A Telehealth Mindfulness-Based Intervention for Pain: Effective and Practical

A randomized clinical trial in more than 800 veterans, including some with headache, showed that the intervention was effective, whether delivered in group sessions or as a self-paced program.

Mindfulness is a technique that aims to increase awareness of one’s own internal thoughts, feelings, and bodily sensations, with the goal of keeping a non-judgmental focus on the present. A growing body of research has shown that mindfulness-based therapies offer significant benefits for people with chronic pain and migraine, but whether these approaches can be implemented successfully at scale has remained uncertain.

But now, a new randomized clinical trial provides strong evidence that a telehealth mindfulness-based intervention (MBI) can be carried out, at low cost in a large number of people, to improve pain outcomes.

This study of veterans recruited from three US Veterans Affairs (VA) facilities reports that a telehealth MBI improved pain-related function, as well as biopsychosocial outcomes, in participants who had a range of pain diagnoses, including more than 100 people with headache. The intervention worked equally well in those who received the intervention in group sessions and in those who completed a self-paced program, with benefits lasting up to a year.

“These findings support the broader integration of mindfulness-based interventions as viable interventions for managing chronic pain and migraine. The telehealth aspect of this trial is among the strengths of the study in terms of novelty and practicality,” said Dawn Buse, a psychologist and pain and migraine researcher at Albert Einstein College of Medicine, Bronx, New York, US, in an email to Migraine Science Collaborative. Buse was not involved in the study.

“A novel finding was that participants in the self-paced MBI did as well as those in the group MBI. Having a self-paced option could expand the appeal of MBIs to individuals who are uncomfortable in groups or whose availability to attend classes is irregular,” wrote Dan Cherkin, who studies non-pharmacological treatments for chronic pain at the University of Washington, Seattle, US, in an accompanying commentary on the study. Cherkin was also not a part of the new work.

The study and commentary appeared in the October 2024 issue of JAMA Internal Medicine.

Overcoming barriers
Many studies show that mindfulness is effective for a number of chronic pain conditions, as well as migraine. And, as the authors noted in their paper, clinical guidelines now recommend evidence-based non-pharmacological treatments for pain.

But there are several obstacles to their widespread use, according to study first author and social psychologist Diana Burgess of the VA Health Systems Research Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, and the University of Minnesota, Minneapolis, US.

“Participating in mindfulness programs can be very time intensive, so MBI programs can have high dropout rates. Second, they can be very resource intensive and expensive to run because you need specially trained mindfulness supervisors,” Burgess told MSC in an interview.

Burgess said her and her colleagues’ aim was to streamline the MBI to make it “very user friendly” for study participants, and less resource intensive for the researchers to study it in a trial. Their solution was to use telehealth to deliver the program.

“Our big insight was that we can pre-record mindfulness content with a trained instructor, and then deliver the content to people either individually or in groups,” said Burgess.

Setting up a clinical trial
The trial involved 811 US veterans, 48% of whom were women and 52% men, who had a wide range of chronic pain conditions; extremity pain/arthritis, back pain, and headache were among the most common. With regard to headache, there were 48 participants in the group MBI, and 46 in the self-paced intervention, accounting for roughly 18% and 17% of total study participants, respectively; 41 veterans (15%) with headache were in the control group.

The variety of pain conditions included in the study was by design, said Burgess, as mindfulness has been shown to improve a broad range of pain-related disorders. The idea was to make the study more generalizable to real-world care, in which MBIs would be offered to people with a variety of pain conditions who could benefit from them.

The trial would compare the group telehealth MBI, and the self-paced version, to usual care (which served as a control; those in this group did not have access to the MBIs during the trial). Participants in all groups were told not to discontinue drug treatments, said Burgess. For both the group and self-paced MBI, participants received the same pre-recorded mindfulness content, which included relaxation and meditation techniques to train subjects to regulate their attention and emotions, and to establish body awareness.

“In the group sessions, there were eight 90-minute sessions. It was very structured, first discussing what mindfulness is, then doing simple exercises like breath mindfulness. Then there would be a discussion, followed by mindful movement,” said Burgess.

In the self-paced arm of the study, participants completed the MBI on their own, but also had three phone calls with a facilitator at the start, middle, and end of the program. The calls covered how participants were progressing, what their plans were to practice MBI, how to overcome any challenges that were coming up, and the like.

The trial lasted eight weeks, with those in the group MBI arm participating in their group sessions by telehealth, and those in the self-paced arm doing eight 30- to 60-minute sessions on their own, along with the phone calls.

The study’s primary outcome, assessed at 10 weeks, six months, and one year after the eight-week MBI program, was pain-related function, according to the Brief Pain Inventory interference subscale score, which uses a 0 to 10 scale to measure pain interference with work, relationships, enjoyment of life, and other domains. Secondary outcomes included pain intensity, anxiety, depression, and sleep disturbances, among others.

Improved outcomes on all measures
Both the group and self-paced MBI programs yielded improvements in pain-related function, with significantly lower pain interference scores in each group compared to usual care. Over the study’s three time points, group MBI participants had an average score of 4.8, and the self-paced participants had a score of 4.5, compared to 5.2 for those in the usual care arm. The improvement did not differ significantly when comparing the group arm to the self-paced arm.

“Overall, we found that people’s pain improved, including the main outcome of the study, which was how much pain interferes with your life, as well as pain intensity,” said Burgess.

The likelihood of achieving a 30% improvement in pain interference from baseline (assessed in what is known as a responder analysis) was significantly greater for the group MBI at 10 weeks and six months after the program, compared to usual care. The benefits lasted longer for those in the self-paced group, with reductions in pain interference seen at 10 weeks, six months, and one year.

The responder analysis results were important, the authors wrote in their paper, since they gave an indication that the changes they observed were clinically meaningful for individual patients.

The group and self-paced MBI programs were again similarly effective, compared to usual care, on almost all of the study’s secondary outcomes. That included improvements in pain intensity, patient global impression of change, physical function, fatigue, sleep disturbance, social roles and activities, depression, and post-traumatic stress disorder.

“This study is exciting, as it shows the feasibility of implementing non-pharmacological pain management strategies in a manner that is both efficient and broadly accessible within healthcare systems,” Buse told MSC.

In addition, the results show that telehealth is a scalable and relatively low-resource way to deliver MBI programs effectively, she said, “overcoming traditional access barriers such as the need for dedicated space and mindfulness-certified instructors, or therapy costs.”

Making mindfulness a staple of pain and migraine treatment
A growing body of research has demonstrated that MBIs can offer benefits for people with pain and migraine. But the results have been inconsistent, with some studies showing that mindfulness had no impact on outcomes.

“The data are generally supportive but mixed. While these therapies consistently show benefits for secondary outcomes like depression, anxiety, and pain acceptance, their impact on pain severity is less robust and varies between studies,” said Buse.

There are many reasons behind the mixed results, but differences in study design, sample sizes, and variations in how mindfulness programs are delivered are among the biggest factors. Another is the challenge of adherence to mindfulness practices and continued engagement with them; if a person doesn’t follow the treatment, it won’t work.

“Lack of motivation, consistency in practice, and engagement are common issues that can diminish the effectiveness of the intervention,” said Buse.

Of note, studies that have reported positive outcomes for migraine and pain often have relatively small effect sizes. These small differences may not always translate to clinically meaningful improvements. Further, it may be that mindfulness approaches will bear fruit only in certain individuals.

“This isn’t a magic bullet, but then again, pain medications often aren’t either. Some people may benefit more from mindfulness than others,” said Burgess.

Burgess said that a next step for research is to narrow down the specific pain conditions for which MBIs will be most useful.

“It may be that mindfulness could be better for some conditions rather than others. The cutting-edge thing now is the precision medicine approach to find people who would benefit from mindfulness,” said Burgess.

Buse said the study provides an excellent basis and rationale for studying telehealth-delivered MBIs to treat people with migraine.

“The successful implementation of MBIs via telehealth in a diverse cohort with chronic pain underscores the feasibility of remote interventions for people with migraine and other headache diseases who face significant barriers to accessing in-person care,” said Buse.

She added that the study provides a “pragmatic option” for delivering effective, non-pharmacological treatments to a broader population of any adult with chronic pain. Going forward, she said, future research should aim to standardize mindfulness intervention protocols, ensure adequate sample sizes, and adopt rigorous methodological designs, including controlled trial designs.

But whether MBIs can be implemented beyond the VA, in other health care settings, could be challenging, according to Cherkin.

“Overcoming barriers to implementing MBIs in health care organizations with different values, funding schemes, and incentives will likely be more difficult.”

On a more positive note, in terms of basic science, investigators are starting to understand the mechanisms underlying the positive effects of MBIs, giving further confidence that these interventions are promising ways to address disease.

“Basic science research is beginning to elucidate how MBIs affect brain activity and physiological markers such as cortisol, C-reactive protein, systolic blood pressure, and triglyceride levels,” Cherkin wrote in his commentary.

Fred Schwaller, PhD, is a freelance science writer based in Germany.

References
Telehealth mindfulness-based interventions for chronic pain: The LAMP randomized clinical trial
Burgess et al.
JAMA Intern Med. 2024 Oct 1;184(10):1163-73.

Overcoming challenges to implementing mindfulness-based pain interventions
Cherkin D.
JAMA Intern Med. 2024 Oct 1;184(10):1174-5.

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