Mindfulness Training Reduces Stress of Rheumatic Disease

Janis C. Kelly

December 20, 2011

December 20, 2011 — A randomized pilot study has shown that a mindfulness-based group therapy intervention produced significant and durable relief for patients with inflammatory rheumatoid joint diseases. Joint problems in this study, published online December 20 in the Annals of the Rheumatic Diseases, included rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.

Mindfulness — or maintaining an active, watchful mind with an attentive awareness of reality — is 1 of the 7 Buddhist factors of enlightenment; the authors hypothesized that it might help patients cope with chronic joint pain.

"Our key finding was that the mindfulness approach improved psychological distress, self-efficacy pain and symptoms, emotional processing, and fatigue in patients with inflammatory rheumatic joint diseases," lead author Heidi A. Zangi, RN, MNSc, told Medscape Medical News. Ms. Zangi is from the National Resource Center for Rehabilitation in Rheumatology in Oslo, Norway.

The 36 patients randomized to the intervention group were trained in mindfulness exercises, which focus on experiencing the present moment, no matter how difficult. Training took place in 10 group sessions over a period of 15 weeks; a booster session was held about 6 months after the intervention ended. The 35 patients in the control group received usual care plus a take-home CD of mindfulness exercises to use if they wanted to. In total, 67 participants completed all the assessments.

The treatment sessions, which were facilitated by healthcare professionals trained in mindfulness techniques, addressed particular topics, such as recognizing individual limitations, and strong emotions, such as anger, joy, and sorrow.

The mindfulness exercises, which were part of the vitality training program (VTP), encouraged participants to become aware of and to deliberately concentrate on their feelings, thoughts, and bodily experiences, including pain, without judging or trying to avoid them.

Ms. Zangi explained that "it is required that the group facilitators themselves have experienced mindfulness-based training. They have to able to [teach] the exercises and manage patients' diverse reactions to these exercises. I think that the group facilitators' competence is a key success factor. They are not psychologists, but are healthcare professionals working in the field of rheumatology, making the intervention more feasible than if less-available staff were used.... The feasibility of the intervention is, of course, also a question of the cost effectiveness. The VTP is resource demanding, and comparison with other interventions has yet to be done."

Participants were also given creative exercises, such as guided imagery, music, and drawing, and they shared their experiences with other members of the group.

Stress levels, coping abilities, and symptom control, including pain and fatigue, were assessed using validated scores immediately after all 10 sessions had finished and again 12 months later.

The number of participants with a stress score above 23 on the General Health Questionnaire fell from 13 at the start of the study to 2 twelve months after the sessions had finished. Comparable figures in the control group were 10 and 8 participants, respectively.

There was a tangible decline in measured levels of fatigue in the intervention group, but not in the control group. The improvement in fatigue increased from the posttreatment period to the 12-month follow-up in the intervention group, but was unchanged from baseline in the control group.

The lasting improvements found with the VTP course "indicate that the participants may have incorporated some mindfulness strategies into their daily lives, and that these strategies have strengthened their ability to respond to their stressful experience in a more flexible way," the authors write.

Ms. Zangi said that "the most interesting outcome is long term, with increasing effect sizes at 12 months. Effects of other psychoeducational interventions, such as self-management programs and cognitive behavioral interventions, are mostly small and diminish over time. There are, however, a few exceptions. Studies have shown that cognitive-behavioral therapy interventions tailored to individual needs in recent-onset disease have beneficial effects on depression, anxiety, and fatigue."

She added that this "study documented effects also in patients with long-term disease. Promising effects of mindfulness-based stress reduction have been documented in another study" in patients with rheumatoid arthritis (Arthritis Rheum. 2007;57:1134-1142).

The VTP addressed disease-related emotions and attempted to help patients attend to their emotions in a nonjudgmental way, the authors conclude. Follow-up showed that participants in the intervention group significantly increased their emotional processing (i.e., acknowledging and understanding emotions), compared with the control group.

Eric L. Matteson, MD, chair of rheumatology at the Mayo Clinic in Rochester, Minnesota, reviewed the study for Medscape Medical News. "I did find this interesting and convincing. It is a challenge to implement some of the techniques in clinical practice. Having group therapy sessions that are led by skilled nurses and MDs can be a useful approach to the implementation of this kind of strategy," he said.

"I think most MDs try to use components of it in their office practice, but there is too little time to adequately learn the techniques to make that work," Dr. Matteson added. Lack of reimbursement is also a problem, he said.

The study authors and Dr. Matteson have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online December 20, 2011. Abstract

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