579702
research-article2015
MSJ0010.1177/1352458515579702Multiple Sclerosis JournalR Simpson, F Mair
MULTIPLE SCLEROSIS MSJ JOURNAL
Editorial
Mindfulness-based interventions for people with multiple sclerosis Robert Simpson, Frances Mair and Stewart Mercer
Date received: 9 March 2014; accepted: 10 March 2015 Mindfulness-based interventions (MBIs) are increasingly being applied in healthcare settings around the world, in particular as a means of managing stress in those with chronic conditions. Various meta-analyses examining their use in this area have been conducted over the past decade, all of which suggest some benefit, but in general there is a notable call for more rigorous research, to include both active control groups, and a wider demographic spread.1,2,3 The highestquality evidence for MBIs is for the use of mindfulness-based cognitive therapy (MBCT) in the treatment of those with recurrent depression, and this is reflected in national clinical guidelines for the condition.4 The use of MBIs in the multiple sclerosis (MS) population has not been widely studied. A recent systematic review demonstrated a relative paucity of high-quality research, with evidence for effectiveness being limited to improvements in measures for anxiety, depression, health-related quality of life, standing balance, and fatigue.5 The UK National Institute for Clinical Excellence (NICE) now includes the recommendation of MBIs as one potential treatment for fatigue.6
although recent evidence from an MBCT dismantling trial calls into question whether the meditation practices exert any additional benefit over and above the cognitive content of the course for the treatment of recurrent depression.9 In the case of MS, it may also be important to ask what works, given the wide range of symptoms and disability levels that may otherwise limit participation in the ‘core’ mindfulness practices. Both cognitive impairment and physical disability are common amongst people with MS. Such factors may serve as a practical barrier to participation in research studies, highlighting the important point that MBIs may need to be adapted to make them more suitable for the wide and varied population of people with MS. For example, the majority of studies thus far have included participants who score at or below 6 on the expanded disability status scale (EDSS) (able to walk up to 100m with a walking aid), and most of these individuals have had relapsing−remitting phenotypes (RRMS).5 Very little is thus known about if or how MBIs might help people with progressive phenotypes, or with more severe disabilities.
A major issue concerning the use of MBIs in healthcare settings is that, despite various models, there is no consensus definition on the construct of mindfulness itself, and further, no one is really sure how they work. MBIs originally derive from a combination of Buddhist meditation practices and Hatha Yoga postures, both of which are believed to have quite distinct neural mechanisms, although there is a degree of overlap, with attention regulation systems playing a prominent role.7 Professor Jon Kabat-Zinn, who introduced their use in clinical settings in the 1980s, has defined mindfulness as: ‘paying attention in a particular way: on purpose, in the present moment, and nonjudgementally’.8 Typically, MBIs are delivered in a standard group format, with core content focusing on the development of ‘mindfulness’ through breath awareness, body awareness, and mindful movement.8
In their randomised controlled trial, Bogosian et al.10 can be seen to extend the boundaries defined above. The authors report on a novel and innovative approach to delivering an MBI specifically for people with progressive MS. Using a virtual classroom approach, they have developed a SKYPE distant-delivered MBI, tailored to meet the needs of this particular population. The intervention is informed by the MBCT approach to treating depression, with the depression-specific cognitive content having been modified to address more generic issues associated with progressive MS. A range of key stakeholder opinions informed development of the intervention, which resulted in the authors employing an MBI that did not include mindful movement in any format, which is a significant departure from more traditional approaches. A range of relevant measures were collected (general distress, anxiety, depression, pain, impact of MS, quality adjusted life years) in an attempt to ascertain the potential effectiveness and cost-effectiveness for an MBI in this group.
Deconstructing MBIs to systematically tease apart their active ingredients has not yet been achieved,
Multiple Sclerosis Journal 2015, Vol. 21(9) 1093–1094 DOI: 10.1177/ 1352458515579702 © The Author(s), 2015. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Correspondence to: Robert Simpson Department of General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9XN, UK. Robert.Simpson@glasgow. ac.uk Robert Simpson Frances Mair Stewart Mercer Institute of Health and Wellbeing, University of Glasgow, Glasgow
http://msj.sagepub.com 1093
Downloaded from msj.sagepub.com by guest on August 16, 2015
Multiple Sclerosis Journal 21(9) The key findings from the Bogosian et al.10 study are: •• This type of approach seems feasible for people with progressive MS and more marked physical disability. •• Significant improvements in distress scores, with large and sustained effect sizes. •• Significant improvements in scores for anxiety, depression, and psychological impact of MS, with medium and sustained effect sizes. •• Non-significant improvements in fatigue, pain, and physical impact of MS. •• A high likelihood of cost-effectiveness. There are some interesting points to consider here. Firstly, because this study used an online classroom, the researchers were able to recruit nationally – this has notable implications for resource allocation in a financially constrained, nationalised health service, such as that in the UK. It is impossible to say how the virtual classroom compares to the more standard experience and dynamics of being in a group, taking place in the same physical space. Secondly, as noted, the intervention did not include mindful movement. It is not possible to determine how this may have impacted on findings in a small pilot study such as this, but it does reinforce the validity of questioning what the active ingredients in an MBI actually involve, and whether they are the same for every level of function or disability. Indeed, physical activity is widely seen as a key component in MS neuro-rehabilitation6,11 and can be delivered in myriad different ways. In this regard, it is also interesting to note that the main participant benefits in the study were in the mental health domain. Bogosian et al.10 have added substantially to the empirical literature on the use of MBIs in people with MS and it is important that these preliminary findings are followed up in a definitive trial, ideally with an active control comparison group – a common criticism of the mindfulness literature in general. Important as these findings are, we need to hear more from those that matter most in this story – people with MS. Qualitative research, which can be nested within trials, could help answer such questions as: how do people with MS find mindfulness, what works for them, and why, as well as what aspects, if any, are unhelpful? Collating such information together with future research aimed at determining the active components of MBIs can be used to inform clinicians and patients alike as to whether an MBI might be a suitable treatment for them, or not. Visit SAGE journals online http://msj.sagepub.com
SAGE journals
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
References 1. Goyal M, Singh S, Sibinga E, et al. Meditation programs for psychological stress and wellbeing: A systematic review and meta-analysis. JAMA Internal Medicine 2014; 174(3): 357–368. 2. Mars T and Abbey H. Mindfulness meditation practise as a healthcare intervention: A systematic review. International Journal of Osteopathic Medicine 2010; 13(2): 56–66. 3. Grossman P, Niemann L, Schmidt S, et al. Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research 2004; 57(1): 35–43. 4. National Institute for Health and Clinical Excellence. Depression in adults: The treatment and management of depression in adults, www.nice.org.uk/guidance/ cg90 (2008, accessed 19 March 2015). 5. Simpson R, Booth J, Lawrence M, et al. Mindfulness based interventions in multiple sclerosis − a systematic review. BMC Neurology 2014; 14(1): 15. 6. National Institute for Clinical Excellence. Multiple sclerosis: Management of multiple sclerosis in primary and secondary care, www.nice. org.uk/guidance/cg186 (2014, accessed 19 March 2015). 7. Tomasino B, Chiesa A and Fabbro F. Disentangling the neural mechanisms involved in Hinduism-and Buddhism-related meditations. Brain and Cognition 2014; 90: 32–40. 8. Kabat-Zinn J. Wherever you go, there you are: Mindfulness meditation in everyday life. New York, NY: Hyperion Books. 1994. 9. Williams M, Crane C, Barnhorfer T, et al. Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: A randomized dismantling trial. Journal of Consulting and Clinical Psychology 2014; 82(2): 275. 10. Bogosian A, Chadwick P, Windgassen S, et al. Distress improves after mindfulness training for progressive MS: a pilot randomised trial. Multiple Sclerosis Journal 2015 (forthcoming). 11. Motl R. Benefits, safety, and prescription of exercise in persons with multiple sclerosis. Expert Review of Neurotherapeutics 2014; 14(12): 1429–1436.
1094 http://msj.sagepub.com
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research-article2015
MSJ0010.1177/1352458515579702Multiple Sclerosis JournalR Simpson, F Mair
MULTIPLE SCLEROSIS MSJ JOURNAL
Editorial
Mindfulness-based interventions for people with multiple sclerosis Robert Simpson, Frances Mair and Stewart Mercer
Date received: 9 March 2014; accepted: 10 March 2015 Mindfulness-based interventions (MBIs) are increasingly being applied in healthcare settings around the world, in particular as a means of managing stress in those with chronic conditions. Various meta-analyses examining their use in this area have been conducted over the past decade, all of which suggest some benefit, but in general there is a notable call for more rigorous research, to include both active control groups, and a wider demographic spread.1,2,3 The highestquality evidence for MBIs is for the use of mindfulness-based cognitive therapy (MBCT) in the treatment of those with recurrent depression, and this is reflected in national clinical guidelines for the condition.4 The use of MBIs in the multiple sclerosis (MS) population has not been widely studied. A recent systematic review demonstrated a relative paucity of high-quality research, with evidence for effectiveness being limited to improvements in measures for anxiety, depression, health-related quality of life, standing balance, and fatigue.5 The UK National Institute for Clinical Excellence (NICE) now includes the recommendation of MBIs as one potential treatment for fatigue.6
although recent evidence from an MBCT dismantling trial calls into question whether the meditation practices exert any additional benefit over and above the cognitive content of the course for the treatment of recurrent depression.9 In the case of MS, it may also be important to ask what works, given the wide range of symptoms and disability levels that may otherwise limit participation in the ‘core’ mindfulness practices. Both cognitive impairment and physical disability are common amongst people with MS. Such factors may serve as a practical barrier to participation in research studies, highlighting the important point that MBIs may need to be adapted to make them more suitable for the wide and varied population of people with MS. For example, the majority of studies thus far have included participants who score at or below 6 on the expanded disability status scale (EDSS) (able to walk up to 100m with a walking aid), and most of these individuals have had relapsing−remitting phenotypes (RRMS).5 Very little is thus known about if or how MBIs might help people with progressive phenotypes, or with more severe disabilities.
A major issue concerning the use of MBIs in healthcare settings is that, despite various models, there is no consensus definition on the construct of mindfulness itself, and further, no one is really sure how they work. MBIs originally derive from a combination of Buddhist meditation practices and Hatha Yoga postures, both of which are believed to have quite distinct neural mechanisms, although there is a degree of overlap, with attention regulation systems playing a prominent role.7 Professor Jon Kabat-Zinn, who introduced their use in clinical settings in the 1980s, has defined mindfulness as: ‘paying attention in a particular way: on purpose, in the present moment, and nonjudgementally’.8 Typically, MBIs are delivered in a standard group format, with core content focusing on the development of ‘mindfulness’ through breath awareness, body awareness, and mindful movement.8
In their randomised controlled trial, Bogosian et al.10 can be seen to extend the boundaries defined above. The authors report on a novel and innovative approach to delivering an MBI specifically for people with progressive MS. Using a virtual classroom approach, they have developed a SKYPE distant-delivered MBI, tailored to meet the needs of this particular population. The intervention is informed by the MBCT approach to treating depression, with the depression-specific cognitive content having been modified to address more generic issues associated with progressive MS. A range of key stakeholder opinions informed development of the intervention, which resulted in the authors employing an MBI that did not include mindful movement in any format, which is a significant departure from more traditional approaches. A range of relevant measures were collected (general distress, anxiety, depression, pain, impact of MS, quality adjusted life years) in an attempt to ascertain the potential effectiveness and cost-effectiveness for an MBI in this group.
Deconstructing MBIs to systematically tease apart their active ingredients has not yet been achieved,
Multiple Sclerosis Journal 2015, Vol. 21(9) 1093–1094 DOI: 10.1177/ 1352458515579702 © The Author(s), 2015. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Correspondence to: Robert Simpson Department of General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9XN, UK. Robert.Simpson@glasgow. ac.uk Robert Simpson Frances Mair Stewart Mercer Institute of Health and Wellbeing, University of Glasgow, Glasgow
http://msj.sagepub.com 1093
Downloaded from msj.sagepub.com by guest on August 16, 2015
Multiple Sclerosis Journal 21(9) The key findings from the Bogosian et al.10 study are: •• This type of approach seems feasible for people with progressive MS and more marked physical disability. •• Significant improvements in distress scores, with large and sustained effect sizes. •• Significant improvements in scores for anxiety, depression, and psychological impact of MS, with medium and sustained effect sizes. •• Non-significant improvements in fatigue, pain, and physical impact of MS. •• A high likelihood of cost-effectiveness. There are some interesting points to consider here. Firstly, because this study used an online classroom, the researchers were able to recruit nationally – this has notable implications for resource allocation in a financially constrained, nationalised health service, such as that in the UK. It is impossible to say how the virtual classroom compares to the more standard experience and dynamics of being in a group, taking place in the same physical space. Secondly, as noted, the intervention did not include mindful movement. It is not possible to determine how this may have impacted on findings in a small pilot study such as this, but it does reinforce the validity of questioning what the active ingredients in an MBI actually involve, and whether they are the same for every level of function or disability. Indeed, physical activity is widely seen as a key component in MS neuro-rehabilitation6,11 and can be delivered in myriad different ways. In this regard, it is also interesting to note that the main participant benefits in the study were in the mental health domain. Bogosian et al.10 have added substantially to the empirical literature on the use of MBIs in people with MS and it is important that these preliminary findings are followed up in a definitive trial, ideally with an active control comparison group – a common criticism of the mindfulness literature in general. Important as these findings are, we need to hear more from those that matter most in this story – people with MS. Qualitative research, which can be nested within trials, could help answer such questions as: how do people with MS find mindfulness, what works for them, and why, as well as what aspects, if any, are unhelpful? Collating such information together with future research aimed at determining the active components of MBIs can be used to inform clinicians and patients alike as to whether an MBI might be a suitable treatment for them, or not. Visit SAGE journals online http://msj.sagepub.com
SAGE journals
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
References 1. Goyal M, Singh S, Sibinga E, et al. Meditation programs for psychological stress and wellbeing: A systematic review and meta-analysis. JAMA Internal Medicine 2014; 174(3): 357–368. 2. Mars T and Abbey H. Mindfulness meditation practise as a healthcare intervention: A systematic review. International Journal of Osteopathic Medicine 2010; 13(2): 56–66. 3. Grossman P, Niemann L, Schmidt S, et al. Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research 2004; 57(1): 35–43. 4. National Institute for Health and Clinical Excellence. Depression in adults: The treatment and management of depression in adults, www.nice.org.uk/guidance/ cg90 (2008, accessed 19 March 2015). 5. Simpson R, Booth J, Lawrence M, et al. Mindfulness based interventions in multiple sclerosis − a systematic review. BMC Neurology 2014; 14(1): 15. 6. National Institute for Clinical Excellence. Multiple sclerosis: Management of multiple sclerosis in primary and secondary care, www.nice. org.uk/guidance/cg186 (2014, accessed 19 March 2015). 7. Tomasino B, Chiesa A and Fabbro F. Disentangling the neural mechanisms involved in Hinduism-and Buddhism-related meditations. Brain and Cognition 2014; 90: 32–40. 8. Kabat-Zinn J. Wherever you go, there you are: Mindfulness meditation in everyday life. New York, NY: Hyperion Books. 1994. 9. Williams M, Crane C, Barnhorfer T, et al. Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: A randomized dismantling trial. Journal of Consulting and Clinical Psychology 2014; 82(2): 275. 10. Bogosian A, Chadwick P, Windgassen S, et al. Distress improves after mindfulness training for progressive MS: a pilot randomised trial. Multiple Sclerosis Journal 2015 (forthcoming). 11. Motl R. Benefits, safety, and prescription of exercise in persons with multiple sclerosis. Expert Review of Neurotherapeutics 2014; 14(12): 1429–1436.
1094 http://msj.sagepub.com
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