Jennifer A. Haythornthwaite

Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis

IMPORTANCE Many people meditate to reduce psychological stress and stress-related health problems. To counsel people appropriately, clinicians need to know what the evidence says about the health benefits of meditation. OBJECTIVE To determine the efficacy of meditation programs in improving stress-related outcomes (anxiety, depression, stress/distress, positive mood, mental health-related quality of life, attention, substance use, eating habits, sleep, pain, and weight) in diverse adult clinical populations. EVIDENCE REVIEW We identified randomized clinical trials with active controls for placebo effects through November 2012 from MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL, AMED, the Cochrane Library, and hand searches. Two independent reviewers screened citations and extracted data. We graded the strength of evidence using 4 domains (risk of bias, precision, directness, and consistency) and determined the magnitude and direction of effect by calculating the relative difference between groups in change from baseline. When possible, we conducted meta-analyses using standardized mean differences to obtain aggregate estimates of effect size with 95% confidence intervals. FINDINGS After reviewing 18 753 citations, we included 47 trials with 3515 participants. Mindfulness meditation programs had moderate evidence of improved anxiety (effect size, 0.38 [95% CI, 0.12-0.64] at 8 weeks and 0.22 [0.02-0.43] at 3-6 months), depression (0.30 [0.00-0.59] at 8 weeks and 0.23 [0.05-0.42] at 3-6 months), and pain (0.33 [0.03- 0.62]) and low evidence of improved stress/distress and mental health-related quality of life. We found low evidence of no effect or insufficient evidence of any effect of meditation programs on positive mood, attention, substance use, eating habits, sleep, and weight. We found no evidence that meditation programs were better than any active treatment (ie, drugs, exercise, and other behavioral therapies). CONCLUSIONS AND RELEVANCE Clinicians should be aware that meditation programs can result in small to moderate reductions of multiple negative dimensions of psychological stress. Thus, clinicians should be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress. Stronger study designs are needed to determine the effects of meditation programs in improving the positive dimensions of mental health and stress-related behavior.

NeuPSIG guidelines on neuropathic pain assessment

&NA; This is a revision of guidelines, originally published in 2004, for the assessment of patients with neuropathic pain. Neuropathic pain is defined as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system either at peripheral or central level. Screening questionnaires are suitable for identifying potential patients with neuropathic pain, but further validation of them is needed for epidemiological purposes. Clinical examination, including accurate sensory examination, is the basis of neuropathic pain diagnosis. For more accurate sensory profiling, quantitative sensory testing is recommended for selected cases in clinic, including the diagnosis of small fiber neuropathies and for research purposes. Measurement of trigeminal reflexes mediated by A‐beta fibers can be used to differentiate symptomatic trigeminal neuralgia from classical trigeminal neuralgia. Measurement of laser‐evoked potentials is useful for assessing function of the A‐delta fiber pathways in patients with neuropathic pain. Functional brain imaging is not currently useful for individual patients in clinical practice, but is an interesting research tool. Skin biopsy to measure the intraepidermal nerve fiber density should be performed in patients with clinical signs of small fiber dysfunction. The intensity of pain and treatment effect (both in clinic and trials) should be assessed with numerical rating scale or visual analog scale. For future neuropathic pain trials, pain relief scales, patient and clinician global impression of change, the proportion of responders (50% and 30% pain relief), validated neuropathic pain quality measures and assessment of sleep, mood, functional capacity and quality of life are recommended.

How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature

Sleep disturbance is perhaps one of the most prevalent complaints of patients with chronically painful conditions. Experimental studies of healthy subjects and cross-sectional research in clinical populations suggest the possibility that the relationship between sleep disturbance and pain might be reciprocal, such that pain disturbs sleep continuity/quality and poor sleep further exacerbates pain. This suggests that aggressive management of sleep disturbance may be an important treatment objective with possible benefits beyond the improvement in sleep. Little is known, however, about how to effectively treat sleep disturbance associated with pain or whether such treatment might have beneficial effects on reducing pain. A small, but growing literature has applied cognitive-behavioral therapies (CBT) for either pain management or insomnia to patients with chronic pain. In this article, we review the longitudinal literature on sleep disturbance associated with chronic pain and clinical trial literatures of cognitive-behavior therapy for pain management and insomnia secondary to chronic pain with the aim of evaluating whether the relationship between clinical pain and insomnia is reciprocal. While methodological problems are common, the literature suggests that the relationship is reciprocal and CBT treatments for pain or insomnia hold promise in reducing pain severity and improving sleep quality. Directions for future research include the use of validated measures of sleep, longitudinal studies, and larger randomized clinical trials incorporating appropriate attentional controls and longer periods of follow-up.

Opioids versus antidepressants in postherpetic neuralgia A randomized, placebo-controlled trial

Background Tricyclic antidepressants (TCA) provide less than satisfactory pain relief for postherpetic neuralgia (PHN), and the role of opioids is controversial. Objective To compare the analgesic and cognitive effects of opioids with those of TCA and placebo in the treatment of PHN. Methods Seventy-six patients with PHN were randomized in a double-blind, placebo-controlled, crossover trial. Each subject was scheduled to undergo three treatment periods (opioid, TCA, and placebo), approximately 8 weeks’ duration each. Doses were titrated to maximal relief or intolerable side effects. The primary outcome measures were pain intensity (0 to 10 scale), pain relief (0 to 100%), and cognitive function. Analyses included patients who provided any pain ratings after having received at least a single dose of a study medication. Results Fifty patients completed two periods, and 44 patients completed all three. Mean daily maintenance doses were morphine 91 mg or methadone 15 mg and nortriptyline 89 mg or desipramine 63 mg. Opioids and TCA reduced pain (1.9 and 1.4) more than placebo (0.2;p < 0.001), with no appreciable effect on any cognitive measure. The trend favoring opioids over TCA fell short of significance (p = 0.06), and reduction in pain with opioids did not correlate with that following TCA. Treatment with opioids and TCA resulted in greater pain relief (38 and 32%) compared with placebo (11%;p < 0.001). More patients completing all three treatments preferred opioids (54%) than TCA (30%;p = 0.02). Conclusions Opioids effectively treat PHN without impairing cognition. Opioids and TCA act via independent mechanisms and with varied individual effect.

Readiness to adopt a self-management approach to chronic pain: the Pain Stages of Change Questionnaire (PSOCQ)

Abstract This manuscript describes the development and initial validation of a self‐report questionnaire designed to assess an individuals readiness to adopt a self‐management approach to their chronic pain condition. Theory and preliminary empirical work informed the development of a pool of items that were administered to a sample of individuals reporting chronic pain. Analyses of the data support a four factor measure that is consistent with the transtheoretical model of change and associated stages of change model. Each of the four factors, precontemplation, contemplation, action, and maintenance, was found to be internally consistent and stable over time. There was also substantial support for each factors discriminant and criterion‐related validity.

Catastrophizing as a mediator of sex differences in pain: differential effects for daily pain versus laboratory-induced pain

Abstract Sex differences in the experience of pain have been widely reported, with females generally reporting more frequent clinical pain and demonstrating greater pain sensitivity. However, the mechanisms underpinning such differences, while subject to intense speculation, are not well‐characterized. Catastrophizing is a cognitive and affective process that relates strongly to enhanced reports of pain and that varies as a function of sex. It is thus a prime candidate to explain sex differences; indeed, several prior studies offer evidence that controlling for catastrophizing eliminates the gap between men and women in reported pain. We recruited 198 healthy young adults (115 female) who took part in laboratory studies of pain responses, including thermal pain, cold pain, and ischemic pain, and who also completed questionnaires assessing catastrophizing, mood, and day‐to‐day painful symptoms (e.g. headache, backache). Women reported greater levels of catastrophizing, more recent painful symptoms, and demonstrated lower pain thresholds and tolerances for noxious heat and cold relative to men. Mediational analyses suggested that after controlling for negative mood, catastrophizing mediated the sex difference in recent daily pain but did not mediate the much larger sex differences in pain threshold and tolerance. These findings highlight the role of catastrophizing in shaping pain responses, as well as illuminating potentially important differences between experimental pain assessment and the clinical experience of pain.

Coping with pain: What works, under what circumstances, and in what ways?

Geissen Robinson, and Riley present a stimulating conceptual model of coping with chronic pain in which the authors argue that maladaptive beliefs and coping are primary determinants of adjustment and influence adaptive beliefs and coping through their influence on perceptions of control. We discuss some aspects of the model that require further refinement. First, the assessments of beliefs, appraisals, and coping need to be independent of outcome, obviating the use of “adaptive” and “maladaptive” in conceptual models. Unqualified statements about the universal adaptiveness, or maladaptiveness, of appraisal and coping strategies are likely to be unusual, since some strategies may result in higher emotional adjustment but not physical adjustment or vice versa. Second, beliefs, appraisals, and coping are distinct conceptual dimensions. Conceptual models that delineate relevant dimensions of these constructs rather than unify these partially independent constructs will likely have greater utility. Third, broadening the conceptualization of pain appraisal to include the individuals interpretation of the meaning of the pain is likely to provide expanded understanding of the pain coping process. Fourth, factors active in the individuals environment, particularly social relationships, need to be integrated into any comprehensive model of coping with chronic pain. And fifth, the bidirectional relationships between beliefs, appraisals, and coping need to be integrated into conceptual models. These processes are interrelated and feed back to one another as the individual struggles to cope with the challenges and threat posed by pain. The inherent complexity of coping with pain requires conceptualizations that address its transactional nature and methodologies that capture this dynamic process. Our comments direct future investigators to address when coping works, in what way it works, and for whom it works.

Psychological aspects of neuropathic pain.

Abstract Studies on the psychosocial impact of neuropathic pain conditions, including postherpetic neuralgia, diabetic neuropathy, complex regional pain syndrome, post spinal cord injury, postamputation, and AIDS‐related neuropathy, are reviewed. Although limited, data are consistent with the larger literature on chronic pain and indicate that neuropathic pain reduces quality of life, including mood and physic and social functioning. Depression and pain coping strategies such as catastrophizing and social support predict pain severity, and a single diary study demonstrates a prospective relation between depressed mood and increased pain. Clinical trials of psychological interventions have not been reported, although some case series of successful treatment of neuropathic pain are reported, primarily in the area of biofeedback. Given the evidence indicating the broad impact of neuropathic pain on many areas of function, it is surprising that so few studies have investigated the impact of psychological interventions in these populations.

Discordance between pain and radiographic severity in knee osteoarthritis: Findings from quantitative sensory testing of central sensitization

OBJECTIVE Radiographic measures of the pathologic changes of knee osteoarthritis (OA) have shown modest associations with clinical pain. We sought to evaluate possible differences in quantitative sensory testing (QST) results and psychosocial distress profiles between knee OA patients with discordant versus congruent clinical pain reports relative to radiographic severity measures. METHODS A total of 113 participants (66.7% women; mean ± SD age 61.05 ± 8.93 years) with knee OA participated in the study. Radiographic evidence of joint pathology was graded according to the Kellgren/Lawrence scale. Central sensitization was indexed through quantitative sensory testing, including heat and pressure-pain thresholds, tonic suprathreshold pain (cold pressor test), and repeated phasic suprathreshold mechanical and thermal pain. Subgroups were constructed by dichotomizing clinical knee pain scores (median split) and knee OA grade scores (grades 1-2 versus 3-4), resulting in 4 groups: low pain/low knee OA grade (n = 24), high pain/high knee OA grade (n = 32), low pain/high knee OA grade (n = 27), and high pain/low knee OA grade (n = 30). RESULTS Multivariate analyses revealed significantly heightened pain sensitivity in the high pain/low knee OA grade group, while the low pain/high knee OA grade group was less pain-sensitive. Group differences remained significant after adjusting for differences on psychosocial measures, as well as age, sex, and race. CONCLUSION The results suggest that central sensitization in knee OA is especially apparent among patients with reports of high levels of clinical pain in the absence of moderate-to-severe radiographic evidence of pathologic changes of knee OA.

Duration of Sleep Contributes to Next-Day Pain Report in the General Population

&NA; Cross‐sectional research in clinical samples, as well as experimental studies in healthy adults, suggests that the experiences of pain and sleep are bi‐directionally connected. However, whether sleep and pain experiences are prospectively linked to one another on a day‐to‐day basis in the general population has not previously been reported. This study utilizes data from a naturalistic, micro‐longitudinal, telephone study using a representative national sample of 971 adults. Participants underwent daily assessment of hours slept and the reported frequency of pain symptoms over the course of one week. Sleep duration on most nights (78.0%) was between 6 and 9 h, and on average, daily pain was reported with mild frequency. Results suggested that hours of reported sleep on the previous night was a highly significant predictor of the current day’s pain frequency (Z = −7.9, p < .0001, in the structural equation model); obtaining either less than 6 or more than 9 h of sleep was associated with greater next‐day pain. In addition, pain prospectively predicted sleep duration, though the magnitude of the association in this direction was somewhat less strong (Z = −3.1, p = .002, in the structural equation model). Collectively, these findings indicate that night‐to‐night changes in sleep affect pain report, illuminating the importance of considering sleep when assessing and treating pain.