Meditation Interventions for Chronic Disease Populations: A Systematic Review.

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JHNXXX10.1177/0898010115570363Journal of Holistic NursingMeditation in Chronic Disease / Chan, Larson

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Critical Reviews

Meditation Interventions for Chronic Disease Populations A Systematic Review Roxane Raffin Chan, RN, PhD, AHN-BC

jhn

research-article2015

Journal of Holistic Nursing American Holistic Nurses Association Volume XX Number X XXXX 201X 1–15 © The Author(s) 2015 10.1177/0898010115570363 http://jhn.sagepub.com

Michigan State University College of Nursing

Janet L. Larson, RN, PhD, FAAN

University of Michigan School of Nursing

The rapidly growing body of research regarding the use of meditation interventions in chronic disease presents an opportunity to compare outcomes based on intervention content. For this review, meditation interventions were described as those interventions delivered to persons with chronic disease where sitting meditation was the main or only content of the intervention with or without the addition of mindful movement. This systematic review identified 45 individual research studies that examined meditations effect on levels of anxiety, depression, and chronic disease symptoms in persons with chronic disease. Individual studies were assessed based on interventional content, the consistency with which interventions were applied, and the research quality. This study identified seven categories of meditation interventions based on the meditation skills and mindful movement practices that were included in the intervention. Overall, half of the interventions had clearly defined and specific meditation interventions (25/45) and half of the studies were conducted using randomized control trials (24/45). Keywords: meditation/mindfulness; chronic disease; evidence-based practice

Background and Significance Many health centers and rehabilitation programs provide meditation interventions for persons with chronic disease guided by a body of research that has grown rapidly since 2005. This growth in research provides an opportunity to describe critical components within these complex meditation interventions (Thomas & Cohen, 2014) and to evaluate the effectiveness of meditation interventions based on the skills and techniques included within these different meditation interventions (Bond et al., 2009).

Meditation Different meditation interventions are based to some degree on a particular meditation school of

thought or philosophy. Each of these schools or philosophies contains some combination of the two core skills that are taught with the goal to increase an individual’s ability to be mindful, or aware, of their internal and external environment. Core skills are taught using varying degrees of difficulty based on the current abilities of the learner, the specific spiritual foundation of the teacher, and the goal of the spiritual lesson. In the chronic disease population, some meditation interventions have included a spiritual component (Carson et al., 2005; Rungreangkulkij,

Authors’ Note: The authors acknowledge the support from the NIH Grant No. F31NRO12334. Please address correspondence to Roxane Raffin Chan, RN, PhD, AHN-BC, Assistant Professor, Michigan State University College of Nursing, 1355 Bogue Street, Room #C242, East Lansing, MI 48824-1317, USA; email: [email protected].

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2 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX

Wongtakee, & Thongyot, 2011; Tavee, Rensel, Planchon, Butler, & Stone, 2011) while others, such as all those based on mindfulness-based stress reduction (MBSR), de-emphasized or neutralized the spiritual components (Kabat-Zinn, 1982). Regardless of the meditation school or philosophy providing the theoretical basis for the intervention, all meditation interventions include some combination of the two core mental skills and sometimes also a type of mindful exercise. Meditation is a complex activity composed of two individual but complementary skills (Hasenkamp & Barsalou, 2012) that develop one’s ability to pay attention in the present moment without judgment (Kabat-Zinn, Lipworth, & Burney, 1985). There is evidence to suggest that each meditation skill has a distinct and identifiable neurological mechanism (Dunn, Hartigan, & Mikulas, 1999). The first attentional meditation skill requires a self-regulation of attention to an exclusive focus and will be referred to in this article as “exclusive attention.” The second attentional skill requires an attention to the shifting background of one’s internal or external environment, and will be referred to in this article as “inclusive attention.” Both of these attentional skills are accomplished through the use of a self-guided state of relaxed logic or suspension of belief (Bond et al., 2009). Traditionally, these two attentional skills were taught along with some form of mindful movement, which may not be true in meditation interventions used today. The practice of mindful movement improves interceptive awareness, flexibility, circulation, and proprioception (e.g., tai chi, qi gong, and yoga). Exclusive Attention. Exclusive attention is often considered a foundational skill of meditation (Dalai Lama, 2001). An example of a meditation that focuses on the skill of exclusive attention would be mantra meditation. In this meditation, a person focuses on a single word. As the mind wanders, the person is directed to return to this single word. This skill activates and develops the anterior cingulated cortex, allowing beginning practitioners to develop a greater ability to maintain focus and attention (Hölzel et al., 2007; Hölzel et al., 2011; Jhal, Krompinger, & Baime, 2007; Slagter et al., 2007; van Leeuwen, Singer, & Melloni, 2012). Development of increased exclusive attention is necessary in order to advance to other meditation skills such as inclusive attention

(Hölzel et al., 2011; Maupin, 1965). However, it is often used singularly as in Benson’s (1975) relaxation response, mantra-based meditation interventions (Curiati et al., 2005; Rajesh, Jayachandran, Mohandas, & Radhakrishnan, 2006), and compassionate or loving-kindness meditations (Fredrickson, Coffey, Pek, Cohn, & Finkel, 2009; Salzberg, 2002). Inclusive Attention. Practicing inclusive attention develops the skill of attentional awareness among all internal and external sources of stimulation (Dunn et al., 1999). It is most often described as a change in neurological function that occurs when attention is allowed to shift from one focal point to another in turn (Delevoye-Turrell & Bobineau, 2012; Telles et al., 2013). An example of a practice that would increase your inclusive attentional ability is to become aware of one particular sound in the environment and then take your attention away from that first sound to allow yourself to become aware of a different sound in the environment. The therapeutic goal of practicing inclusive attention is to increase awareness of feelings, sensations, and surroundings, including negative sensations (Baer, 2003). Research on inclusive meditation demonstrated increased neurological density in the medulla (VestergaardPoulsen et al., 2009) and reduced reactivity to external signals (Van den Hurk, Janssen, Giommi, Barendregt, & Gielen, 2010) and internal signals (Perlman, Salomons, Davidson, & Lutz, 2010), resulting in improved processing of physical sensations or whole body awareness. Mindful Movement. Researchers who include mindfulness meditation in their interventions understand that physical movement combined with mindful awareness improves flexibility and increases body awareness. Using movement in this manner was originally done in preparation for sitting meditation. Practicing mindful movement prior to sitting meditation improves a person’s ability to be aware of body sensations, which is integral to the Eastern concept of the mind in the body (Kerr, 2002). This led some researchers to identify yoga, qi gong, and tai chi as a new category of exercise therapy (Larkey, Jahnke, Etnier, & Gonzalez, 2009) that, different from strength training or aerobic exercise, increases somatic awareness and improves proprioception (Wolf et al., 2003). In this study, we will refer to these practices together as “mindful movement.” It is


Meditation in Chronic Disease / Chan, Larson 3

proposed that the increased body awareness facilitated by mindful movement allows persons with chronic disease to identify more positively with their body, resulting in increased activity levels and quality of life (Wang, Collet, & Lau, 2004).

Research Goals As outlined by the Medical Research Council (Anderson, 2008), complex behavioral interventions such as meditation require research to be reviewed more than once, with each review focusing on a different component of interventional complexity. This structured review seeks to begin this process by selecting three major outcomes (anxiety symptoms, depression symptoms, and chronic disease symptoms) and reviewing results of many studies categorized based on the variability between meditation intervention content. This will allow for the necessary comparing and contrasting of intervention content (Shepperd et al., 2009) needed to assess which meditational skills combinations are most efficient and effective in a given population of chronic disease patients. To have the best opportunity to accomplish this task, all meditation interventions that meet the inclusion criteria to date have been included in this structured review.

Method A systematic search was conducted of research published between 1960 and 2013 in three databases: CINHAL, PsycINFO, and MEDLINE/ PubMed. The following search terms were used: “meditation,” “mindfulness,” “compassion,” “lovingkindness,” “internal QiGong,” and “relaxation response.” Each interventional term was then combined with terms related to chronic disease: “CHF,” chronic heart failure,” “COPD,” “chronic obstructive pulmonary disease,” “chronic disease,” “chronic pain,” “back pain,” “multiple sclerosis,” “Crohn’s disease,” “arthritis,” “HIV,” “chronic fatigue syndrome,” and “fibromyalgia.” The word cancer was not included as a search term. Studies were included if meditation was identified as the single or primary component of a multicomponent mind/body intervention; they were written in English, they were published in a peerreviewed journal, and they reported one or more of the following outcome measures: anxiety, depression,

or chronic disease symptoms. Experimental and quasi-experimental research designs were included. Studies were excluded if the sample size was fewer than 15 or if other significant components were added to the intervention, such as nutritional changes or active therapy like massage or acupuncture. The search produced 183 abstracts that included 3 metaanalysis articles, 11 review articles, and 121 research articles. Abstracts were reviewed by two people, and 45 original research articles were identified for inclusion in this review (see Figure 1).

Intervention Quality Evaluation High-quality meditation interventions have clear learning objectives based on theory and science, a method to promote consistent teaching between groups and trained teachers with a history of personal meditation experience. The use of meditation as an intervention for persons with chronic disease has led to the individualization of meditation interventions, making it necessary to document the extent to which the intervention was standardized and the meditation instructor’s understanding, experience, and training for the meditation intervention employed (Salzberg, 2002). To assess the quality of the meditation intervention a checklist of six necessary characteristics was developed. The first two questions assess the theoretical basis of the meditation intervention and ask if the meditation intervention was based on a known meditation practice and if there was documented adherence to the meditation practice chosen or a stated rationale for changes made to the intervention. The last four questions address the fidelity of the intervention and assess if a manual was developed to guide the instruction, if the instructors were trained in the particular practice being taught, if the instructors had a personal practice of meditation, and if fidelity checks were done between different cohorts or different instructors. Each intervention was rated between 0 (if none were present) and 6 (if all quality measures were present; see Table 1 for results).

Research Design and Quality Assessment Research quality ratings were based on the Johns Hopkins University evidence rating scales (Newhouse, Dearholt, Pugh, & White, 2005). There



121 Potentially relevant research articles identi ied and screened

54 abstracts reviewed by JL and RC

Excluded articles: Not meditation, 19; Not interventional study, 22; Not primary research article, 8; Not chronic disease, 8

Excluded articles: Too broad, 1; Sample size too small, 4; Measures not pertinent, 4

45 articles included

Figure 1. Consort Flow Chart

are two components to this quality measure. The first component is based on research design and has three ratings (Levels I-III). Level I contains randomized controlled trials, Level II contains quasi-experimental trials, and Level III contains nonexperimental research. The second component is the quality of the research trial levels, A, B, and C. Level A research demonstrates sufficient sample size, adequate control, and definitive conclusions along with a thoughtful literature review with reference to scientific evidence. Level B research demonstrates sufficient sample size and definitive conclusion with some control and a fairly comprehensive literature review. Level C represents research of low quality that demonstrates insufficient sample size, no control, and inconsistent results or little evidence. Each study was rated and received I, II, or III and a letter grade of A, B, or C (Newhouse et al., 2005; see Table 1 for results).

Results The effects of meditation were examined in 21 studies of people with some type of chronic pain diagnosis, 5 studies of people diagnosed with a variety of different chronic diseases, 4 studies of people diagnosed with HIV/AIDS, 4 studies of people diagnosed with chronic heart failure, 3 studies of people diagnosed with chronic obstructive pulmonary disease, 3 studies of people diagnosed with diabetes, 2 studies

of people diagnosed with multiple sclerosis, and 1 study each for people diagnosed with tinnitus, organ transplant, and epilepsy

Analysis of Intervention Design and Research Quality Studies included in the review were first organized based on the meditation skills included in the meditation intervention. In all, seven categories could be identified. Most studies (24/45) were based on MBSR. Seventeen did not vary from the MBSR framework. Seven were modified MBSR and followed the MBSR program but added components to the intervention, such as disease-specific education. Of those meditation interventions that were not based on MBSR, 6 meditation interventions contained both meditation skills combined with mindful movement, 5 contained both meditation skills, and 10 studies included only a single meditation skill (see Table 2). Most of the studies examined the effects of 8-week long meditation interventions regardless of the meditation intervention skill content (29/45). The remaining meditation interventions varied a great deal with one study investigating single sessions intervention (Teixeira, 2010) and one studying a 15-day inpatient intervention that was followed by 4 months of weekly meetings (Brazier, Mulkins, &



5

Exclusive/inclusive/movement; yoga-based program using Sudarshan Kriya, meditation, and asanas; 15-day inpatient program with 12 follow-up sessions Exclusive/inclusive/movement; MBPM developed by Breathworks Community Interest Company”; 8 sessions Exclusive; loving-kindness. 8 sessions

Brazier, Mulkins, and Verhoef, 2006

Exclusive/movement; Spring Forest qi gong; 8 sessions Exclusive/inclusive/movement; unique program using both meditation on breath, mindfulness meditation, and qi gong movment; 8 sessions

Coleman, 2011

Curiati et al., 2005

Creamer, Singh, Hochberg, and Berman, 2000

Exclusive; based on yoga breathing techniques and visualizations of healthy heart; 2 sessions

Exclusive; based on transcendental meditation program; 16 sessions

Chhatre et al., 2013

Chang et al., 2005

Exclusive/movement; 13-form qi gong that was modified from 18-formTajjiqi gong developed by Master Lin Hou Sheng in 1982 with meditation focusing on the breath; 24 sessions Exclusive/inclusive; unique program using resources from the Mind Body Medical Institute; 15 sessions

W. Chan, Lee, Suen, and Tam, 2011

Carson et al., 2005

Brown, Goodman, and Inzlicht, 2013

Modified MBSR

Meditation Intervention Description

Astin et al., 2003

Author, Year

RCT; control group received weekly meetings on stress

Pre–post

CHF elderly (19)

FIQ (p = .00); RAND health survey (p < .05), Coping Strategies Questionnaire (coping strategies; p < .05), physical activity recall pre–post only (p = .05), 6-minute walk pre–post only (p = .05), tender point score (p < .05), pain threshold (p = .01) Blood neutrophil levels (p = .00); VE/ VO2 (p = .04); LVEF (n.s.); LVDDi (n.s.); VO2 (n.s.)

Immune activation; CD38 and HLA-DR on CD4 and CD8 T cells (n.s.); SF-36 general health + (p = .03) Pain VAS (p = .04)

HIV/AIDs (22)

FM (28)

VO2max (n.s.); exercise testing (n.s.); MHsHF (n.s.); peak O2 consumption (n.s.)

CHF (95)

RCT three-arm; meditation group, cardiac education group, and usual care group RCT; control group received healthy eating education Pre–post

FVC (n.s.); 6-minute walk (p < .03); qi gong vs. exercise (p = .03); qi gong vs. standard care (p = .03)

McGill Pain Inventory pre–post tests (p = .04) + pre- to follow-up test Brief Pain Inventory (p ≤ .05)

McGill Pain Inventory (n.s.)

COPD (206)

Brief Symptom Inventory (p = .05)

Mental Health Inventory (n.s.)

Tender points (n.s.); FIQ (n.s.); 6-minute walk (n.s.)

Chronic Disease Physical Symptom Measures/Results

RCT three-arm; qi gong group, exercise group, and standard care group

BDI Pre–post and pre–2 months (p = .05)

Mental Health Inventory (n.s.)

Depression Symptom Measures/Results

Pain LB (61)

Chronic pain (28)

HIV/AIDs (62)

FM (128)

Diagnosis (N)

Anxiety Symptom Measures/ Results

RCT; usual care control groupa

RCT; nonactive control group

RCT; control group received education/ support RCT; usual care control group

Research Design

Table 1. Review of Research Results

(continued)

IB, 1

IIB, 0

IIB, 5

IB, 2

IA, 0

IA, 4

IA, 6

IB, 3

IA, 2

IA, 2

Research Rating, Intervention Rating

6


Pre–post

Exclusive/inclusive/movement; yoga-based program of asanas, kapalabhati breathing, sithali breathing, and meditation Inclusive; single meditation skill taken from MBSR, practiced 30 minutes of mindfulness meditation each session (10 sessions) with discussion after each meditation and some didactic regarding mindfulness concepts. MBSR

Exclusive; transcendental meditation. 31 sessions

MBSR

MBSR

Kabat-Zinn, 1982

Lush et al., 2009

Modified MBSR

Grossman, TiefenthalerGilmer, Raysz, and Kesper, 2007 Grossman et al., 2010 Jayadevappa et al., 2007

Gross et al., 2010

MBSR

Pre–post

Modified MBSR

Pre–post

RCT; usual care control group RCT; control group received education regarding CHF Pre–post

RCT; control group received health eating education QE

QE

COPD (33)

RCT; usual care control group

MBSR

Goldenberg et al., 1994

Pelvic pain (22)

RCT; waitlist control

Modified MBSR

FM (43)

BDI (n.s.)

CES-D (p = .03)

CHF (23)

Pain (63)

CES-D (p = .03)

Hospital Anxiety and Depression Scale (p = .03)

CES-D (n.s.)

Inventory of Depressive Symptoms (n.s.)

BDI (n.s.)

CES-D (p < .00)

Depression, Anxiety, and Positive Outlook Scale (p = .01)


MS (150)

FM (58)

Organ transplant (137)

FM (87)

Failed back surgery (42)

HIV (76)

Various (83)

Pre–post

MBSR

Pain (53)

Diagnosis (N)

Dobkin and Zhao, 2011 Duncan et al., 2012 Esmer, Blum, Rulf, and Pier, 2010 Fox, Flynn, and Allen, 2011 Fulambarker et al., 2012

QE

Research Design

Exclusive/Inclusive/movement; MBPM developed by Breathworks Community Interest Company; 8 sessions


Cusens, Duggan, Thorne, and Burch, 2010

Author, Year

Table 1. (continued)

Beck Anxiety Inventory (n.s.)

Hospital Anxiety and Depression Scale (p = .04) STAI (p = .02)

STAI + (p = .02)

Depression, Anxiety, and Positive Outlook Scale (n.s.)


Medical Symptom Checklist (p < .00); body parts problem assessment scale (p < .00) SCL (p = .00)

6-minute walk (p = .03); BNP (n.s.)

Pittsburgh Sleep Quality Index (p = .05); SF-12 Physical Health Scale (p = .05); health VAS (p = .05) Pain Perception Scale (n.s.); pain VAS (p = .02); Somatic Symptom Inventory (p = .02)

FM symptom VAS (p < .05); FIQ (p = .05)

SF-36 physical function (p = .02); general health (p = .01); bodily pain (n.s.) St. George’s Questionnaire (p = .00); FVC (p = .01), FEV1 (n.s.), PEmax (p = .02), PImax (p = .00)

Symptom Bother Checklist (p < .00); actual symptoms reported (p = .01) Function related to back pain (p < .005); Pain VAS + (p < .014)

Medical Symptom Checklist (p < .00)

Chronic Pain Acceptance Questionnaire (p = .01); Pain Intensity Scale (n.s.)


(continued)

IIB, 2

IIB, 4

IB, 4

IA, 4

IIB, 3

IA, 6

IIB, 1

IIB, 2

IIB, 4

IA, 5

IA, 4

IIB, 4

IIB, 4



7

Type 2 diabetes (64)

Tinnitus (25)

QE

QE

Pre–post Prospective cohort

QE

QE

Exclusive; Nadishodana pranayama followed by silent meditation concentrating on third eye; 12 sessions

MBSR

MBSR

MBSR

Inclusive; based on Buddhist three universal natural laws and the four noble truths; 6 sessions.

Inclusive; based on Vipassana Bhavana or insight meditation; 4 sessions

Rungreangkulkij, Wongtakee, and Thongyot, 2011

Sadlier, Stephens, and Kennedy, 2008

Plews-Ogan, Owens, Goodman, Wolfe, and Schorling, 2005 Pradhan et al., 2007 Rajesh, Jayachandran, Mohandas, and Radhakrishnan, 2006 Robinson, Mathews, and Witek-Janusek, 2003 Rosenzweig et al., 2007 Rosenzweig et al., 2010

MBSR

MBSR

RCT; control group attended a support group RCT; three-arm; meditation group, massage therapy group, and usual care group RCT; waitlist control

Modified MBSR

Type 2 diabetes (14) Various (133)

HIV (56)

Rheumatoid arthritis (63) Epilepsy (20)

Pain (30)

COPD (86)

Pain LB (37)

RCT; waitlist control group

Majumdar, Grossman, DietzWaschkowski, Kersig, and Walach, 2002 Morone, Rollman, Moore, Li, and Weiner, 2009 Mularski et al., 2009

Various (21)

Diagnosis (N)

Modified MBSR

Research Design Pre–post


MBSR

Author, Year

Q Depression Scale; Subjects who attended meditation group had significantly greater (6.5) chance to return to normal than control group (relative risk = 6.5, 95% confidence interval [1.4, 30.6]) Hospital Anxiety and Depression Scale (n.s.)

SCL-90 (p = .05) for FM subjects (n.s.)

SCL-90 (n.s.)



Hospital Anxiety and Depression Scale (n.s.)

SCL-90 (p = .05 (for FM subjects, n.s.)


Hallam Tinnitus Questionnaire (p < .02); hearing subscale (n.s.); tinnitus VAS (n.s.)

HA1c at 1 month follow-up (p = .03); mean arterial pressure (n.s.) SF-36 physical functioning (p = .05) for FM and headache/migraine subjects (n.s.); general health symptoms (n.s.)

NK number (p < .05) and activity (p < 005); DHEAS (n.s.); cortisol DHEAS (n.s.)

Seizure level (p < .00)

Pain intensity (n.s.); pain acceptance (p = .00); SF-36 physical function scale (p = .00) 6-minute walk (n.s.); Borg Dyspnea Scale (n.s.); St. George Respiratory’s Scale (n.s.) Pain sensation (n.s.); pain unpleasantness (n.s.)

Friedburg Complaint List (p < .05)


(continued)

IC, 1

IIA, 4

IIB, 4

IIC, 2

IIB, 4

IIA, 3

IA, 5

IB, 1

IA, 6

IB, 3

IIB, 4


8


MBSR MBSR

Sephton, 2007 Simpson and Mapel, 2011

Inclusive; single meditation skill taken from MBSR, practiced mindfulness meditation for 10 minutes each session along with didactic regarding mindfulness and different life aspects; 8 sessions

Zautra et al., 2008

Multiple sclerosis and peripheral neuropathy (61) Diabetes DPN (22)

QE

RCT; control group received nutrition education RCT; control group received daily new discussion group RCT; control group attended multidisciplinary pain intervention RCT; three-arm; mindfulness group, CBT group, and arthritis information group Rheumatoid arthritis (144)

Pain (99)

Various (38)

CHF (117)

FM (28)

STAI (n.s.)

Geriatric Depression Scale (p = .01)

CES-D (p = .01)

BDI (p < .01)

BDI + (p < .05) Depression Anxiety and Stress Scale (p = .00)

CES-D (n.s.)

Pain (177)

FM (91) Various (29)

BDI (p = .05)


Pain (71)

Diagnosis (N)

QE

Pre–post

RCT; control group received education/ support RCT; waitlist control RCT; waitlist control

QE

Research Design

STAI (n.s.)

Depression Anxiety and Stress Scale (p = .00)

STAI for state anxiety (p = .05), for trait anxiety (n.s.)


Pain VAS (p < .00); tender points (p = .00); swelling (p < .00); IL-6 (P = .02; IL-6 only significant for those with depression)

Hand grip strength (p = .03); joint range of motion (n.s.); 5-HT (n.s.); salivary cortisol (n.s.) Pain intensity (n.s.); pain-related distress (n.s.)

Neuropathic Pain Scale (n.s.)

Kansas City Cardiomyopathy Questionnaire (p = .02) VAS pain scores (p = .03); bodily pain (p = .3)

FIQ (p ≤ .05)

Pain scores (p = .00)

FIQ (n.s.); sleep (n.s.)


IA, 3

IA, 4

IA, 4

IB, 2

IIB, 4

IIB, 4

IIB, 1

IIB, 5 IC, 4

IA, 3

IIB, 3


Note: MBSR = mindfulness-based stress reduction; RCT = randomized controlled trial; FM = fibromyalgia; FIQ = Fibromyalgia Impact Questionnaire; MBPM = mindfulness-based pain management; LB = low back; COPD = chronic obstructive pulmonary disease; FVC = forced vital capacity; CHF = chronic heart failure; VO2max = maximal oxygen uptake; MHsHF = The Minnesota Living with Heart Failure Questionnaire; CD = cluster of differentiation; HLA-DR = human leukocyte antigen-death receptor; SF = Short Form; VAS = Visual Analog Scale; BDI = Beck Depression Inventory; VE/VO2 = ventilatory equivalents for oxygen; LVEF = left ventricular ejection fraction; LVDDi = left ventricular end-diastolic volume index; VO2 = oxygen consumption; QE = quasi-experimental; CES-D = Center for Epidemiologic Studies–Depression Scale; FEV1 = forced expiratory volume in one second; PEmax = maximal expiratory pressure; PImax = maximal inspiratory pressure; STAI = State–Trait Anxiety Index; MS = multiple sclerosis; BNP = brain natriuretic peptide; SCL = Symptom Checklist; NK = natural killer; DHEAS = dehydroepiandrosterone sulfate; HA1c = hemoglobin A1c; DPN = diabetic peripheral neuropathy; 5-HT = 5-hydroxytryptamine; CBT = cognitive behavioral therapy; IL-6 = interleukin-6. a. Only pre–post within-subjects data were reported.

MBSR

Exclusive/movement; Buddhist sitting focus on breath combined with tai chi qi gong movement; 18 sessions Inclusive; based on Buddhist zazen practice; one session with weekly phone contact Exclusive/movement; eight-section Brocades program; 36 sessions

Wong et al., 2011

Tsang et al., 2012

Sullivan et al., 2009 Tavee, Rensel, Planchon, Butler, and Stone, 2011 Teixeira, 2010

Exclusive/inclusive/movement; unique program using meditation on breath, mindfulness meditation, and qi gong movement; 8 sessions Modified MBSR

MBSR

Schmidt, 2011

Singh, Berman, Hadhazy, and Creamer, 1998

MBSR


Sagula and Rice, 2004

Author, Year


Meditation in Chronic Disease / Chan, Larson 9 Table 2. Meditation Interventions by Categories Meditation interventions

Count

MBSR Modified MBSR Exclusive meditation/inclusive meditation/movement Exclusive meditation/movement Exclusive meditation/inclusive meditation Exclusive meditation Inclusive mediation

17 7 6 4 1 5 5

Note: MBSR = mindfulness-based stress reduction.

Verhoef, 2006). Several studies also had some form of follow-up in order to encourage study participants to continue home practice (Brazier et al., 2006; Pradhan et al., 2007; Teixeira, 2010). Kabat-Zinn (1982) developed a follow-up meditation class for those interested in continuing with the classes after the original 10-week course. More than half of the studies documented adherence to a well-developed meditation program and/or clear rational for deviation from the system (25 out of 45). Two thirds of the studies documented teacher training and experience, very few (10 out of 45) documented the use of a teaching manual, and four documented the use of a system of fidelity checks between teachers or classes. Half of the studies used a randomized controlled design (24/45) resulting in a Level I rating. Of the 24 studies that used a randomized controlled design, slightly more than half used an active control group as opposed to a waitlist or usual care control group (15/24; See Table 1 for a more complete description).

Analyses of Intervention Effectiveness Anxiety Symptoms. The effect of meditation on anxiety symptoms was measured in 12 studies (see Figure 2). There was a wide variety of measures of anxiety used, three used the State–Trait Anxiety Index, and two studies used the Hospital Anxiety and Depression Scale. Other measures of anxiety used included the Symptom Checklist-90; the Brief Symptom Inventory; the Mental Health Index; the Depression, Anxiety, and Positive Outlook Scale; the Depression and Anxiety Symptom Scale; and the Brief Anxiety Form (see Table 1). The effects of meditation on anxiety symptoms were mixed. Significant improvements in anxiety

were observed in seven studies, five MBSR interventions (Gross et al., 2010; Grossman, TiefenthalerGilmer, Raysz, & Kesper, 2007; Rosenzweig et al., 2007; Sagula & Rice, 2004; Simpson & Mapel, 2011), one modified MBSR intervention (Gross et al., 2010), and one exclusive intervention (Carson et al., 2005). A review of studies by chronic disease revealed that meditation was not able to consistently reduce anxiety symptoms for any one particular disease category. Anxiety symptoms were reduced in half the studies involving subjects with chronic pain (2/4) with similar results for subjects with fibromyalgia (1/2). Rosenzweig et al (2010) found anxiety lowered in those with a variety of chronic pain issues except for those with fibromyalgia. Meditation significantly reduced anxiety in a single study of people after organ transplant (Gross et al., 2010) and in a single study of people with multiple sclerosis (Grossman et al., 2010). It also reduced anxiety in two studies involving subjects with various chronic diseases (Rosenzweig et al., 2010; Simpson & Mapel, 2011). Studies that did not show a significant reduction in anxiety involved subjects with HIV/AIDs (Brazier et al., 2006) and tinnitus (Sadlier, Stephens, & Kennedy, 2008; see Table 1 for details of results). Depression Symptoms. The effect of meditation on depression symptoms was measured in 23 studies (see Figure 3). A great variety of depression scales were employed. The most frequently used measures of depression were the Center for Epidemiologic Studies–Depression Scale (6/23), the Beck Depression Inventory (6/23), and the Symptom Checklist-90 (2/23). Other measures included the Hospital Anxiety and Depression Scale; Brief Symptom Inventory; Depression, Anxiety, and Stress Scale; Mental Health Inventory; Q Depression Scale; and the Inventory of Depressive Symptoms (see Table 1). Fifteen of the 23 studies that measured depression symptoms reported a significant decline in these symptoms. Significant improvements in symptoms were reported in seven studies that used MBSR symptoms (Dobkin & Zhao, 2011; Grossman et al., 2007; Pradhan et al., 2007; Rosenzweig et al., 2010; Sagula & Rice, 2004; Sephton et al., 2007; Simpson & Mapel, 2011), in two studies using a modified MBSR (Grossman et al., 2010; Sullivan et al., 2009), and in three studies using both meditation skills along with



Figure 2. Effect of Meditation on Anxiety Symptoms

Figure 3. Effect of Meditation on Depression

mindful movement (Creamer, Singh, Hochberg, & Berman, 2000; Singh, Berman, Hadhazy, & Creamer, 1998; Sullivan et al., 2009). Interventions using exclusive meditation/movement, exclusive meditation, and inclusive meditation reported significant improvements in one study each (R. R. Chan, 2014; Jayadevappa et al., 2007; Rungreangkulkij et al., 2011, respectively). A significant reduction in depression was observed in a broad range of diagnoses, including epilepsy (Rajesh et al., 2006), diabetes (Rungreangkulkij et al., 2011), multiple sclerosis (Grossman et al., 2010), chronic heart disease (Jayadevappa et al., 2007), and various chronic pain conditions (Cusens, Duggan, Thorne, & Burch,

2010). Conflicting results were observed for subjects with chronic pain. In five studies of people with a variety of chronic pain conditions, meditation produced no improvement (Fox, Flynn, & Allen, 2011; Lush et al., 2009; Schmidt et al. 2011; Wong et al., 2011). Rosenzweig et al. (2010) demonstrated significant improvement in some groups but not with others. Meditation significantly reduced depression in persons with back/neck pain, arthritis, and comorbid pain but not in subjects with headache/migraine pain or fibromyalgia (Rosenzweig et al., 2010). Depression was not significantly decreased in subjects with HIV/AIDs (Brazier et al., 2006; Duncan et al., 2012), tinnitus (Sadlier et al., 2008), or organ transplant (Gross et al., 2010; see


Meditation in Chronic Disease / Chan, Larson 11

Figure 4. Effect of Meditation on Chronic Disease Symptoms

Table 1 for details of results). Chronic Disease Physical Symptoms. Most studies targeted physical symptoms of chronic disease (39 out of 45), with 31 of those studies reporting significant improvement in chronic disease symptoms as measured by at least one measure (see Figure 4). Because most studies measured more than one chronic disease symptom, many studies reported significant improvement in some measures and not in others. For a detailed review of these results, see Table 1. Every category of meditation intervention identified in this systematic review demonstrated success in significantly decreasing chronic disease symptoms (see Figure 4). Due to the large number of studies reported on in this category, details of the results along with details of the study and primary author identification are listed in Table 1. Meditation reduced chronic disease symptoms for subjects with epilepsy (Rajesh et al., 2006), multiple sclerosis and peripheral neuropathy (Tavee et al., 2011), and tinnitus (Sadlier et al., 2008). Both positive and negative results were found for all other chronic diseases. In some studies that report mixed results, improvement was seen in perception or acceptance of a specific chronic disease symptom while the symptom itself was not diminished (Cusens et al., 2010; Gross et al., 2010; Morone, Rollman, Moore, Li, & Weiner, 2009; Rosenzweig et al., 2007; Rosenzweig et al., 2010). In other studies with mixed results, there was improvement in one chronic disease symptom and not in another (Chang et al.,

2005; Creamer et al., 2000; Curiati et al., 2005; Robinson, Mathews, & Witek-Janusek, 2003; Rosenzweig et al., 2007). Interestingly, improvement in physical symptoms did not necessarily occur simultaneously with an improvement in either anxiety or depression. However, in most of those studies that analyzed both anxiety and depression, we found that anxiety and depression either simultaneously improved or simultaneously failed to improve (see Table 1 for details of results).

Discussion This systematic review demonstrated that meditation improved anxiety symptoms, depression symptoms, and symptoms of chronic disease. However, there was little consistency across disease and across different types of meditation interventions. The observed inconsistencies were not readily explainable. Although meditation interventions that contained both core meditation skills along with a mindful movement component represented a great portion of the studies, they did not always demonstrate the largest proportion of successful studies. It is interesting to note that meditation interventions that employed only the skill of exclusive attention were consistently successful at reducing anxiety, depression, and/or chronic disease symptoms. Exclusive attention is commonly viewed across meditation schools and philosophies as an entry-level skill because it is easy to explain and teach and can be



effectively taught in a single session (Benson, 1975). It can also be taught with or without a spiritual focus (R. R. Chan, 2014). Based on this body of evidence, the exclusive skill of meditation is promising, but the number of studies within each disease is limited. Further research is needed to fully explore the effects of different meditation skills with or without a mindful movement component. Other characteristics contained within and surrounding a meditation intervention need to be compared and evaluated (Blackwood, O’Halloran, & Porter, 2010). Characteristics such as those inherent in the person learning meditation, the person teaching the meditation intervention, and the dose of the class are some examples of important aspects that need to be compared and contrasted between meditation interventions within a structured format.

Future Research An important concept when working with complex interventions is to understand which components of the intervention need remain consistent and which can be applied in a flexible manner to meet the individual or group needs. This review of meditation interventions in chronic disease helped identify that a variety of meditation interventions can result in significant improvements in anxiety symptoms, depression symptoms, and chronic disease symptoms. By acknowledging the distinct physiological mechanisms and outcomes that exclusive meditation, inclusive meditation, and mindful movement bring to the meditation intervention, health care providers can tailor meditation interventions in a manner that results in increased efficiency. To further our understanding of what meditation skills need to be included in meditation interventions, it would be beneficial to conduct research comparing different meditation interventions within identified chronic disease populations. Outcome measures that incorporate individual characteristics such as baseline anxiety levels will strengthen these studies.

References Anderson, R. (2008). New MRC guidance on evaluating complex interventions. British Medical Journal, 337, a1937. Astin, J., Berman, B., Bausell, B., Lee, W., Hochberg, M., & Forys, K. (2003). The efficacy of mindfulness meditation plus Qigong movement therapy in the treatment of fibro-

myalgia: A randomized controlled trial. Journal of Rheumatology, 30, 2257-2262. Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125-143. Benson, H. (1975). The relaxation response. New York, NY: Morrow. Blackwood, B., O’Halloran, P., & Porter, S. (2010). On the problems of mixing RCTs with qualitative research: The case of the MRC framework for the evaluation of complex health care interventions. Journal of Research in Nursing, 15, 511-521. Bond, K., Ospina, M., Hooton, N., Bialy, L., Dryden, D., Buscemi, N., . . . Carlson, L. E. (2009). Defining a complex intervention: The development of demarcation criteria for “meditation.” Psychology of Religion and Spirituality, 1, 129-137. Brazier, A., Mulkins, A., & Verhoef, M. (2006). Evaluating a yogic breathing and meditation intervention for individuals living with HIV/AIDS. American Journal of Health Promotion, 20(3), 192-195. Brown, K., Goodman, R., & Inzlicht, M. (2013). Dispositional mindfulness and the attenuation of neural responses to emotional stimuli. Social Cognitive and Affective Neuroscience, 8, 93-99. Carson, J., Keefe, F., Lynch, T., Carson, K., Goli, V., Fras, A., & Thorp, S. R. (2005). Loving-kindness meditation for chronic low back pain: Results from a pilot trial. Journal of Holistic Nursing, 23, 287-304. Chan, R. R. (2014). Mantra meditation as a bedside spiritual intervention. Medsurg Nursing, 23(2), 84-88. Chan, W., Lee, A., Suen, L., & Tam, W. (2011). Tai Chi Qigong improves lung functions and activity tolerance in COPD client: A single blind controlled trial. Complementary Therapies in Medicine, 19, 3-11. Chang, B. H., Hendricks, A., Zhao, Y., Rothendler, J. A., LoCastro, J. S., & Slawsky, M. T. (2005). A relaxation response randomized trial on patients with chronic heart failure. Journal of Cardiopulmonary Rehabilitation, 25(3), 149-157. Chhatre, S., Metzger, D., Frank, I., Boyer, J., Thompson, E., Nidich, S., . . . Jayadevappa, R. (2013). Effects of behavioral stress reduction Transcendental Meditation intervention in persons with HIV. AIDS Care, 25, 1291-1297. Coleman, J. (2011). Spring forest Qigong and chronic pain: Making a difference. Journal of Holistic Nursing, 29, 118-127. Creamer, P., Singh, B., Hochberg, M., & Berman, B. (2000). Sustained improvement produced by nonpharmacologic intervention in fibromyalgia: Results of a pilot study. Arthritis Care and Research, 13, 198-204. Curiati, J., Bocchi, E., Freire, J., Arantes, A., Braga, M., Garcia, Y., . . . Fo, W. J. (2005). Meditation reduces sympathetic activation and improves the quality of life in elderly patients with optimally treated heart failure: A


Meditation in Chronic Disease / Chan, Larson 13 prospective randomized study. Journal of Alternative and Complementary Medicine, 11, 465-472. Cusens, B., Duggan, G., Thorne, K., & Burch, V. (2010). Evaluation of the breathworks mindfulness-based pain management programme: Effects on well-being and multiple measures of mindfulness. Clinical Psychology & Psychotherapy, 17, 63-78. Dalai Lama. (2001). Stages of meditation (G. L. Jordhen, L. C. Ganchenpa, & J. Russell, Trans.). Ithaca, NY: Snow Lion. Delevoye-Turrell, Y., & Bobineau, C. (2012). Motor consciousness during intention-based and stimulus-based actions: Modulating attention resources through mindfulness meditation. Frontiers in Psychology, 3, 290. Retrieved from http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3438819/ Dobkin, P., & Zhao, Q. (2011). Increase mindfulness: The active component of the mindfulness-based stress reduction program? Complementary Therapies in Clinical Practice, 17, 22-27. Duncan, L., Moskowitz, J., Neilands, T., Dilworth, S., Hecht, F., & Johnson, M. (2012). Mindfulness-based stress reduction for HIV treatment side effects: A randomized, wait-list controlled trial. Journal of Pain and Symptom Management, 43, 161-171. Dunn, R., Hartigan, J., & Mikulas, W. (1999). Concentration and mindfulness meditation: Unique forms of consciousness. Applied Psychophysiology and Biofeedback, 24(3), 147-165. Esmer, G., Blum, J., Rulf, J., & Pier, J. (2010). Mindfulnessbased stress reduction for failed back surgery syndrome: A randomized controlled trial. Journal of the American Osteopathic Association, 110, 646-652. Fox, S., Flynn, E., & Allen, R. (2011). Mindfulness meditation for women with chronic pelvic pain: A pilot study. Journal of Reproductive Medicine, 56, 158-162. Fredrickson, B., Coffey, K., Pek, J., Cohn, M., & Finkel, S. (2009). Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build personal resources. Journal of Personality and Social Psychology, 95, 1045-1062. Fulambarker, A., Farooki, B., Kheir, F., Copur, A., Srinivasan, L., & Schultz, S. (2012). Effect of yoga in chronic obstructive pulmonary disease. American Journal of Therapeutics, 19, 96-100. Goldenberg, D., Kaplan, K., Nadeau, M., Brodeur, C., Smith, S., & Shid, C. (1994). A controlled study of a stress-reduction, cognitive-behavioral treatment program in fibromyalgia. Journal of Musculoskeletal Pain, 2(2), 53-66. Gross, C., Kreitzer, M., Thomas, W., Reilly-Spong, M., Cramer-Bornemann, M., Nyman, J., . . . Ibrahim, H. N. (2010). Mindfulness-based stress reduction for solid organ transplant recipients: A randomized controlled trial. Alternative Therapies in Health and Medicine, 16(5), 30-38.

Grossman, P., Kappos, L., Gensicke, H., D’Souza, M., Mohr, D., Penner, I., & Steiner, C. (2010). MS quality of life, depression, and fatigue improve after mindfulness training. Neurology, 75, 1141-1149. Grossman, P., Tiefenthaler-Gilmer, U., Raysz, A., & Kesper, U. (2007). Mindfulness training as an intervention for fibromyalgia: Evidence of post intervention and 3-year follow-up benefits in well-being. Psychotherapy and Psychosomatics, 76, 226-233. Hasenkamp, W., & Barsalou, L. W. (2012). Effects of meditation experience on functional connectivity of distributed brain networks. Frontiers in Human Neuroscience, 6, 1-14. doi: 10.3389/fnhum.2012.00038 Hölzel, B., Lazar, S., Gard, T., Schuman-Olivier, Z., Vago, D., & Ott, U. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives on Psychological Science, 6, 537-559. Hölzel, B., Ott, U., Hempel, H., Hackl, A., Wolf, K., Stark, R., & Vaitl, D. (2007). Differential engagement of anterior cingulate and adjacent medial frontal cortex in adept meditators and non-meditators. Neuroscience Letters, 421, 16-21. Jayadevappa, R., Johnson, J., Bloom, B., Nidich, S., Desai, S., Chhatre, S., . . . Schneider, R. (2007). Effectiveness of transcendental meditation on functional capacity and quality of life of African Americans with congestive heart failure: A randomized control study. Ethnicity & Disease, 17, 72-77. Jhal, A., Krompinger, J., & Baime, M. (2007). Mindfulness training modifies subsystems of attention. Cognitive, Affective, & Behavioral Neuroscience, 7(2), 109-119. Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation. General Hospital Psychiatry, 4, 33-47. Kabat-Zinn, J., Lipworth, K., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163-189. Kerr, C. (2002). Translating “mind-in-body” two models of patient experience underlying a randomized controlled trial of qigong. Culture, Medicine and Psychiatry, 26, 419-447. Larkey, L., Jahnke, R., Etnier, J., & Gonzalez, J. (2009). Meditative movement as a category of exercise: Implications for research. Journal of Physical Activity & Health, 6, 230-238. Lush, E., Salmon, P., Floyd, A., Studts, J., Weissbecker, I., & Sephton, S. (2009). Mindfulness meditation for symptom reduction in fibromyalgia psychophysical correlates. Journal of Clinical Psychology in Medical Settings, 16, 200-207. Majumdar, M., Grossman, P., Dietz-Waschkowski, B., Kersig, S., & Walach, H. (2002). Does mindfulness meditation contribute to health? Outcome evaluation of a German


14 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX sample. Journal of Alternative and Complementary Medicine, 8, 719-730. Maupin, E. (1965). Individual difference in response to a Zen meditation exercise. Journal of Consulting Psychology, 29(2), 139-145. Morone, N., Rollman, B., Moore, C., Li, Q., & Weiner, D. (2009). A mind-body program for older adults with chronic low back pain: Results of a pilot study. Pain Medicine, 10, 1395-1407. Mularski, R., Munjas, B., Lorenz, K., Sun, S., Robertson, S., Schmelzer, W., . . . Shekelle, P. G. (2009). Randomized controlled trial of mindfulness-based therapy for dyspnea in chronic obstructive lung disease. Journal of Alternative and Complementary Medicine, 15, 1083-1090. Newhouse, R., Dearholt, S., Pugh, L., & White, K. (2005). The Johns Hopkins Nursing Evidence-Based Practice Rating Scale. Baltimore, MD: Johns Hopkins University. Perlman, D., Salomons, T., Davidson, R., & Lutz, A. (2010). Differential effects of pain intensity and unpleasantness of two meditation practices. Emotion, 10, 65-71. Plews-Ogan, M., Owens, J., Goodman, M., Wolfe, P., & Schorling, J. (2005). Brief report: A pilot study evaluating mindfulness-based stress reduction and massage for the management of chronic pain. Journal of General Internal Medicine, 20, 1136-1138. Pradhan, E., Baumgarten, M., Langenberg, P., Handwerger, B., Gilpin, A., Magyari, T., . . . Berman, B. M. (2007). Effect of mindfulness-based stress reduction in rheumatoid arthritis patients. Arthritis and Rheumatism, 57, 1134-1142. Rajesh, B., Jayachandran, D., Mohandas, G., & Radhakrishnan, K. (2006). A pilot study of a yoga meditation protocol for patients with medically refractory epilepsy. Journal of Alternative and Complementary Medicine, 12, 367-371. Robinson, F., Mathews, H., & Witek-Janusek, L. (2003). Psycho-endocrine-immune response to mindfulnessbased stress reduction in individuals infected with the human immunodeficiency virus: A quasiexperimental study. Journal of Alternative and Complementary Medicine, 9, 683-694. Rosenzweig, S., Greeson, J., Reibel, D., Green, J., Jasser, S., & Beasley, D. (2010). Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice. Journal of Psychosomatic Research, 68, 29-36. Rosenzweig, S., Reibel, D., Greeson, J., Edman, J., Jasser, S., McMearty, K., & Goldstein, B. J. (2007). Mindfulnessbased stress reduction is associated with improved glycemic control in type 2 diabetes mellitus: A pilot study. Alternative Therapies in Health and Medicine, 13(5), 36-38. Rungreangkulkij, S., Wongtakee, W., & Thongyot, S. (2011). Buddhist group therapy for diabetes patients with depressive symptoms. Archives of Psychiatric Nursing, 25,

195-205. Sadlier, M., Stephens, S., & Kennedy, V. (2008). Tinnitus rehabilitation: A mindfulness meditation cognitive behavioural therapy approach. Journal of Laryngology & Otology, 122, 31-37. Sagula, D., & Rice, K. (2004). The effectiveness of mindfulness training on the grieving process and emotional wellbeing of chronic pain patients. Journal of Clinical Psychology in Medical Settings, 11, 333-341. Salzberg, S. (2002). Lovingkindness: The revolutionary art of happiness. Boston, MA: Shambala Press. Schmidt, S., Grossman, P., Schwarzer, B., Jena, S., Naumann, J., & Walach, H. (2011). Treating fibromyalgia with mindfulness-based stress reduction: Results from a 3-armed randomized trial. Pain, 152, 361-369. Sephton, S., Salmon, P., Weissbecker, I., Ulmer, C., Floyd, A., Hoover, K., & Studts, J. L. (2007). Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: Results of a randomized clinical trial. Arthritis and Rheumatism, 57(1), 77-85. Shepperd, S., Lewin, S., Straus, S., Clarke, M., Eccles, M. P., Fitzpatrick, R., . . . Sheik, A. (2009). Can we systematically review studies that evaluate complex interventions? PLoS Medicine, 6(8), e1000086-e1000086. Simpson, J., & Mapel, T. (2011). An investigation into the health benefits of mindfulness-based stress reduction (MBSR) for people living with a range of chronic physical illnesses in New Zealand. New Zealand Medical Journal, 124(1338), 68-74. Singh, B., Berman, B., Hadhazy, V., & Creamer, P. (1998). A pilot study of cognitive behavioral therapy in fibromyalgia. Alternative Therapies, 4(2), 67-70. Slagter, H. A., Lutz, A., Greischar, L. L., Francis, A. D., Nieuwenhuis, S., Davis, J. M., & Davidson, R. J. (2007). Mental training affects distribution of limited brain resources. PLoS Biology, 5(6), e138. Sullivan, M., Wood, L., Terry, J., Brantley, J., Charles, A., McGee, V., . . . Cuffe, M. S. (2009). The support, education, and research in chronic heart failure study (SEARCH): A mindfulness-based psychoeducational intervention improves depression and clinical symptoms in patients with chronic heart failure. American Heart Journal, 157(1), 84-90. Tavee, J., Rensel, M., Planchon, S., Butler, R., & Stone, L. (2011). Effects of meditation on pain and quality of life in multiple sclerosis and peripheral neuropathy. International Journal of MS Care, 13, 163-168. Teixeira, E. (2010). The effect of mindfulness meditation of painful diabetic peripheral neuropathy in adults older than 50 years. Holistic Nursing Practice, 24, 277-283. Telles, S., Raghavendra, B., Naveen, K., Manjunath, N., Kumar, S., & Subramanya, P. (2013). Changes in autonomic variables following two meditative states described in yoga texts. Journal of Alternative and Complementary Medicine, 19, 35-42.


Meditation in Chronic Disease / Chan, Larson 15 Thomas, J. W., & Cohen, M. (2014). A methodological review of meditation research. Frontiers in Psychiatry, 5(74). Advance online publication. doi:10.3389/fpsyt.2014.00074 Tsang, H. W., Tsang, W. W., Jones, A. Y., Fung, K. M., Chan, A. H., Chan, E. P., & Au, D. W. (2012). Psycho-physical and neurophysiological effects of qigong on depressed elders with chronic disease. Aging & Mental Health, 17, 336-348. Van den Hurk, P., Janssen, B., Giommi, F., Barendregt, H., & Gielen, S. (2010). Mindfulness meditation associated with alterations in bottom-up processing: Psychophysiological evidence for reduced reactivity. International Journal of Psychophysiology, 78, 151-157. van Leeuwen, S., Singer, W., & Melloni, L. (2012). Meditation increases depth of information processing and improves the allocation of attention in space. Frontiers in Human Neuroscience, 6, 133. Vestergaard-Poulsen, P., van Beek, M., Skewes, J., Bjarkam, C., Stubberup, M., Bertelsen, J., & Roepstorff, A. (2009). Long-term meditation is associated with increased gray matter density in the brain stem. NeuroReport, 20, 170-174. Wang, C., Collet, J., & Lau, J. (2004). The effect of Tai Chi on health outcomes in patients with chronic conditions: A systematic review. Archives of Internal Medicine, 164, 493-501. Wolf, S., Barnhart, H., Kutner, N., McNeely, E., Coogler, C., & Xu, T. (2003). Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized bal-

ance training. Journal of the American Geriatrics Society, 51, 1794-1803. Wong, S. Y., Chan, F. W., Wong, R. L., Chu, M. C., Kitty Lam, Y. Y., Mercer, S. W., & Ma, S. H. (2011). Comparing the effectiveness of mindfulness-based stress reduction and multidisciplinary intervention programs for chronic pain: A randomized comparative trial. Clinical Journal of Pain, 27, 724-734. Zautra, A., Davis, M., Reich, J., Nicassio, P., Tennen, H., Finan, H., . . . Irwin, M. R. (2008). Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without a history of recurrent depression. Journal of Consulting and Clinical Psychology, 76, 408-421. Roxane Raffin Chan, RN, PhD, AHN-BC, is an board certified advanced holistic nurse who specializes in the integration of holistic concepts into the care of patients with acute and chronic disease. She is currently researching the development of meditation interventions for persons with chronic obstructive pulmonary disease, traumatic brain injury and pre-diabetic adolescents. Janet L. Larson, RN, PhD, FAAN, is an expert in the pulmonary rehabilitation of people with chronic obstructive pulmonary disease (COPD). She maintains an active program of research, studying factors that influence symptoms, physical activity, and quality of life for people with COPD.


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