2 = 63.08, df = 1 (p < .00001);
I2 = 98%
1.56 (−1.31, 4.43) Z = 1.07 (p = .29)
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large effects on depression and anxiety (Luciano et al., 2014) . The explicit formulation of life values and the emphasis on committed action of the ACT-model may install hope and increase behavioral change and thereby explain the larger effects of ACT when compared to MBSR and MBCT. The smaller effects of MBSR and MBCT in this meta-analysis corrob-orate with a recent meta-analysis of the effects of mindfulness on anxiety and depression (Hofmann, Sawyer, Witt, & Oh, 2010). For fibromyalgia, none or small effects of MBSR or MBCT were found in (randomized) controlled studies (Lakhan & Schofield, 2013; Lauche, Cramer, Dobos, Langhorst, & Schmidt, 2013).
Except for quality of life, the quality of the studies was not found to moderate outcomes. For quality of life, studies of medium quality were found to have significant lower effect. However, this result needs to be interpreted with caution since the number of high- and low-quality studies were only one study each.
Overall, the effect sizes found in this study were at least comparable to those found in a recent meta-analysis of CBT for chronic pain patients (Williams et al., 2012). Williams and co-workers found small post treatment effect sizes on pain intensity, disability and mood in their meta-analysis of sixteen RCTs, in which CBT was compared to TAU or a waiting list. However, only the effect size of mood was maintained at follow-up (Williams et al., 2012). This finding is in contrast to those of the current meta-analysis which showed that the effects on all outcomes, except pain intensity, increased at follow-up.
The subgroup analysis on control group showed that (M)TAU and waitlist did not differ from the active control conditions of support groups or education, apart from a significant difference in favour of (M)TAU on anxiety. Pain education as developed by Moseley and his colleagues has been shown to have beneficial effects as a treatment on its own (Moseley & Butler, 2015). This pain education program, however, differs fundamentally form the pain management education used in most of the studies in this meta-analysis, by the important role for explanation of the biological basis of pain. It thereby offers alternative and more helpful conceptualisations of pain and of inadequate (catastrophic) cognitions patients may be fused with. Five studies compared acceptance- and mindfulness-based interventions to active treatments such as CBT (Wetherell et al., 2011; Zautra et al., 2008), relaxation (Schmidt et al., 2011; Thorsell et al., 2011) or MDT (Wicksell et al., 2009). Small effects were found in favour of CBT, and moderate to large effects were found in favour of acceptance- and mindfulness-based treatments compared to relaxation or MDT. However, the number of studies is small and none of differences were found to be significant in the pooled analyses.
Study limitations and strengths
The number of studies on acceptance- and mindfulness-based interventions has increased considerably since our former systematic review and meta-analysis. Therefore, we were able to restrict ourselves to the more rigorous test of RCTs. However, this study also contains a number of limitations. First, the average quality of studies has not improved over the past six years. Although the number of high quality studies has increased compared to our previous search up to 2009, a number of studies of low quality have still been recently published. The rating of quality may be an underestimation since we rated a criterion as not-fulfilled if it was not reported in the article. It is also plausible that mean quality would be enhanced if all researchers would routinely report on their randomization procedures and the training of therapists. Second, we combined studies of ACT with mindfulness-based studies. This allows
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for a comparison of the recent results with the results of the former systematic review and meta-analysis. However, the ACT and mindfulness based treatments can only be compared at post-treatment, since the number of studies were too small to perform subgroup analyses at follow-up. As studies continue to increase, future meta-analyses may differentiate between acceptance- and mindfulness-based interventions to understand their unique effects. Third, a small number of studies were represented in some of the subgroup analyses.
The data extraction of this study revealed a great number of qualitative, narrative or sys-tematic reviews. By now, the field is saturated with reviews. The meta-analytic approach of this study and the reported effect sizes not only offer insight into the strength of effects, but can also be used to benchmark pre- to post-treatment as well as follow-up measurements in daily practice (Morley, 2011).
Conclusions and recommendations
To conclude, acceptance- and mindfulness-based interventions for chronic pain are, on the whole, moderately effective on a number of beneficial outcomes, especially in the long term. Nevertheless, there is room for progress and treatment improvement.
It is necessary to study whether interventions work in accordance to their underlying theoretical basis. In CBT, the main hypothesized working mechanism is the changing of the content of thoughts such as catastrophizing cognitions and of emotions such as kinesi-ophobia (Crombez, Eccleston, Van Damme, Vlaeyen, & Karoly, 2012). In acceptance- and mindfulness-based treatments, mindfulness and psychological flexibility are hypothesized to be the main process of change (McCracken & Morley, 2014). In a MBSR study among adults with problematic stress resulting from chronic pain, chronic disease or other life circumstances, increases in mindfulness preceded decreases in perceived stress (Baer et al., 2012). A meta-analysis of samples with a mix of mental and physical health prob-lems, showed that ACT seemed to work through its proposed mechanism of change while CBT did not (Ruiz, 2012). In a mediation analysis within a sample of patients with chronic whiplash-associated disorders, psychological inflexibility was identified as a mediator on pain-related disability and life satisfaction, but kinesiophobia was not (Wicksell et al., 2010). The mediating role of psychological inflexibility was also found in individuals with pain that finished an online ACT program, but there were indications that catastrophizing, a putative mediating variable in a CBT model, was also an independent mediator on pain interference (Trompetter, Bohlmeijer, Fox, & Schreurs, 2015). Therefore, it is recommended to include variables from the CBT, mindfulness, as well as from the psychological flexibility model in future studies.
Knowledge on mechanisms of change can help to enhance or integrate our existing theoretical models of chronic pain, thereby progressing opportunities for more effective treatment. More than one measurement moment must be scheduled during the interven-tion phase to discern how processes unfold over time. But the scheduling of more intensive measurement is advisable to really grasp time-varying processes in relation to specific intervention characteristics and subsequent changes in outcome. We suggest that the appli-cation of intensive measurements once per day, or even more times per day by the use of mobile technology gives real insight into unfolding processes over time within individuals (Richardson & Reid, 2013). When scheduling the intensity and timing of measurements during interventions, however, we must not merely measure mechanisms just for the sake of
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measuring. Timing and spacing of measurements needs to be well thought out and be related to theory and intervention characteristics. It must be scheduled in such a way that one is most certain to catch unfolding of processes one is interested in (Selig & Preacher, 2009).
Furthermore, outcomes could also be improved if treatments are matched to the char-acteristics of patients. In general, sample sizes of current RCTs are too small to answer questions on what works for whom; therefore, studies should be designed to investigate specific hypotheses.
Finally, clinicians and researchers should invest in treatment integrity. In this meta- analysis, only seven studies performed a treatment integrity check. Clearly, this is a challenging criterion that is still too liberally applied in this and other meta-analyses since the mere report of an integrity check already receives credit. If we want to improve the effects of interventions, it is absolutely necessary to ensure that interventions are provided as intended.
Overall, we can conclude that individuals with pain, in general, respond rather well to acceptance- and mindfulness-based interventions and that beneficial effects are retained after treatment. ACT seems to be more effective in treating depression and anxiety in indi-viduals with pain than mindfulness-based treatments.
Note
1. Information on the quality assessment per study is obtainable from the corresponding author.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
M. M. Veehof http://orcid.org/0000-0003-3907-3322H. R. Trompetter http://orcid.org/0000-0003-4518-6999E. T. Bohlmeijer http://orcid.org/0000-0002-7861-1245K. M. G. Schreurs http://orcid.org/0000-0002-1229-0151
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Zautra, A. J., Davis, M. C., Reich, J. W., Nicassario, P., Tennen, H., Finan, P., … Irwin, M. R. (2008). Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. Journal of Consulting and Clinical Psychology, 76, 408–421. doi:10.1037/0022-006X.76.3.408
Zeidan, F., Martucci, K. T., Kraft, R. A., Gordon, N. S., McHaffie, J. G., & Coghill, R. C. (2011). Brain mechanisms supporting the modulation of pain by mindfulness meditation. Journal of Neuroscience, 31, 5540–5548. doi:10.1523/JNEUROSCI.5791-10.2011
Appendix 1. Search strategy Pubmed (OVID)
(“attention”[MeSH Terms] OR “attention”[All Fields]) OR (“mindfulness”[MeSH Terms] OR “mind-fulness”[All Fields]) OR vipassana[All Fields] OR (“meditation”[MeSH Terms] OR “meditation”[All Fields]) OR MBSR[All Fields] OR MBCT[All Fields] OR “mindfulness-based stress reduction”[All Fields] OR “mindfulness-based cognitive therapy”[All Fields] OR “acceptance based”[All Fields] OR “acceptance-based”[All Fields] OR (acceptance[All Fields] AND (“Commitment”[Journal] OR “commitment”[All Fields]))AND((“chronic pain”[MeSH Terms] OR (“chronic”[All Fields] AND “pain”[All Fields]) OR “chronic pain”[All Fields]) OR (“fibromyalgia”[MeSH Terms] OR “fibromyalgia”[All Fields]) OR “chronic fatigue syndrome”[All Fields] OR “whiplash associated disorder”[All Fields] OR WAD[All Fields] OR “repetitive strain injury”[All Fields] OR RSI[All Fields] OR dystrophy[All Fields] OR (com-plaints[All Fields] AND (“arm”[MeSH Terms] OR “arm”[All Fields]) AND (“neck”[MeSH Terms] OR “neck”[All Fields]) AND (“shoulder”[MeSH Terms] OR “shoulder”[All Fields])) OR CANS[All Fields] OR “complex regional pain syndrome”[All Fields] OR CRPS[All Fields])AND(hasabstract[text]AND(“2009/01/01”[PDAT] : “2013/12/31”[PDAT])ANDEnglish[lang])
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