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Relaxation and Mindfulness in Pain: A Review
Dunford, E. & Thompson, M. (2010). Relaxation and mindfulnessin pain: a review. Reviews in Pain. 4, 18-23.
NB: The e-mail address for the authors are not printed inside this document.Miles Thompson can be contacted via this web site: www.mvdct.org.uk
http://www.mvdct.org.uk/http://www.mvdct.org.uk/ -
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Outline
Ts ate podes a seete naate eew of te exstng,
pee-eewed edene fo te use of eaxaton and mndfunesswt ndduas sueng fom pan. Hang dened bot tems,
te pape w outne te sope of ts eew befoe pesentng ts
ndngs. It onudes by dsussng boade aeas eeant to ts
eew as we as potenta esea detons.
Terms
An obsee watng ete a eaxaton o a mndfuness ass
toug te gass of a doo mgt stugge to te tem apat. Bot
woud pobaby noe a goup of patpants sttng o yng st
wt te eyes sut. Howee te deng dentons assoated
wt tese tenques nt at te sgnant aatons n wat tey
am to aee.
Reaxaton as been dened as tose pates wose pmay stated
goa s etaton of a psyopysooga state of eaxaton o ypo
aousa (p.3). A ommon denton of mndfuness s payng
attenton n a patua way: on pupose, n te pesent moment,
and non-judgmentay. Fo te pupose of ts ate we suggest
te foowng paae dentons of eaxaton and mndfuness,
debeatey - and possby oe-smpstay - set up to ontast one
anote: Reaxaton ams to aow ndduas to edue te feengs
of stess o tenson, we mndfuness ams to aow ndduas to
obsee te feengs of stess o tenson.
Reaxaton as a na tenque omes n many deent foms
nudng: pogesse muse/musua eaxaton, autogen
tanng, bofeedbak and guded magey. Deent aetes of
mndfuness aso exst su as Mndfuness-Based Stess Reduton(MBSR), Mndfuness Based Cognte Teapy (MBC) as we as
exstng wtn deent teapeut modes su as Aeptane and
Commtment Teapy (AC) and Daeta Beaou Teapy
(DB)3.
It s ea fom te paagaps aboe tat deenes exst between
eaxaton and mndfuness. Of ouse peope wo ae eanng
mndfuness mgt nd te exeses eaxng and tose wo ae
eaxed mgt nd t ease to e mndfuy. Howee t appeas tat
te tenques ae deent agendas.
Review Method
Ts ate does not am to pode a quanttate o meta-anayt
eew of te edene base fo eaxaton and mndfuness. Instead
t opes to ge a moe genea oeew of te uent state of te
teatue. Seaes usng Web of Sene and PsyINFO databases
wee onduted on 7t August 8. Tey wee mted between te
yeas 958 and 8 and used te tems eaxaton and pan, and
mndfuness and pan. Te eew tageted peous systemat
eews and goup-based esea studes pubsed n pee-eewed
jounas usng ete eaxaton o mndfuness n pan popuatons
(ete aute o on). Ate abstats wee ead by one auto
and exuded f tey: a) used eaxaton o mndfuness as ony onepat of a wde teapeut nteenton; b) dd not nude a sepaate
Reaxaton and Mndfuness n Pan: A ReewEmma Dunfod BSBath Centre for Pain Services.
Mes Tompson DCnPsyBath Centre for Pain Services.
S r i :
Ts ate eews te exstng, pee-eewed edene fo te use of eaxaton and mndfuness nbot aute and on pan.
Tee s some edene tat eaxaton an edue pan outomes n bot aute and on pan,owee tee s edene tat tese mpoements ae not mantaned oe tme.
Moe mted esea suggests tat mndfuness an ead to mpoements n psyooga measuesand pysa funtonng and tese mpoements appea to be mantaned at foow-up.
Fute esea s needed. Bot eseaes and pattones need to be eae on te outomes tatte tenques best fatate and te poesses w ae ate wtn tem.
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sensaton n on ow bak pan, atts and pegnany-eated
pan. Autogen tanng, jaw eaxaton and systemat eaxaton
wee found to edue postopeate pan. Rytm beatng and
ote eaxaton nteentons wee not found to be eete. In te
studes wee foow-up data wee nuded, mpoements wee not
mantaned at 3 and 6 monts5,6.
Evidence for Mindfulness and Pain
Of te nta esuts fom te seaes ony 3 studes met
te nuson tea of ts eew. A numbe of tese studes
andomsed patpants and/o used onto goups to some extent,
owee many wee pot studes. en ates wee teatment
outome studes nestgatng te eeteness of mndfuness wtn
adut on pan popuatons. Te emande nuded ete
mxed sampes o nestgated aute pan toeane wtn eaty
patpants. A summay of te 3 studes eewed ae pesented nTable 1. Te foowng text dsusses te studes by pan pesentaton
(on pan, bomyaga, atts, mxed and ommunty sampes
and eaty patpants).
Kabat-Znn and s team onduted some of te st esea studes
nto te eeteness of mndfuness7,8. Inteestngy, tese utsed
on pan popuatons. Ts esea found mpoements n
pysa and psyooga measues and tese mpoements wee
mantaned up to 5 monts ate. Moe eenty a study ompaed
mndfuness to massage teapy and standad ae ontos n a
andomsed onto ta. Patpants n te mndfuness ondton
epoted no deene n ete pysa o psyooga symptomsdety foowng te nteenton, but at week foow-up
epoted sgnant mpoements on psyooga measues. In
ontast, patpants n te massage ondton epoted a sgnant
pan eduton mmedatey foowng te nteenton but ts was
not mantaned at foow-up. Mndfuness nteentons ae aso
been found to ead to sgnant edutons n depesson, anxety
and pan-eated gef and sgnant ong tem mpoements n
pan aeptane and pysa funtonng wen ompaed to ontos
n a andomsed onto ta (RC). Futemoe, edene fom
fae to fae and dstane mndfuness nteentons eeas sgnant
mpoements n psyooga dstess, emotona and soa
funtonng and pan atastopsng wen ompaed to a onto
ondton.
A sma numbe of studes ae been onduted wt bomyaga
suees. In RCs, mndfuness nteentons ae been found to
sgnanty edue symptoms of depesson3 and nease sense of
oeene. Futemoe, eent esea epots tat mndfuness
nteentons ead to sgnant edutons n anxety and depesson
and neases n epoted quaty of fe wen ompaed to eaxaton,
exese and soa suppot5. Tese mpoements wee mantaned at
a 3 yea foow-up. Wt eumatod atts suees, no deene
was found at te end of teatment o ndeed at te mont foow-
up. Howee at te 6 mont foow-up, tose n te mndfuness
ondton epoted sgnant mpoements n psyooga dstessand we-beng n ompason to watng st ontos6.
measue of pan n te outomes; ) wee dssetatons o ase studes;
d) ontaned no abstat; o e) wee not wtten n Engs. In ases
of unetanty suoundng wete an ate met te nuson
tea, aaton was sougt toug dsusson wt te ote
auto.
Te esea ommunty as ad substantay onge to estabs
an edene base fo eaxaton tenques and te tem eaxaton
eates to many ote tngs, fo exampe te pysooga eaxaton
of a muse n sugey. Aodngy t was unsupsng tat te
seaes ntay podued 55 esuts fo eaxaton and pan, and
fo mndfuness and pan.
Evidence for Relaxation and Pain
Te eaxaton esea edene oes a wde span of tme and a
wde aety of pan expeenes. Fotunatey, gen ts beadt anddept, 3 systemat eews,5,6 pubsed n 8 and 6 pode
oeews, but not meta-anayses, of te edene base fo eaxaton
between 5 and 5 fo bot aute and on pan n adut
popuatons. Tese eews w fom te bass of te eaxaton
ndngs fo ts ate.
Sees and Caos (8) systemat eew of eaxaton n aute
pan dented seen andomsed onto tas w met te
spe nuson tea. A nestgated te use of eaxaton,
ete dung o foowng a suga poedue. In tems of pan
outomes (e.g. pan sensatons and pan dstess), ony 3 of 7 studes
epoted sgnant edutons7,8,
. Fe studes nuded measues ofwde psyooga outomes (e.g. anxety, mood, opng), of w
ony study epoted a sgnant eduton8. Seea metodooga
weaknesses wee ggted, su as unea dentons of
eaxaton, sma sampe szes and eaxaton nteentons ombnng
deent tenques. Sees and Cao onuded tat based on te
exstng edene t s not possbe to daw onusons about te
eeteness of eaxaton nteentons n aute pan.
Wtn on pan, Cao and Sees (8) dented
andomsed onto ta studes (7 studyng non magnant pan,
studyng ane pan) meetng te nuson tea5. Ony
out of 7 studes fousng on non-magnant pan (e.g. eumatod
atts and bomyaga) epoted sgnant pan edutons at
post-teatment,. Tee of tese studes onduted foow-ups,,3
at tme nteas angng fom weeks to monts but none found
tat sgnant mpoements wee mantaned. Wtn onoogy,
studes wee dented and epoted sgnant deenes n
pan outomes wen eaxaton was ompaed to ontos. Wen
ompaed to ote nteentons, te eew found eaxaton to be
ess eete tan ydoteapy, bofeedbak and oa spnt dees.
Kwekkeboom and Getasdott (6) onduted a moe eent
systemat eew of te eay of eaxaton tenques n bot
aute and on pan6. Oea eaxaton was found to ae a
sgnant eet on pan outomes n 8 of 5 andomsed ontostudes. Pogesse muse eaxaton was found to edue pan
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moment to moment awaeness so tat peope an bette note
te tendenes to at n fe as t unfods. Subte but mpotant
deenes ke ts may be pat of te eason fo te esuts
pesented aboe.
As ee, moe goous metodooges wt bette ontos, moe
aefu seeton of outome measues and onge foow-up
peods ae equed. Studes w dety ompae eaxaton
and mndfuness woud aso be usefu. At pesent, esea tends to
measue deent outomes w makes nte-study ompason
dut. Reseaes aso need to onsde w outomes ae most
appopate. Measung pan s ntute; assessng te mpat of
ote psyooga aabes su as anxety and depesson s aso
usefu. Howee, futue esea soud aso onsde measung
ees of nddua funtonng. Ts w aow eseaes to assess
f eaxaton and mndfuness aow subjets to do moe n te
eeyday es een f pan o psyooga dstess do not deease.
Fute esea aso needs to nestgate te poesses noed n
eaxaton and mndfuness so tat te usefuness an be eauated
and te teang mpoed. Despte te eatey sot tme t as
been a subjet of westen sent study, mndfuness as aeady
stated to expoe tese questons3. Some of ts wok as een been
done wt on pan patents3. Resea suggests tat unde
te umbea tem mndfuness oexst a numbe of nteeated
psyooga poesses w osey mo mpotant fatos n
ontempoay ontextua psyooga esea and teapy3.
Payng moe attenton to poesses su as ognte fuson (wee
entangement wt tougts and feengs domnate oe ote
possbe nuenes on an ndduas beaou), aeptane/wngness and ontat wt te pesent moment, may aow us to
mpoe ou abty to tea mndfuness n te futue (see Hayes,
6, fo moe nfomaton and expanaton of tese tems3).
As yet, many questons st eman about te makeup of te
ate ngedents nsde eaxaton. It s possbe tat onto o
dstaton ae an mpotant oe to pay. If so, te expementa
teatue may aeady aow us to make some ompasons between
aspets of eaxaton and mndfuness. Fo exampe, eaty subjets
ae demonstated neased pan toeane n a od pesso
task wen appyng aeptane (mndfuness) ate tan onto
(eaxaton)33. Equay, eaty subjets wo eeed eet soks
found aeptane to be moe usefu tan dstaton (eaxaton)3.
Of ouse dstaton as been found to be nay eete n te
eduton of paedat pan dung mmunzatons35, but tese ae
sot ed poedues and te utty fo on ondtons s ess
etan. Indeed tee s an extense teatue w suggests tat
foms of tougt suppesson an atuay be ountepodute36.
Dsussons of ts natue ggt ow mpotant t s fo
pattones and eseaes to be ea about wat tey want to
aee and wat te tenques atuay do. Due to te uent
state of te teatue t s ony possbe to daw tentate onusons
about te eay of bot of tese nteentons. Howee, based
on te exstng edene t woud appea tat wst eaxatonnteentons an be benea n te sot tem, mndfuness may be
One study used a mxed sampe onsstng of a aety of meda
ondtons, nudng 37 on pan patents and 6 bomyaga
suees. Foowng te mndfuness nteenton sgnant
mpoements n pysa and psyooga dstess, and eat-
eated quaty of fe wee epoted7. Howee, t s dut to
genease fom tese esuts as pan patpants made up sma
peentages of te sampe (6% and 5% espetey) and no onto
o foow-up data was nuded. Mndfuness as aso been ompaed
to a ognte beaoua stess eduton (CBSR) nteenton n
a ommunty sampe teated fo stess eduton wee pan was
measued8. Te mndfuness nteenton was found to demonstate
bette outomes wen ompaed to te CBSR ondton owee
t s mpotant to note te eatey ow aeage pe-teatment
ees of pan and g aatons of pan soes wtn and between
te sampes n ts study. Fnay, te eet of mndfuness and
guded magey on pan toeane wtn eaty subjets as been
nestgated n an RC9. Patpants n te mndfuness ondton
demonstated neased pan toeane dung an expementayndued aute pan task; owee, te autos onuded tat ts
was not eated to te aquston of mndfuness sks.
Discussion
Despte te fat tat eaxaton tenques ae a onsdeabe
tme adantage n estabsng te empa edene base, t s
nteestng tat te teatue n pan s not moe ompeng n
outome. Geneay speakng, tee s some edene tat eaxaton
tenques an edue pan outomes n aute pan but te
esea s not oewemng. In on pan, agan tee s somesuppotng edene but foow-up data suggests tat te usefuness
of eaxaton edues oe tme. Mndfuness esea as tended
to fous on on pan ondtons and nteestngy te uent
edene s geneay bette tan eaxaton at foow-up een f esuts
mmedatey afte te nteenton ae not aways so stong.
Wen ntepetng te ndngs fom ts eew t s mpotant to
note te deenes between te sepaate edene bases. Te eew
of te eaxaton teatue was based on 3 exstng systemat eews
weeas te eew of te mndfuness teatue was based on atua
studes. Te systemat eews of te eaxaton teatue apped
moe goous seeton tea tan tose n te eew of te
mndfuness teatue. Teefoe auton s needed wen ntepetng
te ndngs fom ts eew as some of te mndfuness studes
wee, fo exampe, unontoed and/o ontaned eatey sma
sampe szes. Indeed t s possbe tat studes wt bette onto and
age numbes mgt not ontnue to suppot te uent ndngs
and unt moe esea as been aed out no m onusons an
be made.
If esea metodoogy and onto s not te eason fo te aboe
esuts t s possbe to ypotesze ote easons. One possbty s
tat t s dut to genease and mantan eaxaton sks outsde
of te assoom/teapy enonment. Indeed t may be patuay
ad to engage n su beaou dung tmes of g stess wtneeyday fe. Mndfuness, on te ote and, expty teaes
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3. Saw L, E A. Reaxaton tanng as a teatment fo on
pan aused by ueate ots. Pan 987; 9(3): 87-93.
. Soman R, Bown P, Adana E, Cee E. Te use of eaxaton
fo te pomoton of omfot and pan eef n pesons wt
adaned ane. Contemp Nuse 99; 3(): 6-.
5. Gay MC, Pppot P, Lumnet O. Deenta eeteness of
psyobooga nteentons fo edung osteoatts pan: a
ompason of Ekson ypnoss and Jaobsen eaxaton. Eu J
Pan ; 3(3): 69-77.
6. Hasson D, Anetz B, Jeeus L. A andomzed na ta of
te teatment eets of massage ompaed to eaxaton tape
eodngs on duse ong-tem pan. Psyote Psyosom
; 73(): 7-.
7. Kabat-Znn J. An outpatent pogam n beaoa mednefo on pan patents based on te pate of mndfuness
medtaton: teoeta onsdeatons and pemnay esuts.
Gen Hosp Psy 98; (): 33-7.
8. Kabat-Znn J, Lpwot L, Buney R. Te na use of
mndfuness medtaton fo te sef-eguaton of on pan. J
Bea Med 985; 8(): 63-9.
9. Pews-Ogan M, Owens JE, Goodman M, Wofe P, Song J.
A pot study eauatng mndfuness-based stess eduton and
massage fo te management of on pan. J Gen Inten Med
5; (): 36-8.
. Sagua D, Re KG. Te eeteness of mndfuness tanng on
te geng poess and emotona we-beng of on pan
patents. J Cn Psyo Med Settngs ; (): 333-.
. Moone NE, Geo CM, Wene DK. Mndfuness medtaton
fo te teatment of on ow bak pan n ode aduts: a
andomzed ontoed pot study. Pan 8; 3(3): 3-9.
. Gadne-Nx J, Bakmant S, Babat J, Gummtt J. Eauatng
dstane eduaton of a mndfuness-based medtaton
pogamme fo on pan management. J eemed eeae
8; (): 88-9.
3. Septon SE, Samon P, Wessbeke I, Ume C, Foyd A,
Hooe K, et a. Mndfuness medtaton aeates depesse
symptoms n women wt bomyaga: esuts of a andomzed
na ta. Atts Reum-Atts Cae Res 7; 57():
77-85.
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moe usefu n te ong tem f te desed esut s te aquston of
sks w ae usefu outsde of te teapy oom.
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3. Bae RA. Mndfuness tanng as a na nteenton: a
oneptua and empa eew. Cn Psyo S Pat 3;
(): 5-3.
. Sees K, Cao D. Reaxaton tenques fo aute panmanagement: a systemat eew. J Ad Nus 998; 7(3): 66-
75.
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systemat eew. J Ad Nus 998; 7(3): 76-87.
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Reaxaton Inteentons fo Pan. J Nus Soas 6; 38(3):
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5. Gossman P, efentae-Gme U, Raysz A, Kespe U.
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Atts Cae Res 7; 57(7): 3-.
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and ommtment teapy: Mode, poesses and outomes.
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33. Hayes SC, Bssett R, Kon Z, Zette RD, Rosenfab IS, Coope
LD, et a. Te mpat of aeptane esus onto atonaes on
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3. MMuen J, Banes-Homes D, Banes-Homes Y, Stewat I,
Luano C, Coane A. Aeptane esus dstaton: bef
nstutons, metapos and exeses n neasng toeane fo
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9.
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Psyo ; 5: 59-9.
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Table 1. Summary of Mindfulness Studies Involving Pain
Author Total N
(control[s])
Random
allocation
Mindfulness
treatment
Main outcome for mindfulness group Fol low-up: Result
Gardener-Nix
et al. (2008)
278 (99 face to
face, 57 videoconferencing,
59 waiting list)
No 10 weeks, 10
hours per week.
Signicant improvements in pain level,
catastrophising, and mental health scorescompared to controls.
None.
Grossman et
al. (2007)
58
(13 active social
support)
Quasi
random
allocation
8 weeks, 2.5
hours per week.
Signicant improvements in quality of
life, coping with pain, anxiety, depression,
somatic complaints and pain ratings,
compared to pre-intervention and control
conditions.
3 years: Improvements maintained.
Kabat-Zinn et
al. (1982)
51 (0) No 10 weeks, 2 hours
per week.
Signicant reductions in pain ratings,
mood disturbance and psychiatric
symptomatology.
2.5, 7 months: Improvements
remained relatively stable.
Kabat-Zinn et
al. (1985)
142
(21 standardcare, 21 waiting
list)
No 10 weeks, 2 hours
per week.
Signicant improvements in present
moment pain, physical functioning, mood,psychological measures such as anxiety
and depression. Improvements not
observed in the control conditions.
2.5, 4.5, 7, 12 and 15 months:
Improvements sustained except forpresent moment pain.
Kingston et
al. (2007)
42
(21 guided
imagery control)
Yes 6 x 1 hour
sessions.
Signicant improvement in pain tolerance
in healthy subjects compared to controls.
Authors conclude this was not due to
mindfulness skills.
None.
Morone et al.
(2008)
37
(18 waiting list)
Yes 8 weeks, 1.5
hours per week.
Signicant improvements in acceptance,
activity engagement and physical
functioning compared to the control
condition.
3 months: Improvements
maintained.
Plews-Ogan
et al. (2005)
30
(10 massage
condition, 10
standard care
control)
Yes 8 weeks, 2.5
hours per week.
No signicant differences in pain or mental
health ratings compared to controls.
12 weeks: Signicant
improvements in mental health
ratings compared to controls.
Pradhan et al.
(2007)
63
(32 waiting list)
Yes 8 weeks, 2.5
hours per week.
No signicant difference compared to
controls.
6 months: Signicant
improvements in psychological
distress, well-being, depressive
symptoms and mindfulness.
Reibel et al.
(2001)
136 (0) No 8 weeks, 2.5
hours per week &
1 x 7 hour day.
Signicant improvements in health-related
quality of life, physical and psychological
distress in a mixed diagnosis sample.
1 year: Improvements maintained.
Sagula et al.
(2004)
57
(18 waiting list)
No 8 weeks, 1.5
hours per week.
Signicant reductions in depression and
state anxiety. Moved more quickly through
the stages of pain-related grief compared
to the control group.
None.
Sephton et al.
(2007)
91
(40 waiting list)
Yes 8 weeks, 2.5
hours per week.
Signicant improvement in depressive
symptoms compared to controls.
2 months: Improvements
maintained.
Smith et al.
(2008)
50
(14 cognitive
behavioural
stress reduction
condition)
No 8 weeks, 3 hours
per week.
Signicant reductions in pain, perceived
stress, depression, psychological well-
being, neuroticism, energy, binge eating
and mindfulness.
None.
Weissbeckeret al. (2002)
61(24 waiting list)
Yes 8 weeks, 2.5hours per week.
Signicant increase in sense of coherencecompared to controls.
None.