Online mindfulness training for chronic pain

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1 Online mindfulness training for chronic ain - a randomized controlled trial Jessica Henriksson and Emma Vasara Möller Ht 013 Psykologrogrammet Examensarbete, 30h Handledare: Michael Rönnlund

2 Tack! Vi vill tacka vår handledare Michael Rönnlund för allt engagemang och all vägledning. Tack även till alla å Mindfulnesscenter som möjliggjorde detta examensarbete. Särskilt tack till Ola Schenström för det entusiasmerande stödet och till Susanne Sahlén Nyberg för den ovärderliga tekniska assistansen. Tack även till alla vid smärtrehabiliteringen å Norrlands universitetssjukhus för all hjäl under terminens gång och för assistans med rekrytering av deltagare. För detta vill vi även tacka alla inblandade från rimärvården i Västerbottens läns landsting. Slutligen vill vi tacka alla övriga inblandade under resans gång och rikta ett extra stort tack till alla deltagare i rojektet utan vilka detta examensarbete inte hade varit möjligt.

3 ONLINE MINDFULNESS TRAINING FOR CHRONIC PAIN -A RANDOMIZED CONTROLLED TRIAL Jessica Henriksson and Emma Vasara Möller Mindfulness is a way of managing chronic ain and its consequences as it fosters an acceting aroach to ain that can be beneficial in several asects of life affected by ain. This study sought to examine whether an online mindfulness training rogram could reduce the exerience of ain, increase accetance of ain, and increase quality of life in a grou of individuals suffering from chronic ain. The study was a randomized controlled trial with a artly active control grou. Initially 5 articiants were randomized to the intervention grou and 55 to the control grou. The dro out rates were high, 1 articiants from the intervention grou and 40 articiants from the control grou comleted ost measurement. Increased levels of mindfulness, reduced ain related distress, and heightened ain accetance, as well as increased quality of life, was observed in the intervention grou. A strong tendency towards a erceived reduction of ain intensity was also evident in the intervention grou. As the mindfulness rogram had ositive effects on the overall exerience of ain it may serve as a cost-effective and useful method of dealing with chronic ain. Mindfulness är ett sätt att hantera kronisk smärta och dess konsekvenser då det lär ut en acceterande inställning till smärta som kan vara till hjäl i flera asekter av livet åverkade av smärta. Denna studie undersökte huruvida ett online-baserat mindfulnessrogram kunde minska ulevelsen av smärta, öka accetans av smärta och öka livskvaliteten hos en gru individer med kronisk smärta. Studien var randomiserad och kontrollerad med en delvis aktiv kontrollgru. Initialt randomiserades 5 deltagare till exerimentgruen och 55 deltagare till kontrollgruen. Bortfallet var högt, 1 deltagare från exerimentgruen och 40 deltagare från kontrollgruen fullgjorde eftermätningarna. Ökade nivåer av mindfulness, reducerat smärtrelaterat lidande, ökad accetans av smärta såväl som ökad livskvalitet återfanns i exerimentgruen. En stark tendens till minskad ulevd smärtintensitet var också tydlig hos exerimentgruen. Då mindfulnessrogrammet hade ositiva effekter å den övergriande ulevelsen av smärta kan det fungera som en kostnadseffektiv och användbar metod att hantera kronisk smärta. Keywords: Mindfulness, chronic ain, ersistent ain, Internet-based treatment, Breathworks, accetance-based treatment Conditions involving chronic ain cause individual suffering as well as substantial social costs (SBU, 006). The International Association for the Study of Pain (International Association for the Study of Pain, 013) defines ain as An unleasant sensory and emotional exerience associated with actual or otential tissue damage, or described in terms of such damage. This is the most widesread definition of ain. The exerience of ain is affected by factors such as the individual s emotions, context, historical and cultural background, as well as the individuals araisals of the symtoms (Turk & Okifuji, 00). Chronic ain is often defined as ain that has ersisted longer than three or six months (e. g. Breivik, Collett, Ventafridda, Cohen & Gallacher, 006; Gerdle, Björk, Henriksson & Bengtsson, 004) and may be distinguished from acute ain which 1

4 has a shorter duration. Chronic ain, however, is not the same as rolonged acute ain. Instead, it could be described as an exerience of a disabling disease (Chaman & Gavrin, 1999). The diagnosis is non-uniform with differences in distribution, states, severity and functional imact (Bergman et al., 00). Once the ain has been established as chronic, the chances of becoming ain free are relatively small (e.g. Andersson, 004; Bergman, Herrström, Jacobsson & Petersson, 00). Chronic ain is a relatively common condition. The revalence of moderate to severe chronic ain in a Swedish samle has been estimated to 18% (Breivik et al., 006). Other studies have shown revalence rates for chronic ain in general at about 50% (Gerdle, Björk, Henriksson & Bengtsson, 004; Jakobsson, 010). In regard to effects of chronic ain on other subject variables, it has been shown that individuals suffering from chronic ain are less satisfied with their lives comared to controls. The largest differences in life satisfaction were found in the domains of hysical and sychological health (Silvemark, Källmén, Portala & Molander, 008). This is in accordance with results from other studies associating chronic ain with decreased quality of life (e.g. Breivik et al., 006; Lamé, Peters, Vlaeyen, Kleef & Patijn, 005). Chronic ain has, in addition, been shown to affect asects of life such as slee, BMI, fatigue, and mobility negatively (Jakobsson, 010). As these symtoms often accomany the ain it could result in feelings of sickness, exhaustion and imairment. This state of suffering resembles deression but is different from deression as it is a wider concet, not necessarily sychoathological. In cases of chronic ain, the individual is more focused on suffering in the future than on negative affect towards the self (Chaman & Gavrin, 1999). Chronic ain is hard to treat effectively. The most common treatment for chronic ain is a variety of ain reduction treatments such as analgesic and oioid drugs. This kind of treatment only reduces ain by 30-40% in about half of the atients. Surgery for chronic ain conditions, esecially chronic back ain, is common but does not remove the ain to a satisfactory level (Turk, 00). Multimodal rehabilitation is used for chronic ain for atients with extensive and comlex needs. This tye of rehabilitation includes contribution from different lines such as sychology, hysiotheray, medicine et cetera. Multimodal rehabilitation rovides better long term results on asects of life such as return to work than less extensive interventions do (SBU, 006). Cognitive Behavioral Theray (CBT) has shown to mainly be associated with imrovements in quality of life. CBT also aear to have some effect on ain and sychological distress. In articular, coing skills training with a focus on cognitive skill develoment and ractice seems to be effective (Eccleston, Morley & Williams, 013). Given that the foregoing methods for reducing ain have some drawbacks (e.g. with regard to costs, time consumtion et cetera, an increased interest in alternative means to reduce ain has been seen in recent years. Recent research

5 has also focused on mindfulness-based interventions (MBIs) for chronic ain (Reiner, Tibi & Lisitz, 013), that also served as a basis for the resent study. Mindfulness has been described as aying attention in a articular way; on urose, in the resent moment, and nonjudgmentally (Kabat-Zinn, 1994,. 4). Bisho et al. (004) roosed an oerational definition of mindfulness consisting of two comonents: self-regulation of attention and orientation to exerience. Selfregulation of attention involves skills in sustained attention and attention switching as well as inhibition of elaborative rocessing. Orientation to exerience involves curiosity, oenness and accetance towards the current exerience. These attitudes rovide a non-elaborative awareness to the exerience as well as a decentered and more insightful ersective on thoughts and feelings. By this definition, mindfulness is a metacognitive rocess as it requires both control of cognitive rocesses and the ability to monitor the stream of consciousness (Bisho et al., 004). Brown and Ryan (003) found ositive relationshis between mindfulness and several health benefits such as life satisfaction and otimism. Being mindful has also been found to exhibit a negative relationshi with deression, anxiety and self-consciousness (Brown & Ryan, 003). Thus, mindfulness seems to ositively influence sychological well-being. It has become a oular element in sychological treatments (Baer, 009) and is considered a owerful and widely alicable intervention in counseling (Brown, Marquis & Guiffrida, 013). MBIs have been used in treatment of atients with chronic ain. Unfortunately, there is no consensus regarding the effects MBIs have on ain intensity. More secifically, two reviews (Chiesa & Serretti, 011; Veehof, Oskam, Schreurs & Bohlmeijer, 011) show inconclusive results regarding MBIs on ain intensity while a third review (Reiner et al., 013) concluded that MBIs have an effect on ain intensity. Partially due to the lack of high quality randomized and controlled studies it is therefore difficult to conclude anything absolute regarding the effectiveness of MBIs to reduce erceived ain intensity based on those studies. Desite the uncertainty of MBIs ossible effects on ain intensity there is more of consensus regarding the effects on sychological and secondary outcome measures. MBIs increase ain accetance and tolerance (Chiesa & Serretti, 011) and also aear to have ositive effects on sychological features related to ain such as decreased levels of deressive symtoms and increased levels of life quality (Chiesa & Serretti, 011; Veehof et al., 011). Although Chiesa and Serretti (011) did not find that MBIs necessarily were more efficient in treating ain than education or other tyes of controls, they still roosed a way of which the effects of mindfulness on ain can be understood. In accordance to the oerational definition of mindfulness, Chiesa and Serretti hyothesized that MBIs alters how sychological rocesses and contents are exerienced rather than altering the ain itself. Veehof et al. (011) also questioned whether ain intensity is a valid outcome measure for atients with chronic ain since MBIs do not intend to change the ain itself but rather romote accetance of ain. Reiner et al. (013) who concluded that MBIs can reduce ain intensity also hyothesized that the 3

6 reduction in ain intensity could be an effect of reduced ain avoidance and increased engagement in valuable activities. Whether the effect is on the ain itself or via secondary measures such as increased quality of life or reduced ain avoidance, mindfulness seems to have a ositive effect on the exerience of ain. A study examining more acute ain found decreases in ain and anxiety ratings when exosed to exerimentally induced ain after only three days of mindfulness training (Zeidan, Gordon, Merchant & Goolkasian, 010). Liu, Wang, Chang, Chen, and Si (013) also found significant ositive effects of brief mindfulness training on ain tolerance and distress when exosed to exerimentally induced ain. Immediate effects of a single mindfulness exercise on chronic ain have also been observed in a clinic setting (Ussher et al., 01). Studies on brief online mindfulness training rograms indicate that mindfulness rograms can be successfully administered online (Cavanagh et al. 013; Glück & Maercker, 011). Online mindfulness training rograms are easily accessible and could be a owerful comlement to ain treatment and rehabilitation rograms as it is a cost-effective means of adding to, or administrating a mindfulness comonent in the treatment. To our knowledge, there are no revious studies on online mindfulness training rograms for chronic ain. A study on mindfulness for chronic ain taught via videoconference showed ositive results in arity to face-to-face training (Gardner-Nix, Backman, Barbati & Grummitt, 008) but was more interactive than the rogram used in the resent study as it included ersonal contact with an instructor. Two recent studies (Krusche, Cyhlarova & Williams, 013; Morledge et al., 013) have investigated the feasibility and effects of longer mindfulness rograms without ersonal contact and found romising effects but none of them investigated rograms directed towards ain. The resent study served as a ilot-study on an online mindfulness rogram for chronic ain. The overall urose was to examine whether an online mindfulness training rogram reduced the exerience of ain in individuals suffering from chronic ain. More secifically, we set out to investigate whether this web-based mindfulness rogram has an effect on exerience of ain, quality of life and accetance of ain. To this end a randomized controlled design with an active control grou with access to an online discussion forum was adoted, a design that, as noted, seldom has been used in ast research on MBIs, desite its advantages in regard to control of otential confounding factors. Method Particiants The articiants were recruited online as well as in rimary care settings and a ain clinic. 6 agreed to a consent form and filled out the first round of questions. 4

7 Inclusion and exclusion criteria To be included in the resent study articiants had to be over 18 years old and suffer from ain at an intensity of four out of ten that had ersisted for at least six months. Particiants were excluded if they scored over six or eight on AUDIT or if their DUDIT score indicated any illicit drug use. As shown in Figure 1, articiants were also excluded on the basis of their HADS results. Cut-off scores of 10 for the deression subscale and 16 for the anxiety subscale were used. As shown in Figure 1 the resent study finally included 107 articiants. 93% (n=100) were female and the average age was 51 years. 48% (n=51) were on a sick-leave due to their ain, and the mean length of absence from work was 8 years. The largest art (36%, n=39) of the articiants reorted that the main location of ain varies. Other resonses were divided fairly equally amongst secific body arts. 46% of the articiants reorted at least some revious exerience of mindfulness. Comleted the screening (n=6) Comleted the re-intervention measurement and were randomized to the mindfulness rogram or the discussion forum (n=107) Excluded before re-intervention measurements (total n=94) High levels of anxiety or deression (n=44) Potentially hazardous alcohol- or drug use (n=31) Low ain intensity (n=14) Incomlete data (n=3) Duration of ain < six months (n=) Decided not to articiate (n=61) Waiting list (n=55) Comleted the ost-measurement (n=40) Mindfulness rogram (n=5) Comleted the rogram and the ostmeasurement (n=1) Figure 1. Flow chart of articiants: exclusion and decided not to articiate. 5

8 Material Alcohol Use Disorders Identification Test (AUDIT) AUDIT is a ten-question questionnaire used as a screening measure for hazardous alcohol use (Fiellin, Reid & O Connor, 000) and alcohol deendence (Hulse, Saunders, Roydhouse, Stockwell, and Basso, 000). The Swedish version of AUDIT has been shown to have good secificity and sensitivity for measuring high-volume drinking and deendence when using a cutoff score at 8 (Selin, 006). The best secificity and sensitivity regarding heavy-drinking among middle-aged women are reached when using a cutoff score at 6 (Aalto, Tuunanen, Sillanaukee & Sea, 006). Hence, the cut-off scores used in the resent study were 8 for men and 6 for women. AUDIT has shown moderate concurrent validity to the alcohol roblem severity domain of the Addiction Severity Index (ASI-6) and an internal consistency (Cronbach s alha) at.89 (Durbeej, Berman, Gumert, Palmstierna, Kristiansson & Alm, 010). Drug Use Disorders Identification Test (DUDIT) DUDIT measures drug use and consequences of that use over the ast year (Voluse, Gioia, Sobell, Dum, Sobell, & Simco, 01). The Swedish version of DUDIT has been found to have an internal consistency (Cronbach s alha) at.94. The instrument has furthermore been demonstrated to have good concurrent validity as reflected by a substantial relationshi the drug roblem severity domain of the ASI-6 (Durbeej et al., 010). For the urose of this study the DUDIT was rimarily used as a measure for current drug use. Particiants who exhibited current drug use were excluded from the study. The articiants were allowed to score above 0 on two questions which measured drug-related social consequences during the last year, if they scored 0 on the other items regarding current drug use. Hosital Anxiety and Deression Scale (HADS) Both of the anxiety and the deression subscale in the Swedish version of the HADS have exhibited adequate internal consistency, with Cronbach s alha =.84 for HAD-A, α =.8 for HAD-D (Lissers, Nygren, & Söderman, 1997). The cut-off scores for this study were different for the deression subscale and the anxiety subscale. For the deression subscale a cutoff score at 10 was used to cature articiants with even mild cases off deression. For the anxiety subscale a cutoff score at 16 was used to only include those with severe anxiety. The cutoff score for these uroses is recommended by the develoers (Snaith & Zigmond, 1994 in Crawford, Crombie & Taylor, 001). When administered on the Internet the HADS has shown to rovide meaningful and valid data (Andersson, Kaldo- Sandström, Ström & Strömgren, 003). Chronic Pain Accetance questionnaire (CPAQ) CPAQ is an instrument measuring accetance in relation to erceived ain. It has been used in several studies on mindfulness and ain (e.g. McCracken & Zhao- O Brien, 010; Cusens, Duggan, Thorne & Burch, 010). Its 0 items are divided in to two subscales: activities engagement and ain willingness (Vowles, McCracken, 6

9 McLeod & Eccleston, 008). Higher scores indicate higher levels of ain related accetance, with ossible scores ranging from 0 to 10. The ossible score on the subscale activities engagement ranges from 0 to 66 and the score on the subscale ain willingness ranges from 0 to 54. CPAQ is regarded as a valid instrument for measuring ain related accetance (McCracken, 004), even when administered online (Fish, McGuire, Hogan, Morrison, & Stewart, 010). The Swedish version of the instrument has shown good sychometric roerties with regard to internal consistency with a Cronbach s alha reaching.91 (Wicksell, Olsson & Melin, 009). Brief screening version of the Multile Pain Inventory The brief screening version of the multile ain inventory is a screening instrument for chronic ain which consists of eight questions from the first section of the Swedish version of the multile ain inventory (MPI-S) (Jakobsson, 009). The original version of the MPI was designed to measure ain from a multidimensional ersective, considering not only ain severity but also other factors such as affective distress and suort from others (Turk, 005). Even though the brief screening version of the MPI-S does not include as many asects of ain as the full version, it still rovides more information regarding the exerience of ain than unidimensional measures and can be considered a better otion when measuring ain. The brief screening version is comrised of four subscales: ain severity, interference, life control and affective distress. In this study the scoring method used calculates the mean score of each subscale as suggested by Jakobsson, 009. Scores can range from 0 to 6, where higher score indicate higher imact of the asects that the subscale is suosed to measure. With Cronbach s alha ranging from.68 to.93 for the different scales, the Swedish brief screening version of the instrument has been found to show accetable reliability and validity in all age grous, excet for the oldest old. A standard scoring method for the instrument does not exist and it can only detect cases with severe dysfunction (Jakobsson, 009). Numerical Rating Scale (NRS) Two numerical rating scales are used in the resent study. One where articiants are asked to rate their average amount of ain during the ast week and another in which articiants are asked to rate the amount of suffering their ain had caused them during the ast week. The scales range from 0 to 10, where 0 indicates "no ain/distress" and 10 "ain/distress as bad as it could be". Five Facet Mindfulness Questionnaire (FFMQ) The FFMQ rovides a multifaceted way of measuring the tendency to be mindful in daily life (Christoher, Neuser, Michael & Baitmangalkar, 01). Measuring mindfulness as a multifaceted construct is recommended by Baer, Smith, Hokins, Krietemeyer and Toney (006) since it can rovide insight in to the comonents of mindfulness and its relationshis with other variables. The five subscales are: observing, describing, acting with awareness, nonreactivity and nonjudging (Baer et al., 006). Possible scores on the full scale on FFMQ ranges from 9 to 145, 7

10 where higher scores indicate higher mindfulness levels. All of the subscales have been found to show accetable validity and reliability (Christoher et al., 01) and this alies to the Swedish version of the instrument as well with Cronbach s alha of.81 (Lilja et al., 011). Life Satisfation (LiSat-11) Life satisfaction was measured by the life satisfaction checklist (LiSat-11). LiSat-11 is an 11 item questionnaire measuring global- as well as domain-secific life satisfaction. The score is received by calculating the mean value of the answers, with ossible scores ranging from 1 to 6. Higher scores indicate higher life satisfaction. It has been found to show accetable construct validity as well as internal reliability with a Cronbach s alha at.8 (Silvemark, Källmén, Portala & Molander, 008). The mindfulness rogram The mindfulness rogram Mindfulness - living with ain is a rogram that intends to hel eole with chronic ain to find new ways of dealing with the ain and has a strong emhasis on accetance of ain. The rogram was originally develoed Vidyamala Burch and Breathworks and was then adated to an online Swedish version by Mindfulnesscenter AB (Breathworks, 013). The rogram in its original form has been evaluated showing ositive changes on several ain-related health roblems such as ain catastrohizing and ain accetance even though ain intensity ratings remained the same even after comleting the rogram (Cusens, Duggan, Thorne & Burch, 010). The main comonents in the rogram are mindfulness exercises, which the articiants are to erform twice daily. The duration of each exercise is about ten minutes and the exercises follow eight stes, one for each week of the rogram. The stes were labeled: 1) The breathing body, ) Dwelling in the body, 3) Mindfulness of moving and living, 4) Accetance and self-comassion, 5) The treasure of leasure, 6) Being whole, 7) Turning outwards - comassion for others, and 8) The journey continues - living with choice. Each ste includes a few exercises secific to that ste even though some exercises are reeated in several stes (Breathworks, 013). The discussion forum The articiants in the control grou were rovided an anonymous and monitored online discussion forum. Each week a new discussion toic was introduced by the authors and the discussions were then held amongst the articiants without any inut from the authors. The discussion toics were not related to mindfulness and did not have a theraeutic character. The toics included were for examle: How is chronic ain resented in the media?, Is it helful to meet other individuals with chronic ain? and What exerience do you have of the health care system?. Before entering the discussion forum the articiants were asked to read information regarding anonymity in the forum. They were also informed of a revious study of Lorig et al. (00) who found ositive effects on ain, disability, role function, and health distress in subjects with chronic back ain after articiation in an internet-based discussion. 4 articiants created a user for the 8

11 discussion forum which enabled them to articiate as well as take art in the discussions. 7 users osted comments while the remaining 15 articiants did not ost comments but could have been active as readers. There was no way of controlling for their activity in the forum. Therefore the discussion forum was defined as a artly active control condition. Design The design of the resent study was a between grous, randomized controlled trial. Procedure Particiants were informed of the study and were asked to fill out a consent form via a web age. They comleted a screening rocedure involving administration of Hosital Anxiety and Deression Scale (HADS), Alcohol Use Disorders Identification Test (AUDIT), Drug Use Disorders Identification Test (DUDIT), together with questions concerning demograhics and questions concerned with ain. Particiants who met the inclusion criteria were sent re-intervention questionnaires a week before the rogram started. The questionnaires that the articiants were to answer were Chronic Pain Accetance Questionnaire (CPAQ), brief screening version of the Multile Pain Inventory (MPI), Five Facet Mindfulness Questionnaire (FFMQ) and Life Satisfaction Questionnaire -11 (LiSat- 11). These questionnaires were comlemented by an Numeric Rating Scale (NRS) regarding the distress caused by their current ain and questions about their exerience of mindfulness. They were also asked to fill out an NRS regarding the current severity of their ain the day before the rogram started. After submitting the final NRS the articiants were randomly assigned to a control- and a intervention grou. The randomization was conducted using an online randomizer ( Next, the articiants received information on whether they were to begin by articiating in the discussion forum or the mindfulness rogram. On the fourth week of the rogram, encouraging s were sent to the articiants in the exerimental grou. Program comletion was defined as having comleted at least six weeks of the mindfulness rogram. 1 individuals comleted the rogram. Of the remaining articiants, 13 were on the first ste of the rogram while the other 15 articiants were divided amongst the five stes in between the first and the final two. Once the mindfulness rogram was comleted, articiants in both grous received ost-intervention questionnaires. The articiants in the control grou were given access to the mindfulness rogram when they comleted the ostintervention questionnaires. Ethical considerations The intervention was defined as a edagogic rogram which is equated with reading a self-hel book. Hence, the mindfulness rogram was not considered as treatment, thus eliminating the need for record keeing in accordance to Swedish 9

12 regulations. To identify the articiants their addresses were used. As e- mail addresses are unique but not necessarily couled with ersonal data or information they were used as identifying information throughout the study. The articiants were asked to fill in a consent form with information about the study before the study began. By agreeing to the consent form the articiants validated that they had read and agreed to the information and conditions of the study. The consent form included information regarding confidentiality of the results and made it clear that all articiation was voluntary. Results The first analyses addressed otential effects associated with attrition, or dro-out. Next, analyses of variance (ANOVAs) were conducted to comare the mean levels (re- vs. ost-intervention) on the following variables: mindfulness level, ain intensity and ain exerience, accetance of ain, distress caused by ain and life satisfaction. Effect sizes for all the significant results were calculated using artial eta square ( ). Within grou effect sizes for the intervention grou were calculated using Cohen s d. Cohen (199) defined a small effect size as d > 0., a medium effect size as d > 0.5 and a large as d > 0.8. Dro-out analysis Analyses of the dro-out was conducted by t-tests (for indeendent grous) on the following variables: age, level of mindfulness, ain intensity, sick-leave due to ain, otential ain diagnosis, otential medication for ain, duration of ain and quality of life. No significant differences between the articiants who droed out and the returnees were observed. Thus, the two grous may be regarded as comarable at time of entry in the study. To analyze the data x mixed ANOVAs were conducted. More secifically, the grou factor (intervention vs. control) was a between-subjects factor and time varied within subjects (reeated measures). Mindfulness levels To comare mindfulness levels between the intervention grou and control grou the total score on FFMQ was used as deendent variable. Figure shows means of the FFMQ in the two grous and as we can see the means reveal little change for the control grou but a substantial mean increment for the intervention grou. The ANOVA results substantiated this imression by showing a significant main effect of time F(1, 59) = 7.90, MSE = , <.05, =.1 reflecting the fact that the total score on FFMQ was higher on the second time of measurement. The main effect of grou was on the other hand not significant F(1, 59) = 3.49, MSE = 187., >.05. Most critical, the interaction effect was highly significant F(1, 59) = 1.05, <.001, =.17. The intervention grou exhibited higher levels of mindfulness than the control grou after having comleted the mindfulness rogram. The intervention grou exhibited significantly higher end results than the control 10

13 grou which did not significantly differ between the two times of measurement. The effect size within the intervention grou was large and calculated to d = Figure. Pre and ost measurement means on the FFMQ for the intervention and control grou. FFMQ was next analyzed at the subscale level. The results of the ANOVAs on these subscales were similar to the result of the total score on FFMQ, suggesting that no secific subscale is resonsible for the result on the ANOVA of the total score. Pain measurements For comarison on ain intensity ratings, the scores on NRS were used as a deendent variable. The main effect of time was significant F (1, 59) = 10.80, MSE = 1.76, <.05, =.13, reflecting a lower score on ain in the second time of measurement. As for the main effect of grou the result showed no difference in scored ain intensity between the grous F (1, 59) =.08, MSE = 5.40, >.05. The interaction effect of time and grou on the NRS score exhibited no significant difference F (1, 59) = 3.5, >.05. Even though changes in ain intensity measured with an NRS did not reach significance a tendency towards less ain for the intervention grou was evident. As an alternative measure of the exerience of ain, the subscales of MPI-S brief screening version were used. Pain intensity was measured by using the ain severity subscale as the deendent variable. Means are resented in Figure 3. The ANOVA revealed significant main effects on time F (1, 59) = 7.53, MSE = 0.6, <.01, =.11, indicating that the scores were lower at the second time of 11

14 measurement. No significant main effect of grou was observed F (1, 59) =.98, MSE = 0.80, >.05. The results of the interaction effect of grou and time were significant F (1, 59) = 5.57, <.05, =.09 which imlies that the mindfulness rogram has an effect on ain intensity when measured with MPI-S brief screening version. The effect size within the intervention grou was measured to a medium level (d = 0.59). Figure 3. Pre and ost measurement means for the intervention and control grou on the ain severity subscale of the MPI. To comare the grous on the second subscale in the brief screening version of the MPI-S the interference subscale was used as deendent variable. Means are shown in Figure 4. A significant main effect of time was observed F (1, 59) = 18.86, MSE = 0.80, <.001, =.4, as the scores were lower on the second time of measurement comared to the first. There was no main effect of grou F (1, 59) =.46, MSE = 3.99, >.05 but when time and grou interacts it reveals a significant interaction effect F (1, 59) = 8.67, <.01, =.13. The intervention grou scored significantly lower on interference on the second time of measurement while there was no significant difference between the two times of measurements in the control grou. The effect size within the intervention grou was large (d = 0.74). 1

15 Figure 4. Pre and ost measurement means for the intervention and control grou on the interference subscale of the MPI. The erceived life control in relation to ain was measured with the third subscale of the brief screening version of the MPI-S. The subscale was used as the deendent variable in this ANOVA, where a main effect of time was observed F (1, 59) = 9.61, MSE = 0.98, <.01 =.14. At the second time of measurement the erceived life control was higher. There was no main effect of grou F (1, 59) = 3.8, MSE =.48, >.05. No significant interaction effect aeared F (1, 59) =.48, >.05 meaning that the difference between the scores at the second time of measurement in the intervention grou and control grou was not significant in relation to the scores at the first time of measurement. To comare exeriences of affective distress in regard to ain the fourth and last subscale in MPI-S brief screening version was used as deendent variable. In Figure 5 the means can be viewed. A significant main effect of time F (1, 59) = 8.6, MSE = 0,93, <.01, =.1 was revealed, the scores were lower at the second time of measurement. No significant main effect of grou was observed F (1, 59) = 3.63, MSE =.46, >.05. The interaction effect, on the other hand, was significant F (1, 59) = 9.48, <.01, =.14. The intervention grou decreased significantly in measured affect distress from the first to the second time of measurement but no such difference could be observed in the control grou. The effect size for the intervention grou was calculated to d = 0.8, a large effect size. 13

16 Figure 5. Pre and ost measurement means for the intervention and control grou on the affective distress subscale of the MPI. Accetance of ain CPAQ measures accetance of ain and can be divided into two subscales: ain willingness and activities engagement. For comarison of ain willingness, this subscale was used as a deendent variable. A significant main effect on time was revealed, F (1, 59) = 1.43, MSE = 14.46, <.001, =.7. indicating that the articiants rated their ain willingness higher at the second time of measurement. There was no significant main effect of grou F (1, 59) = 0.53, MSE = 14.46, >.05. The interaction effect was not significant either F (1, 59) = 1.83, >.05. Comarisons of activities engagement, used this subscale as the deendent variable. Means are resented in Figure 6. A significant main effect of time was observed F (1, 59) = 17.01, MSE = 0.14, <.001, =., but not of grou F (1, 59) = 1.0, MSE = , >.05, indicating that that the mean score was higher at the second time of measurement. The interaction effect was significant F (1, 59) = 7.73, <.01, =.03. This means that the intervention grou exhibited higher levels of activities engagement after the intervention when comared to the control grou. The effect size within the intervention grou was at a medium level (d = 0.6). 14

17 Figure 6. Pre and ost measurement means for the intervention and control grou on the activities engagement subscale of the CPAQ. For comarisons on total score of CPAQ, this was set as a deendent variable. Means are resented in Figure 7. The ANOVA revealed a significant main effect of time F (1, 59) = 9.6, MSE = 44.57, <.001, =.33 meaning that the accetance levels were higher on the second time of measurement. No main effect of grou was observed F (1, 59) = 1.1, MSE = , >.05. When the variables time and grou interacts a significant interaction effect is revealed F (1, 59) = 6.95, <.05, =.11, this suggests that the intervention grou had increased their score from the first measurement to the second measurement when comared to the control grou. The effect size for the intervention grou was at a medium level (d = 0.71). 15

18 Figure 7. Pre and ost measurement means for the intervention and control grou on the total CPAQ scores. Distress caused by ain To evaluate whether the mindfulness rogram decreased the distress that follows the ain an ANOVA with an NRS for distress as deendent variable was created. The means are exhibited in Figure 8. The result showed significant main effects of both time F (1, 59) =.9, MSE =.31, <.001, =.7 and grou F (1, 59) = 5.83, MSE = 6., <.05, =.09. The rated distress was lower at the second time of measurement and in the intervention grou comared to the control grou. The interaction effect of time and grou was significant F (1, 59) = 11.15, <.001, =.16. After comleting the mindfulness rogram the intervention grou exhibited significantly lowered scores of suffering while there was no significant difference among the control grou between the two times of measurement. The effect size within the intervention grou was d = 1.3, which is considered a large effect size. 16

19 Figure 8. Pre and ost measurement means for the intervention and control grou on the NRS measuring distress caused by ain. Life Satisfaction For comarison on life satisfaction LiSat-11 was used as a deendent variable. The mean scores differences are shown in Figure 9 and indicate equivalent ratings at the first measurement between the two grous but aear to be much higher in the intervention grou at the second time of measurement. This observation was confirmed by using an ANOVA which revealed a main effect of time F (1, 59) = 1.01, MSE = 0.13, <.001, =.17 the scores were higher at the second time of measurement. No main effect of grou was observed F (1, 59) = 0.71, MSE = 0.93, >.05. The interaction effect of time and grou was significant F (1, 59) = 4.53, <.05, =.07 which means that the increase in the ratings on LiSat-11 in the intervention grou between the first and second time of measurement was significant and significantly larger than the change in ratings in the control grou. The effect size for the intervention grou was at a medium level at d =

20 Figure 9. Pre and ost measurement means for the intervention and control grou on the LiSat-11. Discussion The urose of this study was to examine whether an online mindfulness training rogram could serve to reduce the exerience of ain in individuals suffering from chronic ain. After comleting the rogram the articiants showed decreased ain intensity and reduced levels of interference of ain in their everyday lives. They also exhibited less affective distress as well as greater accetance of and a decreased level of distress caused by ain. Furthermore, their quality of life imroved and as exected, they showed increased levels of mindfulness. By contrast, the control grou did not exhibit higher levels of mindfulness which indicate that the imrovements in the intervention grou were in fact derived from the mindfulness training. Thus, the mindfulness training rogram was demonstrated to be effective both in regard to reduction of the ain-related exeriences and to imrove asects of life that could be negatively affected by ain. The decreases in ain were not comletely unanimous, though. When measured by a single item asking for an average of ain during the ast week the result did not show significantly lower levels of ain intensity in the intervention grou even though a strong tendency ( = 0.77) towards reduced ain was found. In revious research there is no agreement regarding the effect mindfulness has on ain intensity. In their review Reiner et al. (013) found that mindfulness has an effect on ain intensity while Chiesa and Serretti (011) were unable to confirm this in 18

21 their review. The reviews differed in what kind of ain measures they included. Chiesa and Serretti as well as Veehof et al. used both multidimensional and unidimensional measures of ain while Reiner et al. only reviewed studies that had used unidimensional measures of ain. When measured by the ain severity subscale of the brief screening version of the MPI-S a significant decrease in ain intensity at a medium effect size was revealed. The subscale consists of a comosite of two questions, one regarding average ain during the last week and one regarding current ain. We hyothesize that the inclusion of an item regarding current ain could be related to the lower results on the ain ratings comared to the unidimensional NRS. The emhasis on the resent moment that is central in mindfulness could be an imortant asect to consider when understanding this result. An active comonent in mindfulness training for chronic ain according to Reiner et al. (013) could be detachment of cognitive and emotional ain comonents (Reiner et al., 013). The exerience of ain in the resent moment would then not be aggravated by thoughts and feelings about it. The other subscales in the brief screening version of MPI-S measures other imortant asects of chronic ain, such as its effect on everyday life (Jakobsson, 009). The scores on the two subscales affective distress and interference imroved significantly in the intervention grou comared to the control grou indicating that the mindfulness rogram has a ositive effect on the exerience of ain. No significant imrovements in the subscale life control were found. The lack of significant imrovement on the single item regarding average ain during the ast week goes in line with the results of Cusens, Duggan, Thorne and Burch (010) who also failed to find a significant decrease in ain intensity ratings. They hyothesized that this could be related to the Breathworks rogram as it has an emhasis on accetance and absence of exlicit attemts to decrease ain. As the mindfulness rogram used in the resent study is an adatation of the Breathworks rogram the same exlanation could aly here as well. Veehof et al. (011) concluded that in interventions for chronic ain the ain, due to its chronic nature, is unlikely to decrease much. Therefore, other asects than ain intensity are also relevant when assessing the exerience of chronic ain. Accetance of chronic ain has been associated with several health benefits such as less disability and better work status (McCracken & Eccleston, 003). After rogram comletion, accetance of ain increased for the articiants in the intervention grou. As the mindfulness rogram largely is directed towards increasing accetance of ain through mindfulness this is not surrising. After comleting the rogram articiants showed increases in both overall accetance and activities engagement. Increased engagement in activities can be valuable for individuals with chronic ain as the condition often is associated with withdrawal from reviously valued activities (Vlaeyen & Linton, 01). McCracken, Vowles and Eccleston (004) suggest that an imortant comonent of accetance of chronic ain is engagement 19

22 in ositive everyday activities even when exeriencing ain. Thus, accetance of chronic ain is not only limited to mental rocesses. Another comonent of chronic ain accetance is the realization that avoidance of, or attemts to control ain are ineffective ways of coing as they do not decrease ain (McCracken, Vowles & Eccleston, 004). The articiants in the resent study did not show significant change in ain willingness though. Both intervention and control grou reached significantly higher means in the ost measurements but the interaction effects were not significant. However, the mean scores derived from the ain willingness subscale are relatively high in both re and ost measurement comared to the reorted means in revious studies (e.g. Vowles, McCracken, McLeod & Eccleston, 008), constituting for an even result when considered in relation to the activities engagement subscale. After comleting the mindfulness rogram the articiants exhibited significantly reduced levels of distress caused by ain. This is an imortant finding as decreases in distress due to ain can be viewed as an indicator of the imact of the mindfulness training on the individuals everyday lives. Based on the findings in the resent study we hyothesize that decreases in distress due to ain can be related to increased quality of life, thus affecting the overall exerience of life for the individual. The reduction in distress could also be related to the increase in accetance of ain that the articiants exhibited in the resent study. As roosed by McCracken and O Brien (009), eole with chronic ain might feel less distress when they are able to exerience unleasant sensations without attemting to control them. Mindfulness training could lead to such an attitude as it is educating a nonjudgmental and acceting osition towards ain. As chronic ain is associated with decreased quality of life (Breivik et al., 006; Lamé, Peters, Vlaeyen, Kleef & Patijn, 005) it is an imortant asect to consider when evaluating an intervention for chronic ain. In the resent study, the intervention grou increased their life satisfaction comared to the control grou. This is in accordance with revious research (Chiesa & Serretti, 011). The effect size was at a medium level which is the same as Veehof et al. (011) found in their meta-analysis. The use of a discussion forum for the control condition can be considered as a form of active control grou, which is referable to a simle waiting-list condition (Boot, Simons, Stothart & Stutts, 013). It is also needed in research on mindfulness and chronic ain (Reiner et al., 013). The articiants in the control grou were informed that a revious study (Lorig et al., 00) had shown that a discussion forum can have a ositive effect on the exerience of ain, thus giving them some exectation of ositive effects. Providing the control grou with information that might increase their exectations to benefit from the control condition is recommended by Boot, Simons, Stothart and Stutts (013) as it is considered a way of removing otential lacebo effects. We did not measure exectations in the resent study however, thus making it difficult to clearly state that the control grou had equal exectations as the intervention grou. 0

23 Some limitations of the current study should be noted. Many articiants had revious mindfulness exerience which may have affected the results. If the articiants already were mindful before articiating in the resent study they could already exhibit high levels of the skills that are trained in mindfulness. Thus, generalizability of the findings needs to be further investigated in ain grous without revious mindfulness exerience. However, the constitution of the samle also has some strength, since it does not only consist of chronic ain atients the results are not limited to this grou. This is lacking in some revious studies according to Reiner et al. (013). Turk and Okifuji (00) also oint out the imortance of investigating treatments for chronic ain on individuals that do not seek hel since treatment effect may not be the same in these individuals. As we excluded articiants with high levels of deression which is a common comorbid diagnosis to chronic ain the generalizability of the resent study could be comromised. However, even though mindfulness is considered an alicable method of reventing deression it has been considered less useful in atients with current deression as they might exhibit cognitive deficits due to their deressive state making it difficult to acquire the skills taught through training (Segal, Williams & Teasdale, 00). The articiants ability to comlete the rogram can also be negatively affected by a deressive state. More recent research has found ositive effects on deression after mindfulness training online (Krusche, Cyhlarova & Williams, 013), but this is not yet sufficiently researched. The dro out rates in this study were high (60%), due to which some caution when interreting the results is needed. The high dro out rates imlies difficulties in comleting the rogram for the articiants. Large dro out rates are common in Internet-based studies in which none or little ersonal contact is included (Melville, Casey & Kavanagh, 010). We hyothesize that more articiants would have comleted the rogram if some form of ersonal suort or contact had been rovided or if the articiants had been able to articiate in a discussion forum related to ain and mindfulness during the intervention. It can be noted that 71% of the 1 articiants who comleted the rogram reorted no revious mindfulness exerience. Therefore it can be assumed that, in order to comlete the mindfulness rogram, no revious exerience of mindfulness is needed. The fact that 93% of the articiants were female is noteworthy even though we do not believe that this affected the results in any articular way. A lausible exlanation to the large dro out in the intervention grou could be that the articiants did not exerience imrovements in the early stages of the rogram and therefore discontinued the rogram. On the other hand, exeriences of early imrovement could result in remature dro out as the articiants might not feel the need to continue the rogram. Furthermore, the large dro rate could to some extent be due to technical roblems with the mindfulness rogram, which, for a few days, made the articiants unable to rogress in their mindfulness training. 1

24 Accetance seems to be an imortant asect of the mindfulness rogram in decreasing ain related suffering. In order to gain further understanding of the connection between mindfulness and ain, future research should focus on investigating whether certain comonents in mindfulness training, such as accetance, carries secific imortance for reducing ain and ain-related roblems. The goal in accetance based interventions for chronic ain is not secifically reduced ain but rather a new way of dealing with ain. Our results suort the notion that individuals suffering from chronic ain can benefit from mindfulness training. In conclusion, the mindfulness rogram used in the resent study seems to be an effective way of increasing levels of mindfulness as well as ain related accetance and, to some extent, also decrease ain. As the mindfulness rogram was administered online, without any ersonal contact it is a cost-effective otion or comlement to other tyes of treatments for the disabling disease that is chronic ain. References Aalto, M., Tuunanen, M., Sillanaukee, P., & Sea, K. (006). Effectiveness of structured questionnaires for screening heavy drinking in middle-aged women. Alcoholism: Clinical and Exerimental Research, 30, Andersson, G., Kaldo-Sandström, V., Ström, L., & Strömgren, T. (003). Internet administration of the hosital anxiety and deression scale in a samle of tinnitus atients. Journal Of Psychosomatic Research, 55, Andersson, H. I. (004). The course of non-malignant chronic ain: A 1-year follow-u of a cohort from the general oulation. Euroean Journal of Pain, 8, Baer, R. A. (009). Self-focused attention and mechanisms of change in mindfulness-based treatment. Cognitive Behaviour Theray, 38, Baer, R. A., Smith, G. T., Hokins, J., Krietemeyer, J., & Toney, L. (006). Using self reort assessment methods to exlore facets of mindfulness. Assessment, 13, Bergman, S., Herrström, P., Jacobsson, L. T. & Petersson, I. F. (00). Chronic widesread ain: A three year follow-u of ain distribution and risk factors. Journal of Rheumatology, 9, Bisho, S. R., Lau, M., Shairo, S., Carlson, L., Anderson, N. D., Carmody, J.,... Devins, G. (004). Mindfulness: A roosed oerational definition. Clinical Psychology: Science And Practice, 11, Boot, W. R., Simons, D. J., Stothart, C., & Stutts, C. (013). The ervasive roblem with lacebos in sychology: Why active control grous are not sufficient to rule out lacebo effects. Persectives On Psychological Science, 8, Breathworks, online mindfulness for health course (013). Retrieved December at: htt://