Intervention

The intervention was modeled on the work of Jon Kabat-Zinn and the mindfulness-based stress reduction program he pioneered at the University of Massachusetts Medical Center.¹³ Participants were seen in a group setting once a week for 90 minutes for a total of eight weeks. Mindfulness meditation takes everyday activities such as breathing, sitting, lying down, and walking and turns them into a meditation through directed attention on sensation, thoughts or emotions.

The techniques used were: 1) the body scan, where in a lying position, the participant is guided to place their attention non-judgmentally on each area of the body from the toes to the top of the head, 2) sitting practice, which is focused attention on breathing while sitting on a chair or on a meditation cushion on the floor, 3) walking meditation, which is mindful slow walking with focused attention on body sensation and/or breathing. The study protocol also included “homework” of daily meditation (six of seven days/week) lasting 50 minutes (45 minutes of meditation, 5 minutes to complete the diary). Support materials of audiotape, daily diary and reading materials were provided. The audiotape was a guided 45 minute recording of the steps in the body scan meditation on one side and a guided 30 minute recording of sitting meditation on the other side.²²

The diary listed one full week per page, with space next to each day to record the number of minutes meditated, as well as space for comments about the day’s meditation session. There was also a section for general comments about the meditation experience. Headings were “Amount of time spent meditating,” “Any benefits or problems with the meditation?” and a “Comments” section. Diaries were collected weekly.

Experiencing pain reduction from mindfulness meditation

Many participants commented on the reduction of pain by indicating the methods and processes used to reduce it, such as distraction from pain, heightened awareness of pain sensation leading to behavior change, better coping with pain, and actual pain reduction using the meditation technique. In the context of distraction, some participants described their increased ability to constructively distract from pain by purposely placing their attention on routine activities, “I practice informal meditation, and try to be more fully aware, during every day activities in the house” (participant 22) and “[I] focus on things to distract from pain” (participant 5). Another specific distraction process involved redirecting the mind’s focus to more general body awareness, “I am able to reduce my back and leg pain by deflecting the pain and by focusing on other parts of my body” (participant 2).

Another means of pain reduction was the development of a heightened awareness of body sensations that led to behavior change that reduced pain. It was generally stated that, “I am learning to appreciate awareness of sensations” (participant 2). The awakened realization of subtle body sensations enabled participants to recognize pain earlier than was typical for them, thus allowing them to intervene before the pain escalated, “Upon first signs of pain, I stop and meditate, helpful at times” (participant 10). One participant’s increased awareness of body sensation led her to realize “minor” pains could be easily cured, “I realized I had a toenail so overgrown it was causing definite sharp pain…I shut off the CD [for the body scan meditation] and trimmed it and started again. It seemed silly not to eliminate such a small source of discomfort” (participant 18). We also found that heightened awareness with some participants stimulated imagery that helped reduce their pain and enhance their mood. This is depicted best by the quote, ”I hear a sound in the distance and felt it was bearing my pain away, replacing it with a joyful “lifting” of my spirits” (participant 18).

Interestingly, the process of learning meditation and becoming more aware of the body also allowed some participants to be more introspective. Some realized that they had adopted maladaptive coping strategies such as repression in order to deal with their pain. We received feedback from a participant who detailed her process stating, “It felt good to be ’directed’ to these quite soluble problems and I realized that in my stoic, actually…rather angry, ’at the end of my rope’ reaction to my seemingly insoluble back pain…I was neglecting my whole body trying as it were to blot out all pain even the minor “itch” I can scratch. I was in a strange way turning myself into a whole ’petrified forest’, because one area, my lower back, was in need of relief from the pain.” (participant 18). In general, participants stated they were better able to cope with their pain using various methods realized or learned through mindfulness meditation “I still have the same back pain but am coping with it much better” (participant 6). It was reported several times that pain was improved and meditation was frequently used in different situations, “I have used mindfulness in other situations (i.e. stress, improved memory, decision making)” (participant 14).

As participants became more skilled at using the mindfulness meditation technique, some indicated that it directly eliminated their pain. They spoke of relieving pain by concentrating on their breathing, “I have used the breath concentration to successfully relieve pain in a number of situations” (participant 6). Another stated “When I was able to concentrate I had a great experience. The only time I had a sensation is when I was concentrating on my lower back. I felt like something was happening to that section of my body and … the pain would disappear” (participant 9). Most diary entries described a feeling of relaxation and serenity post meditation which caused participants to continue using meditation for this pain-reducing, mood-elevating effect. “I have no pain lying down and I do feel more comfortable with my back when I am finished. I can stand on my feet longer” (participant 11).

Improvement in attention skills resulting from mindfulness meditation

Participants noted improvement in their ability to pay attention. As one participant described, “My concentration and awareness improved so much. My mind does not wander anymore as much as it used to. I am more focused” (participant 12). Additionally, a participant noted their increased attention was also associated with a sense of well-being, “Learning mindfulness meditation helped me to be more relaxed and focused in day to day living” (participant 4).

Improved sleep resulting from meditation

Participants consistently commented on how meditation increased the quality of sleep. Though it was stated that sleep came very easily during meditation, participants also often said that sleep latency (the time from the decision to sleep to the onset of sleep) was reduced and more restful or refreshing. Even if night awakenings occurred some participants were able to “get back to sleep more readily” (participant 6). A woman who had difficulty with insomnia also found a great benefit from meditation as she reported that “sleeplessness was harming my quality of life in every aspect and I am grateful I no longer have the problem. It has made a huge difference in my life” (participant 4).

Achieving well-being

Learning mindfulness meditation resulted in positive affect and experiences of greater mental and physical well being which occurred immediately post meditation, but also remained long-term. Meditation also provided participants with a tool to positively handle stress.

Well-being: Short-term effects

A meditation session frequently had immediate general physical and mental restorative effects on participants. As alluded to in the pain section of the results, participants consistently and repeatedly wrote about feelings of relaxation and serenity in their diaries. Most stated that their experience of being refreshed or regenerated was stimulated by practicing meditation as one participant wrote after completing a session, “feel refreshed and relaxed” (participant 23). Some participants translated the experience of mindfulness meditation using metaphors, “when I was able to concentrate I felt like the mattress commercial--sleeping on a cloud” (participant 9).

Main findings in the context of the existing literature

Distraction is a commonly used method of coping with pain, and typically refers to the voluntary or involuntary moving of attention away from pain.²⁰ However, distraction as described by our participants, involved purposefully bringing and maintaining attention to the present moment’s activities. Hence, through mindfulness meditation older adults described learning to fully engage in present moment activities like listening to music and exercise. This full engagement increased absorption in another activity and effectively caused distraction from pain. Therefore, mindfulness meditation may have permitted greater attention regulation, so that participants could become aware of, and choose how to direct their attention. It should be noted that these routine activities did not necessarily cause pain reduction prior to learning mindfulness meditation. Thus, participants were equipped with a simple tool for pain reduction that they could apply at any time and in a variety of daily life situations.

Interestingly, the instruction in mindfulness meditation to become more aware of body sensations had a paradoxical effect. Usually, ignoring pain sensations is considered one of the mechanisms people use to cope with pain.²⁶ However, our participants experienced pain reduction by attending to the experience of their pain. The pain reduction may have occurred through several mechanisms. One possible mechanism was an increased awareness of physical activities or postures that worsened pain. Thus simply “stopping” a given activity at the first hint of pain may have allowed a person to intervene before pain escalated.

Another possible mechanism was personal insight into negative emotional processing that worsened pain. Thus, the awareness of a particular body sensation was also noted to be linked to a negative affective response that resulted in heightened pain. Negative affect such as anxiety and fear is known to increase a person’s sensation of pain,¹⁴ and therefore modifying such responses has the potential to reduce the experience of pain. By encouraging awareness of present moment experience, mindfulness meditation taught participants how to become aware of these negative emotional responses to their pain, which in turn may have allowed participants to manage their reactions in a less self-destructive manner.

In Kabat-Zinn’s seminal paper about mindfulness meditation and pain¹² he describes the process of pain reduction occurring by “an attitude of detached observation toward a sensation when it becomes prominent in the field of awareness, and to observe with similar detachment the accompanying but independent cognitive processes which lead to evaluation and labeling of the sensation as painful, as hurt.” Thus, by “uncoupling” the physical sensation, from the emotional and cognitive experience of pain, the patient is able to reduce pain. We believe our findings are consistent with Kabat-Zinn’s proposed mechanism, and expand it, by describing how participants uncouple the different components of the complex experience of pain. Thus, participants’ descriptions of distraction from pain, understanding maladaptive coping strategies for pain, and heightened awareness of pain sensation leading to behavior change are examples of how pain is uncoupled from emotion, cognition, and sensation.

The direct resolution of pain while meditating is intriguing and may be explained by several potential mechanisms. One was already discussed above-the uncoupling of pain into its different components. This is consistent with Melzack's gate control theory,¹⁹ in that conditioned or emotional responses to pain can be modified through meditation by disengaging habitual reactivity, and therefore a top-down inhibition of pain via the gate control system. Another potential mechanism is the relaxation response as proposed by Herbert Benson. The hypometabolic state characterized by decreased heart rate, respiratory rate, and oxygen consumption,^28,2 may well be associated with decreased muscle tension and release of neurotransmitters that cause immediate pain relief. This has direct relevance to older adults with chronic low back pain, as the majority of older adults have myofascial pain as at least one contributor to their low back pain.³⁰

Another possible explanation with support from neuroimaging studies is that mind body therapies may favorably alter pathways that modify the experience of pain. For example, hypnotic suggestions for experiencing either high or low pain unpleasantness produced corresponding changes in activity in the anterior cingulate cortex (ACC), but not the primary somatosensory cortex.²⁵ Top-down inhibition through voluntary control of the rostral ACC has been suggested by deCharms who used real-time functional magnetic resonance imaging to demonstrate that participants could voluntarily increase or decrease stimulation to the rostral ACC. This in turn was associated with an increase or decrease, respectively, in their rating of a painful thermal stimulus.⁷

One of the themes was improved attention skills resulting from mindfulness meditation. Improved attention skills was also asked of participants at 3-month follow-up and 16/25 (64%) of them responded affirmatively that they could concentrate better after learning mindfulness meditation.²² This is a particularly interesting finding since slowing cognitive decline is especially relevant to the aging population. Experimental evidence from Jha suggests that mindfulness meditation may improve the conflict monitoring (prioritizes competing tasks) and alerting (maintaining an alert state of awareness) components of attention.¹¹

Improved sleep from mindfulness meditation has also been described in a variety of populations.^3,4,15 However, qualitative studies mention sleep only briefly⁵, and do not describe the effects on sleep quality and improved sleep latency with the detail used by the older adults in this study. Sleep promotion was both a negative short term side effect, since it interfered with the ability to stay alert and awake during meditation, and also a long-term benefit, because of its ability to enhance sleep quality and reduce sleep latency outside of the meditation setting.

Mindfulness meditation led to increased well being for participants that was present both during meditation and carried over post meditation. This improved well being was associated with an immediate shift towards a positive affect during a meditation session as revealed by participants’ descriptions of being calm and peaceful while meditating. Immediately after meditation, this positive change persisted so much that a participant described feeling like “a new person.” Brain neuroplasticity, with a shift towards a more positive affect as a result of mindfulness meditation has support in the neuroscience literature. Davidson found that participants in an eight week Mindfulness Based Stress Reduction program demonstrated on EEG a left shift in their pre-frontal cortex response to a positive and negative emotion provoking writing task.⁶ This left shift may be an indicator for increased positive affect. Management of emotion with an overall increase in positive affect is emerging as one of the central mechanisms by which mindfulness meditation may effect change.

Strengths of this study

The first person accounts of the experience of mindfulness meditation in older adults with chronic pain allowed us to describe effects that could not be captured by quantitative techniques. We sampled older adults with persistent pain, who have little written about them regarding mind-body therapies for treating pain.^13,21 Many of the findings lend themselves to both qualitative and quantitative research and can apply to a younger population.

Supported by AG23641 K07 of Dr. Stephanie Studenski from the National Institutes of Health. During the time of this work Dr. Morone and Dr. Tindle were supported by the NIH Roadmap Multidisciplinary Clinical Research Career Development Award Grant (1KL2RR024154-01) from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research, and its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.