Background & Aims
The transition from acute to chronic low back pain (cLBP) is associated with reduced neural density in the insular cortex, a neural hub for interoception and the salience network. Common coping with cLBP is by ignoring and distraction. This coping style appears to be beneficial for acute pain but is of questionable benefit for chronic pain. Can an opposite coping style of mindful interoceptive exposure to the experience of pain itself and its phenomenological sensory elements and components be an alternative approach?
Funding: NIAMS U19AR076737 (PI Lotz).
Methods
We performed a single-arm feasibility study in patients with cLBP using a 2-minute attention exercise guided by a smartphone app several times per day over 8 weeks. We assessed feasibility, standard pre-post pain outcomes, function and key psychological parameters by standard questionnaires and EMA. We compared pre to post-intervention QST and task-based fMRI (see poster by Dr. Strigo). We used reflexive thematic qualitative analysis for exit interviews that included an innovative micro-phenomenology technique.
Results
Pre-screened 301 patients, 38 eligible/consented, 31 enrolled, 29 completed, mostly female, mean age 48, majority pain for >5 years. Mean pain intensity [0-10] improved from 4.8 ±1.7 to 3.1 ±1.9 (p <.001); mean PEG score (intensity and interference with daily life; range 0-30) 13.7 ±6.2 to 8.4 ±6.6 (p <.001); pain impact (9 items incl physical function) 22.3 ±8.7 to 19.7 ±8.1 (p =.004). 21 of 29 improved their PEG score by ³30%. There were significant improvements in PCS Rumination and MAIA Not-Worrying. Mid-posterior insula (interoceptive sensory cortex) pain-related fMRI activation recovered with high responders showing significantly greater recovery compared to low responders àPoster Irina Strigo). Exit interviews demonstrated that participants became aware of their usual habit of avoidance and the challenge of and resistance to focusing on pain. They were surprised how pain sensations varied over time and described a variety of three-dimensional pain shapes with a variety of colors, transparency, temperature, and density that, for some, changed dramatically with a mindful attention focus. They reported on using regulation of breathing and found that the threat value of their pain diminished.
Conclusions
This single-arm study assessed a phone-based mindful interoceptive attention task for patients with chronic low back pain by mixed methods including questionnaires, QST, fMRI and interviews. The findings appear to support the notion that mindful interoceptive exposure to the sensations of their cLBP using a simple 2-minute attention exercise with a phone app—rather than ignoring and distracting from it—may be beneficial for cLBP. If confirmed by further research, this would be an innovative paradigm for pain management and could be included in mindfulness interventions.
References
1 Apkarian AV, Baliki MN, Farmer MA. Predicting transition to chronic pain. Curr Opin Neurol. 2013;26(4):360-367.
2 Mehling WE, Daubenmier J, Price CJ, Acree M, Bartmess E, Stewart AL. Self-reported interoceptive awareness in primary care patients with past or current low back pain. J Pain Res. 2013;6:403-18.
3: Goubert L, Crombez G, Eccleston C, Devulder J. Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain. Pain. 2004;110(1-2):220-7
4. Petitmengin C, van Beek M, Bitbol M, Nissou JM, Roepstorff A. Studying the experience of meditation through Micro-phenomenology. Current opinion in psychology. 2018;28:54-9.
Presenting Author
Wolf Mehling
Poster Authors
Wolf Mehling
MD
UCSF
Lead Author
Irina Strigo
Emotion and Pain Laboratory, San Francisco Veterans Affairs Health Care Center
Lead Author
Goldman
Lead Author
Wendy Hartogensis
University of California San Francisco
Lead Author
Shelley Adler
PhD
University of California San Francisco
Lead Author
Rick Hecht
Osher Center for Integrative Health, University of California San Francisco
Lead Author
Jeff Lotz PhD
Department of Orthopedic Surgery, University of California San Francisco
Lead Author
Topics
- Treatment/Management: Pharmacology: Psychological and Rehabilitative Therapies