Acceptance and Mindfulness Based Interventions For The Treatment of Chronic Pain - A Meta Analytic Review

Cognitive Behaviour Therapy
ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: https://www.tandfonline.com/loi/sbeh20
Acceptance- and mindfulness-based interventions

for the treatment of chronic pain: a meta-analytic
review
M. M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs
To cite this article: M. M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs (2016)

Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic
review, Cognitive Behaviour Therapy, 45:1, 5-31, DOI: 10.1080/16506073.2015.1098724
To link to this article: https://doi.org/10.1080/16506073.2015.1098724
© 2016 The Author(s). Published by Informa Published online: 28 Jan 2016.

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Cognitive Behaviour Therapy, 2016
VOL. 45, NO. 1, 5–31
http://dx.doi.org/10.1080/16506073.2015.1098724
OPEN ACCESS
Acceptance- and mindfulness-based interventions for the

treatment of chronic pain: a meta-analytic review
M. M. Veehofa,b , H. R. Trompettera , E. T. Bohlmeijera and K. M. G. Schreursa,c
a
Department of Psychology, Health & Technology, University of Twente, Enschede, the Netherlands;
b
Department of Occupational Therapy, Medische Spectrum Twente, Enschede, the Netherlands; cRoessingh
Research & Development, Enschede, the Netherlands
ABSTRACT ARTICLE HISTORY

The number of acceptance- and mindfulness-based interventions for Received 16 April 2015
chronic pain, such as acceptance and commitment therapy (ACT), Accepted 18 September 2015
mindfulness-based stress reduction (MBSR), and mindfulness-based KEYWORDS
cognitive therapy (MBCT), increased in recent years. Therefore an Mindfulness; acceptance
update is warranted of our former systematic review and meta-analysis and commitment therapy;
of studies that reported effects on the mental and physical health meta-analysis; chronic pain;
of chronic pain patients. Pubmed, EMBASE, PsycInfo and Cochrane acceptance
were searched for eligible studies. Current meta-analysis only included
randomized controlled trials (RCTs). Studies were rated for quality.
Mean quality did not improve in recent years. Pooled standardized
mean differences using the random-effect model were calculated to
represent the average intervention effect and, to perform subgroup
analyses. Outcome measures were pain intensity, depression,
anxiety, pain interference, disability and quality of life. Included were
twenty-five RCTs totaling 1285 patients with chronic pain, in which
we compared acceptance- and mindfulness-based interventions to
the waitlist, (medical) treatment-as-usual, and education or support
control groups. Effect sizes ranged from small (on all outcome
measures except anxiety and pain interference) to moderate (on
anxiety and pain interference) at post-treatment and from small
(on pain intensity and disability) to large (on pain interference) at
follow-up. ACT showed significantly higher effects on depression and
anxiety than MBSR and MBCT. Studies’ quality, attrition rate, type of
pain and control group, did not moderate the effects of acceptance-
and mindfulness-based interventions. Current acceptance- and
mindfulness-based interventions, while not superior to traditional
cognitive behavioral treatments, can be good alternatives.
Introduction
Chronic pain is a major health problem with a large impact on the emotional, physical and
social functioning of patients as well as society (Breivik, Eisenberg, O’Brien, & Openminds,
CONTACT K. M. G. Schreurs k.m.g.schreurs@utwente.nl Department of Psychology, Health & Technology,

University of Twente, Drienerlolaan 5, 7522 NB Enschede
© 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium,
provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
6 M. M. Veehof et al.
2013). Unfortunately, none of the most commonly used pharmacological, medical or sur-
gical treatments are, by themselves, sufficiently able to remove pain, or to substantially
enhance physical and emotional functioning (Turk, Wilson, & Cahana, 2011). This calls for
the inclusion of psychosocial factors in addressing chronic pain and pain-related disabilities.
Among psychological treatments, cognitive behavioral treatments (CBTs) have accumu-
lated the most evidence in the research literature. However, as is the case for biomedical
treatment solutions, effect sizes of CBTs are modest (Williams, Eccleston, & Morley, 2012).
The modest effects of both biomedical interventions and CBTs on pain removal and
control are not surprising given the complex nature of chronic pain. They only shallowly
reflect the large advances that have been made over the last decades in our understanding
and treatment of chronic pain. They do, however, also point out a present necessity to
negotiate with patients’ realistic expectations from treatments. In general total pain relief is
an unrealistic goal and treatments should focus on improving function (Turk et al., 2011).
Acceptance and Commitment Therapy (ACT) emphasizes the necessity of pain acceptance
in order to improve function. ACT is based on the relational frame theory and focusses on
psychological flexibility as the ultimate goal of treatment. Psychological flexibility refers
to the capacity to change or maintain one’s behavior in open contact with thoughts and
feelings and, with attention to the opportunities of the current situation in order to realize
valued life goals (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). In the context of chronic
pain, psychological flexibility means that painful sensations, feelings, and thoughts are
accepted, that attention is focused on the opportunities of the current situations rather than
on ruminating about the lost past or catastrophizing about the future, and that behavior
is focused on realizing valued goals instead of pain control (McCracken & Vowles, 2014).
In ACT, psychological flexibility is attained by acquiring six psychological skills: accept-
ance, cognitive defusion, present moment awareness, contact with self-as context, values
formulation and committed actions (Hayes, Strosahl, & Wilson, 2012). These skills can be
divided in two overlapping processes, i.e. mindfulness and acceptance on the one hand
and commitment and behavior change on the other hand (Hayes, Luoma, Bond, Masuda,
& Lillis, 2006). In ACT mindfulness exercises in the form of meditation are advisable but
not a precept.
Formal meditation is the central technique in mindfulness based stress reduction (MBSR)
(Kabat-Zinn, 1990) and mindfulness-based cognitive therapy (MBCT) (Segal, Williams,
& Teasdale, 2002). Mindfulness is defined as intentional and non-judgmental awareness
(Kabat-Zinn, 1990). It can be conceptualized as a multifaceted construct, consisting of the
facets: observe, describe, act with awareness, nonjudge and nonreact. These last two facets
are strongly related to acceptance (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006).
Although ACT, MBSR and MBCT can be differentiated theoretically, they share an under-
lying focus on the concepts of acceptance and mindfulness. In the systematic review and
meta-analysis with studies published before January 2009, we concluded that acceptance
and mindfulness-based therapies in chronic pain produced small effects that are similar
to CBT (Veehof, Oskam, Schreurs, & Bohlmeijer, 2011). Since our last analysis, the num-
ber of studies on acceptance- and mindfulness-based studies has expanded considerably.
Systematic reviews that qualitatively assess the efficacy of ACT, MBSR and MBCT generally
find beneficial effects in chronic pain conditions (Lakhan & Schofield, 2013; McCracken &
Vowles, 2014). The rapid increase of acceptance- and mindfulness-based studies in chronic
pain allowed for a more rigorous assessment of their effectiveness. The aim of the present
Cognitive Behaviour Therapy 7
study, therefore, was to conduct a meta-analysis to assess the effectiveness of acceptance-

and mindfulness-based treatments for chronic pain patients across randomized controlled
studies.
Methods
A protocol based on the Cochrane Manual for Systematic Reviews of Interventions was used.
Search strategy
We included studies identified in our previous meta-analysis (Veehof et al., 2011) (up to
December 2008), and updated this list of studies by conducting a new search (from January
2009 to December 2013) in the four electronic databases: PubMed, EMBASE, PsycInfo, and
the Cochrane Central Register of Controlled Trials. The databases were searched for English
language studies using the same terms as in our previous search: ‘mindfulness’ or ‘vipassana’
or ‘meditation’ or ‘mindfulness-based stress reduction’ or ‘MBSR’ or ‘mindfulness-based
cognitive therapy’ or ‘MBCT’ or ‘acceptance-based’ or ‘acceptance based’ or ‘acceptance
and commitment’, in combination with ‘chronic pain’ or specific chronic pain conditions
including ‘fibromyalgia’ or ‘chronic low back pain’ or ‘whiplash associated disorder’ or
‘WAD’ or ‘repetitive strain injury’ or ‘RSI’ or ‘dystrophy’. Given recent developments in
diagnosing specific chronic pain conditions, we added the following terms: ‘complaints
arm neck shoulder’ or ‘CANS’ ‘complex regional pain syndrome’ or ‘CRPS’. Furthermore,
the reference lists of newly included studies as well as systematic reviews were examined
for additional eligible studies.
Selection procedure and eligibility criteria

Inclusion criteria were the same as the ones in our previous review, except that all studies had
to have a randomised controlled design (Veehof et al., 2011). The new search initially yielded
1393 titles (PubMed: 927, EMBASE: 222, PsycInfo: 151, Cochrane: 93). After removal of
duplicates, two reviewers (MV and KS) independently selected potentially eligible studies
on the basis of title and abstract. Systematic reviews were initially included in this phase.
The inter-rater reliability was satisfactory (κ = .79) (Everitt, 1992), and disagreements were
resolved by consensus.
A total of 163 studies (including 76 systematic reviews) were identified as being poten-
tially eligible for inclusion in the study, and we subsequently requested the full-text articles.
The final selection was then made by two reviewers (MV and KS). The inter-rater reliability
was very good with a κ value of .93 (Everitt, 1992). Studies were included if they reported
on the effectiveness of a standardized acceptance- (ACT) or mindfulness (MBSR/MBCT)-
based treatment program in patients with chronic pain or chronic pain related conditions.
Given the increasing number of (randomized) controlled studies published in this field in
recent years, only randomized controlled studies were included. Both published and unpub-
lished (e.g. dissertations) studies were included. Studies were excluded if (1) mindfulness
or acceptance was just one of several modalities provided simultaneously to the treatment
group, (2) the intervention consisted of a single treatment session, (3) insufficient data was
reported (and could not be obtained) to calculate standardized mean differences (SMDs),
or (4) absence of appropriate outcome measures (pain, depression, anxiety, pain interfer-
ence, disability or quality of life). Systematic reviews were only examined for additional
potentially eligible studies and were not definitely included.
Data extraction
Data extraction was performed using a standardized data abstraction form created for the
study. Data were extracted on participant characteristics, intervention type, control group
and attrition rate. In agreement with the Clinical Importance of Treatment Outcomes in
Chronic Pain Clinical Trials recommendations (Dworkin et al., 2005), our outcome meas-
ures were pain intensity, depression, anxiety, disability, pain interference, and quality of life.
Quality assessment
Methodological quality of included studies was independently assessed by two review-
ers (MV and KS) using a 8-point scale, based on criteria by the Cochrane Collaboration
(Higgins & Altman, 2008) and the validated Jadad scale (Jadad, 1996) tailored for the
included studies (see Table 1). The inter-rater reliability was satisfactory (κ = .78) (Everitt,
1992), and disagreements were resolved by consensus. When seven or more criteria were
met, the quality of the study was assessed as high. The study quality was assessed as medium
when four, five or six criteria were met and low when three or less criteria were met.
Data analysis
Primary goal was to compare the effects of acceptance- and mindfulness-based interven-
tions with no treatment or an attention control condition. Therefore, for our main analyses,
we only included studies with a waitlist, a (medical) treatment as usual [(M)TAU] or, an
education/support group as a control condition. Secondary goal was to compare effects of
acceptance- and mindfulness-based treatments with an active treatment like CBT, multi-
disciplinary treatment (MDT) or relaxation therapy.
We used RevMan software version 5.2 for calculating (pooled) SMDs to test heterogeneity
and to perform subgroup analyses. SMDs were calculated at post-treatment and follow-up
using post-treatment and follow-up scores respectively with standard deviations from the
experimental group and the control group. Given the presence of statistical heterogeneity
between the studies (tested with the χ2 test and I2-statistic), pooled SMDs were calculated
using the random-effects model representing the average intervention effect. Cohen (Cohen,
1977) has described effect sizes .2, .5, and .8 as small, moderate, and large, respectively.
In our main analysis, subgroup analyses were performed for all outcome measures by
comparing pooled SMDs for significant differences between subgroups. Since these analy-
ses were exploratory, no hypotheses were formulated beforehand. Subgroups were created
based on (1) quality score (divided by low, medium and high quality as mentioned ear-
lier), (2) control group [waitlist or (M)TAU vs. education/support], (3) intervention type
(ACT vs. mindfulness-based), (4) type of pain (categorized as chronic pain without further
specification, fibromyalgia, specific site pain, or rheumatoid arthritis), and (5) attrition rate
(higher or lower than 25%).
Table 1. Methodological quality criteria.a

1. Allocation to conditions was based on randomization according to the text 1/0
2. The randomization scheme was described and appropriate, e.g. using a computer, random number 1/0
table
3. A drop-out analysis was conducted (comparing drop-outs and completers at baseline on outcome 1
measures), or there were no drop-outs
Reasons of attrition were reported, but no analysis was conducted 0
4. Intention to treat analysis was performed, or there were no drop-outs 1/0
5. At least one of the trainers was experienced or trained in teaching Mindfulness or ACT 1
Specific experience or training was not reported 0
6. Patient’s pain was diagnosed by a physician or rheumatologist, or patients were referred from a pain 1
clinic where diagnosis was prior to admission
Recruitment through the media, or diagnosis based on a scale and self-report, or diagnosis not 0
mentioned
7. The study had a minimal level of statistical power to find significant effects of the treatment, and 1
included 50 or more persons in the comparison analysis between treatment and control group. (This
allows the study to find standardized effect sizes of .80 and larger, assuming a statistical power of
.80 and α of .05.)
Sample smaller than 50, or the total the sample was bigger than 50, but the results were only 0
reported divided by different studies
8. Treatment integrity was checked during the study by supervision of the therapists during treatment, 1
or by recording the treatment sessions, or by systematic screening of protocol adherence by a
standardized measurement instrument
Treatment integrity was not checked, or integrity was supervised by one of the therapists, or they 0
tried to keep the intervention sound by intensive consultation
a
Scores are summed, 1 point for each fulfilled criterion, range 0–8.
To assess for publication bias, we performed a funnel plot for all outcome measures by
plotting the pooled SMD at post-treatment against its standard error (as a measure of study
size). When publication bias is absent, the studies are expected to be distributed symmet-
rically around the pooled effect size. Bias can be expected when the plot shows a higher
concentration of studies on one side of the pooled SMD than on the other.
Results
A flow chart of the selection procedure is shown in Figure 1. A total of 87 studies were
identified as being potentially eligible for inclusion in the study. The full-text versions of
these studies were independently assessed by two reviewers (MV and KS). Of the 87 arti-
cles, 67 were excluded for the following reasons: no acceptance- and mindfulness-based
intervention (Coleman, 2011; Cramer et al., 2013; Curtis, Osadchuk, & Katz, 2011; Elinoff,
Lynn, Ochiai, & Hallquist, 2009; Elomaa, Williams, & Kalso, 2009; Evans et al., 2011;
Friedberg et al., 2013; Hirschfeld et al., 2013; Hsu et al., 2010; Liu et al., 2012; Paoloni
et al., 2013; Rasmussen, Mikkelsen, Haugen, Pripp, & Forre, 2009; Rasmussen et al., 2012;
Sawynok, Hiew, & Marcon, 2013; Stinson et al., 2010; Tekur, Chametcha, Hongasandra,
& Raghuram, 2010; Tekur, Nagarathna, Chametcha, Hankey, & Nagendra, 2012; Vincent,
Hill, Kruk, Cha, & Bauer, 2010), mindfulness or acceptance is not the main component
of the intervention (Carbonell-Baeza et al., 2011; Carson, Carson, Jones, Mist, & Bennett,
2012; Carson et al., 2010; Cassidy, Atherton, Robertson, Walsh, & Gillett, 2012; Smeeding,
Bradshaw, Kumpfer, Trevithick, & Stoddard, 2011), no intervention study (Morone et al.,
2012), only CFS no chronic pain (Rimes & Wingrove, 2013), no control group (Abbey &
Nanke, 2013; Baer, Carmody, & Hunsinger, 2012; Duggan et al., 2015; Fox, Flynn, & Allen,
2011; Gauntlett-Gilbert, Connell, Clinch, & McCracken, 2013; Hawtin & Sullivan, 2011;
1393 records identified

through database
searching
1393 records screened

for relevance (title /
abstract)
1133 records excluded

as relevant

as relevant after
removal of duplicates
87 full-text articles 76 full-text (systematic) no additional relevant

assessed for eligibility reviews assessed for studies found
additional references
67 full-text articles
excluded for several
reasons (see text)
20 studies fulfilled
selection criteria
8 studies from previous

meta-analysis fulfilled
selection criteria
28 studies included in
current meta-analysis
Figure 1. Flow chart of the selection procedure.
Hennard, 2011; Ilgen et al., 2011; Jelin, Granum, & Eide, 2012; Kristjánsdóttir et al., 2011;
Ljotsson et al., 2013; Lunde & Nordhus, 2009; Lush et al., 2009; Mathias, Parry-Jones, &
Huws, 2013; McCracken & Gutiérrez-Martínez, 2011; McCracken & Jones, 2012; Oberg,
Rempe, & Bradley, 2013; Rosenzweig et al., 2010; Vernon, 2011; Vowles & McCracken, 2010;
Vowles, McCracken, & O’Brien, 2011; Vowles, Witkiewitz, Sowden, & Ashworth, 2014),
no randomization (Cusens, Duggan, Thorne, & Burch, 2010; Vowles, Wetherell, & Sorrell,
2009), sample contained subjects other than pain patients (Branstetter-Rost, Cushing, &
Douleh, 2009; Fjorback et al., 2012, 2013; Hartmann & Vlieger, 2012; Sampalli, Berlasso,
Fox, & Petter, 2009), no appropriate outcome measure(s) (Cathcart, Barone, Immink, &
Proeve, 2013; Cathcart, Vedova, Immink, Proeve, & Hayball, 2013; Garland & Howard, 2013;
McCracken, Sato, & Taylor, 2013; Vago & Nakamura, 2011), 100% attrition in the control
group (Jastrowski Mano et al., 2013), duplicate study data (Jensen et al., 2012; Wicksell,
Olsson, & Hayes, 2010, 2011), insufficient quantitative data or none at all (Esmer, Blum,
Rulf, & Pier, 2010; Olsson et al., 2013; S. Y. Wong, 2009), single treatment session (Martin,
2012). As a result, 20 new studies were included. Together with the eight randomized con-
trolled studies included in our previous meta-analysis, we definitely included 28 studies.
Our main analyses consists of 25 studies comparing acceptance- and mindfulness-based
interventions with waitlist, (M)TAU or, education/support groups. Two of these 25 studies
also used an active intervention as control (Schmidt et al., 2011; Zautra et al., 2008). Three
studies only made a comparison with an active intervention (Thorsell et al., 2011; Wetherell
et al., 2011; Wicksell, Melin, Lekander, & Olsson, 2009). So, five studies were included for
our secondary analyses, comparing acceptance- and mindfulness-based interventions with
active treatment.
Characteristics of included studies

Characteristics of the selected studies are presented in Table 2. The 25 studies included in
the main analyses evaluated 1285 subjects. In general, the participants were adults with
a mean age between 35 and 60 years. In two studies (Morone, Greco, & Weiner, 2008;
Morone, Rollman, Moore, Li, & Weiner, 2009) the mean age of the participants was higher
(> 70 years). In all studies the majority of the participants were female. Nine studies referred
to patients with chronic pain without further specification and, one to patients with mus-
culoskeletal pain Seven studies included patients with fibromyalgia, six with specific-site
pain (e.g. chronic low back pain, chronic headache), and two with rheumatoid arthritis.
Study sizes ranged from a small pilot study of 14 subjects to a large-scale study involving
112 subjects, with an average of 51 subjects. In ten studies the attrition rate (in one or
both groups) was higher than 25% (range 26.7% to 67.3%). Eleven studies used a MBSR
(-based) program, nine an ACT(-based) program, two a MBCT(-based) program, and one
a combination of MBCT and MBSR. Two studies used other mindfulness-based programs:
Mindfulness-based Pain Management (MBPM) and Four Step Mindfulness-based Therapy
(FSMT). Most mindfulness-based programs (MBSR, MBCT, MBPM, FSMT) consisted of
eight weekly group sessions, each session ranging in length from 1.5 to 2.5 h. In one MBSR
study a self-help program was used. A self-help program was also used in two ACT stud-
ies. In the seven other ACT studies, four to twelve weekly sessions were held, each session
ranging in length from 1.0 to 2.5 h. In two of these studies, the sessions were held with
individual patients. In the other five studies, the sessions were group-based. Ten studies
used a waitlist as the comparison group, eight used an education/support group, and seven
used a (M)TAU as the control group. The majority (n = 14) of the studies scored ‘medium’
12
Table 2. Characteristics of included studies.

Attrition
Mean Sessions: rate %
Quality age (SD Male Inter- Group number, (fol-
Author Follow-up score Pain or range) % vention size duration Control group n low-up) Outcome measures
Comparison with education/support, (M)TAU or waitlist as control group
Astin et al., 2003 16 w 5 Fibromyalgia T: 47.7 I: 1.6 MBSR + 10–20 8, 2.5 h Education/ I: 32 T: 39.0 Pain: SF-36
(10.6) Qigong support (49.0)
C: .0 C: 33 Depression: BDI
QoL: FIQ
M. M. Veehof et al.
Brown & Jones, 2013 – 2 Muscu- I: 48 (10) I: 20.0 MBPM Max 15 8, 2.5 h TAU I: 15 I: 25.0 Pain: MPQ (sensory pain)
lo-skeletal
pain
C: 45 (12) C:30.8 C: 13 C: 35.0 Disability: SF-36 PCS
Buhrman et al., 2013 6m 5 Chronic pain I: 48.8 I: 44.7 ACT Self-help 7 Education/ I: 38 I: 15.8 Pain: MPI
experimental (9.5) (online) support
group only
C: 49.3 C: 36.8 C:38 C:23.7 Depression: HADS
(11.3)
Anxiety: HADS
Interference: MPI
QoL: QOLI
Cathcart, Galatis, – 2 Chronic I: 45.8 I: 43.0 MBCT/ 6, 2 h Waitlist I: 22 I: 20.7 Pain: 0–5 scale
Immink, Proeve, & tension-type (13.1) MBSR
Petkov, 2014 headache
C: 45.3 C: 31.5 C: 19 C: 34.5
(14.2)
Dahl, Wilson, & 6m 4 Chronic pain I: 36.7 I: 9.1 ACT Individ- 4, 1 h MTAU I: 11 0 Pain: NRS
Nilsson, 2004 (12.5) ual
C: 44.4 C: 12.5 C: 8 0 QoL: LSQ
(13.6)
Davis & Zautra, 2013 – 5 Fibromyalgia T: 46.1 T: 2.0 MBSR Self-help 12 (6 w) Education/ I: 19 I: 51.3 Pain: NRS
support
C: 25 C: 37.5
Garland, Manusov, 3m 7 Chronic pain I: 49.3 I: 30 MBCT + 8–12 8, 2 h Education/ I: 31 I:45.6 Pain: BPI
Froeliger, Kelly & (13.7) positive (59.6)
Williams, 2013 psychol-
ogy
C: 47.4 C: 34 support C: 38 C: 34.4 Depression: C-SOSI
(13.6) (51.7)
Interference: BPI-SF
Johnston, Foster, – 2 Chronic pain T: median T: 37.5 ACT Self-help 6 Waitlist I: 6 I: 50.0 Pain: SF-MPQ
Shennan, Starkey, & 43
Johnson, 2010
C: 8 C: 33.3 Depression: CMDI Anxiety: BAI
QoL: QOLI
Luciano et al., 2014 6m 7 Fibromyalgia I: 48.9 I: 3.9 ACT 10–15 8, 2.5 h Waitlist I: 51 I: 9.8 (11.8) Pain: VAS
(5.9)
C: 48.3 C: 5,7 C: 53 C: 5.7 Depression: HADS
(5.7) (11.3)
Anxiety: HADS
QoL: FIQ
Mawani, 2009 – 2 Chronic pain I: 46.2 I: 16.0 MBSR 4–8 8, 2 h Education/ I: 14 I: 51.7 Pain: MPQ PRI
(12.1)
C: 44.7 C: 31.0 support C: 14 C: 56.3
(13.2)
McCracken et al., 3m 6 Chronic pain T: 58.0 T: 31.5 ACT 12–13 4, 4 h TAU I: 28 I: 16.2 Pain: NRS
2013 (12.8) (24.3)
C: 26 C: 25.0 Depression: PHQ-9
(22.2)
Disability: RMDQ
Morone et al., 2008 – 3 Chronic low I:74.1 T: 43.2 MBSR 8, 1.5 h Waitlist I: 19 I: 31.6 Pain: MPQ-SF
back pain (6.1)
C: 75.6 C: 18 C: 5.6 Disability: SF-36 PCS
(5.0)
QoL: SF-36 GH
Morone et al., 2009 2m 4 Chronic low I: 78 (7.1) I: 31.2 MBSR 8, 1.5 h Education/ I: 16 I: 20.0 Pain: MPQ-SF current pain score
back pain (20.0)
C: 73 (6.2) C: 42.1 support C: 19 C: 5.0 (5.0) Disability: RMDQ
Mo’tamedi et al., 2012 – 5 Primary I:34.2 T: .0 ACT 15 8, 1.5 h MTAU I: 15 I:26.7 Pain: MPQ sensory dimension
chronic (7.4)
headache
C: 37.9 C: 15 C:0 Disability: MIDAS
(8.7)
Nash-Mc Feron, 2006 – 4 Chronic I: 50 I: .0 MBSR 20 8, 1.5 h TAU I: 19 I: 5 Pain: SF-36
headache (14.6)
C: 51 C: 35.0 C: 18 C:10 Disability: SF-36 PF
(12.2)
Parra-Delgado & 3m 4 Fibromyalgia I: 53.1 T: .0 MBCT 17 8, 2.5 h TAU I: 15 I: 11.8 Depression: BDI
Latorre-Postigo, 2013 (10.5) (11.8)
C: 52.7 C: 16 C: .0 QoL: FIQ
(10.6)
Plumb Vilardaga, – 4 Chronic pain T: 52.3 T: 25.0 ACT 15 6, 2 h Waitlist I: 11 I: 26.7 Pain: PIR
2012 (13.0)
C: 9 C: 30.8 Depression: DASS
Disability: PDI
QoL: QOLS
(Continued)
13
14
Table 2. (Continued).
Attrition
Mean Sessions: rate %
Quality age (SD Male Inter- Group number, (fol-
Author Follow-up score Pain or range) % vention size duration Control group n low-up) Outcome measures
Pradhan et al., 2007 4m 7 Rheumatoid I: 56 (9) I: 16.0 MBSR 13–18 8, 2.5 h Waitlist I: 28 I: 9.7 (9.7) Depression: SCL-90
arthritis
C: 53 (11) C: 9.0 C: 32 C: 0 (6.3)
Schmidt et al., 2011 8w 6 Fibromyalgia I: 53.4 T: .0 MBSR Max 12 8, 2.5 h Waitlist I: 53 I:15.1 Pain: PPS (sensory pain)
(8.7) (11.3)
C: 52.3 C: 59 C: 11.9 Depression: CES-D
M. M. Veehof et al.
(10.9) (5.1)
QoL: FIQ
Sephton et al., 2007 2m 6 Fibromyalgia I: 48.4 T: .0 MBSR 25 8, 2.5 h Waitlist I: 51 28.6 (38.5) Depression: BDI
(8.9)
C:47.6 C: 39
(11.5)
Wicksell, Ahlqvist, 4m 6 Whiplash-as- I: 48.2 I: 18.2 ACT Individ- 10, 1 h Waitlist + TAU I: 11 I: .0 (9.1) Pain: VAS
Bring, Melin, & sociated (7.8) ual
Olsson, 2008 disorders
C: 55.1 C: 30.0 C: 9 C: 10.0 (.0) Depression: HADS
(11.2)
Anxiety: HADS
Disability: PDI
Interference: VAS
QoL: SWLS
Wicksell et al., 2013 3–4 m 6 Fibromyalgia T: 45.1 T: 0 ACT 6 12, 1.5 h Waitlist I: 20 I: 13.0 Pain: NRS
(6.6) (17.4)
C:16 C: 5.9 Depression: BDI
(17.6)
Anxiety: STAI state
Disability: SF-36 PCS
QoL: FIQ
C. M. Wong, 2009 – 7 Chronic pain I: 48.3 I: 47.4 FSMT 10–12 8, 2 h TAU I: 38 I: 32.0 Pain: NRS
(8.2)
C: 40.1 C: 41.2 C: 27 C: 44.9 Depression: BDI
(12.9)
Interference: MPI
Wong et al.,2011; 3 m, 6 m 7 Chronic pain I: 48.7 MBSR 8, 2.5 h Education/ I: 51 I: 13.7 Pain: NRS
(7.8) support (21.6, 19.6)
(7.8)
(6.3, 6.3) Anxiety: STAI state
Zautra et al., 2008 – 7 Rheumatoid I: 57.3 I:46.3 MBSR 6–10 8 Education/ I: 41 I: 8.3 Pain: NRS
arthritis (15.3) support
C: 52.4 C 23.3 C: 30 C: 2.3 Depression: own scale
(13.0)
Comparison with CBT
Zautra et al., 2008; – 7 Rheumatoid I: 57.3 I:46.3 MBSR 6–10 8 CBT I: 41 I: 8.3 Pain: NRS
arthritis (15.3)
C: 56.1 C:40.0 C: 35 C: 4.0 Depression: own scale
(13.5)
Wetherell et al., 2011; 6m 8 Chronic pain T: 54.9 T: 49.1 ACT 6 8, 1.5 h CBT I:57 I: 24.6 Pain: BPI-SF
(12.5)
C: 57 C: 26.3 Depression: BDI
Interference: BPI-SF
Comparison with MDT/relaxation
Wicksell et al., 2009 3.5 m, 6.5 m 5 Longstand- T: 14.8 T: 21.9 ACT Individ- 10, 1 h MDT I: 16 I: 6.3 (12.5, Pain: VAS
ing idiopath- (2.4) ual 18.8)
ic pain
C:16 C: 12.5 Depression: CES-D
(31.3, 31.3)
Interference: MPI and BPI
Schmidt et al., 2011; 8w 6 Fibromyalgia I: 53.4 T: .0 MBSR Max 12 8, 2.5 h Relaxation I: 53 I:15.1 Pain: PPS (sensory pain)
(8.7) (11.3)
(9.2) (12.5)
QoL: FIQ
Thorsell et al., 2011 6 m, 6 Chronic pain T: 46.0 T: 35.6 ACT Individ- 9 Relaxation I: 52 I: 46.2 Pain: NRS
(12.3) ual (48.1, 67.3)
12 m C: 38 C: 28.9 Depression: HADS
(31.6, 60.5)
Anxiety : HADS
Disability: ÖMPQ
Notes: ACT: acceptance and commitment therapy; C: control group; CBT: cognitive behavioural therapy; FSMT: four step mindfulness-based therapy; h: hours; I: intervention group; m: months; MBCT:
mindfulness-based cognitive therapy; MBPM: mindfulness-based pain management; MBSR: mindfulness-based stress reduction; MDT: multidisciplinary treatment; (M)TAU: (medical) treatment as
usual; SD: standard deviation; T: total group; w: weeks.
Outcome measures: BAI: Beck Anxiety Inventory; BDI: Beck Depression Inventory; BPI: Brief Pain Inventory; CES-D: Center for Epidemiologic Studies Depression Scale; CMDI: Chicago Multi-scale
Depression Inventory; C-SOSI: Calgary Symptoms of Stress Inventory; DASS: Depression Anxiety and Stress Scale; FIQ: Fibromyalgia Impact Questionnaire; HADS: Hospital Anxiety and Depression
Scale; LSQ: Life Satisfaction Questionnaire; MIDAS: Migraine Disability Assessment Scale; MPI: Multidimensional Pain Inventory; MPQ: McGill Pain Questionnaire; NRS: Numerical Rating Scale;
ÖMPQ: Örebro Musculoskeletal Pain Questionnaire; PDI: Pain Disability Index; PHQ-9: Patient Health Questionnaire-9; PIR: Pain Intensity Rating; PPS: Pain Perception Scale; PRI: Pain Rating Index
(MPQ); QoL: Quality of Life Profile for the Chronically Ill; QOLI: Quality Of Life Inventory; QOLS: Quality Of Life Scale; RMDQ: Roland and Morris Disability Questionnaire; SCL-90: 90-item Symptom
Checklist; SF-12/SF-36: 12/36-item Short-Form Health Survey; SF-36 GH/PCS/PF: SF-36 General Health/Physical Component Summary/Physical Functioning; STAI: Stait-Trait Anxiety Inventory;
SWLS: Satisfaction With Life Scale; VAS: Visual Analogue Scale; WSAS: Work and Social Adjustment Scale.
n = sample size of post-treatment analyses, lowest sample size in case sample sizes differed among outcome measures.
15
Figure 2. Funnel plot for depression.
on the quality criteria, six scored ‘high’ and five scored ‘low.’ None of the 25 studies met all
the quality criteria.1
Characteristics of the three additional studies that only used an active control group are
given in Table 2.
Publication bias
Some indication for publication bias was found for the outcome measure of depression.
The funnel plot for depression is presented in Figure 2, and shows asymmetrically d
istributed
studies in the bottom of the figure, which displays smaller studies. This might be due to the
fact that smaller studies are more likely to be published if they have larger-than-average
effects (Borenstein, 2005). The funnel plots for the other outcome measures were sym-
metrically distributed around the pooled SMD, which is an indication for the absence of
publication bias.
Post-treatment effects
Twenty-two studies assessed the effects at post-treatment on pain intensity, 16 on depres-
sion, six on anxiety, four on pain interference, 10 on disability, and 11 on quality of life.
Pooled SMDs and the results of the tests for heterogeneity and overall effect are presented
in Table 3. Small effects were found for pain intensity, depression, disability, and quality of
life with mean SMDs of respectively .24 (95% CI = .06, .42), .43 (95% CI = .18, .68), .40 (95%
CI = .01, .79), and .44 (95% CI = −.05, .93). A moderate effect was found for anxiety and pain
interference with mean SMD of respectively .51 (95% CI = .10, .92) and .62 (95% CI = .21,
1.03). All effects were statistically significant, except for the effect on quality of life (p = .08).
Statistical heterogeneity between the studies was caused by the studies of Luciano et al.
(2014) (for pain, depression, anxiety and quality of life) and Mo’tamedi, Rezaiemaram, and
Table 3. Effects at post-treatment and follow-up.

Outcome Heteroge- Pooled SMD Test for over-
measures Time n Studies neity (95% CI) all effect
Pain Post-treat- 22 Astin et al., 2003; Brown & Jones, χ2 = 41.53, .24 (.06, .42) Z = 2.68
ment 2013; Buhrman et al., 2013; Cath- df = 21 (p = .007)
cart et al., 2014; Dahl et al., 2004; (p = .005);
Davis & Zautra, 2013; Garland I2 = 49%
& Fredrickson, 2013; Johnston
et al., 2010; Luciano et al., 2014;
Mawani, 2009; McCracken et al.,
2013; Morone et al., 2008, 2009;
Mo’tamedi et al., 2012; Nash-Mc
Feron, 2006; Plumb Vilardaga,
2012; Schmidt et al., 2011; Wick-
sell et al., 2008, 2013; C. M. Wong,
2009; Wong et al., 2011; Zautra et
al., 2008
Follow-up 10 Astin et al., 2003; Dahl et al., 2004; χ2 = 20.93, .41 (.14, .68) Z = 3.02
Garland & Fredrickson, 2013; df = 9 (p = .003)
Luciano et al., 2014; McCracken (p = .01);
et al., 2013; Morone et al., 2009; I2 = 57%
Schmidt et al., 2011; Wicksell et al.,
2008, 2013; Wong et al., 2011
Depression Post-treat- 16 Astin et al., 2003; Buhrman et al., χ2 = 52.30, .43 (. 180, .68) Z = 3.38
ment 2013; Garland & Fredrickson, 2013; df = 15 (p = .0007)
Johnston et al., 2010; Luciano et (p < .00001);
al., 2014; McCracken et al., 2013; I2 = 71%
Parra-Delgado & Latorre-Postigo,
2013; Plumb Vilardaga, 2012;
Pradhan et al., 2007; Schmidt et
al., 2011; Sephton et al., 2007;
Wicksell et al., 2008, 2013; C. M.
Wong, 2009; Wong et al., 2011;
Zautra et al., 2008
Follow-up 10 Astin et al., 2003; Luciano et al., χ2 = 30.65, .50 (.19, .80) Z = 3.22
2014; McCracken et al., 2013; df = 9 (p = .001)
Parra-Delgado & Latorre-Posti- (p = .0003);
2
go, 2013; Pradhan et al., 2007; I = 71%
Schmidt et al., 2011; Sephton
et al., 2007; Wicksell et al., 2008,
2013; Wong et al., 2011
Anxiety Post-treat- 6 Buhrman et al., 2013, Johnston χ2 = 15.13, .51 (.10, .92) Z = 2.42
ment et al., 2010; Luciano et al., 2014; df = 5 (p= .02)
Wicksell et al., 2008, 2013; Wong (p = .01);
et al., 2011 I2 = 67%
Follow-up 4 Luciano et al., 2014; Wicksell et al., χ2 = 12.07, .57 (.00, 1.14) Z = 1.97
2008, 2013; Wong et al., 2011 df = 3 (p = .05)
(p = .007);
I2 = 75%
Pain inter- Post-treat- 4 Buhrman et al., 2013; Garland & χ2 = 6.50, .62 (.21, 1.03) Z = 2.94
ference ment Fredrickson, 2013; Wicksell et al., df = 3 (p = .003)
2008; C. M. Wong, 2009 (p = .09);
I2 = 54%
Follow-up 2 Garland & Fredrickson, 2013; χ2 = .58, 1.05 (.55, 1.56) Z = 4.09
Wicksell et al., 2008 df = 1 (p < .0001)
(p = .44);
I2 = 0%
Disability Post-treat- 10 Brown & Jones, 2013; McCracken χ2 = 30.12, .40 (.01, .79) Z = 2.01
ment et al., 2013; Morone et al., 2008, df = 9 (p = .04)
2009; Mo’tamedi et al., 2012; (p = .0004);
Nash-Mc Feron, 2006; Plumb I2 = 70%
Vilardaga, 2012; Wicksell et al.,
2008, 2013; Wong et al., 2011
(Continued)
Table 3. (Continued).
Outcome Heteroge- Pooled SMD Test for over-
measures Time n Studies neity (95% CI) all effect
Follow-up 5 [68, 74, 85, 110, 111, 117] Mc- χ2 = 4.54, .39 (.11, .67) Z = 2.71
Cracken et al., 2013; Morone et al., df = 4 (p = .007)
2009; Wicksell et al., 2008, 2013; (p = .34);
Wong et al., 2011 I2 = 12%
Quality of Post-treat- 11 Astin et al., 2003; Buhrman et al., χ2 = 68.44, .44 (−.05, .93) Z = 1.77
life ment 2013; Dahl et al., 2004; Johnston df = 10 (p = .08)
et al., 2010; Luciano et al., 2014; (p < .00001);
Morone et al., 2008; Parra-Delga- I2 = 85%
do & Latorre-Postigo, 2013; Plumb
Vilardaga, 2012; Schmidt et al.,
2011; Wicksell et al., 2008, 2013
Follow-up 7 Astin et al., 2003; Dahl et al., 2004; χ2 = 41.41, .66 (.06, 1.26) Z = 2.16
Luciano et al., 2014; Parra-Del- df = 6 (p = .03)
gado & Latorre-Postigo, 2013; (p < .00001);
Schmidt et al., 2011; Wicksell et al., I2 = 86%
2008, 2013
Notes: SMD, standardized mean difference; 95% CI, 95% confidence interval; df, degrees of freedom; n.a., not applicable.
Tavallaie (2012) (for disability). Both studies, which were respectively of high and medium
quality, found large beneficial effects of acceptance- and mindfulness-based interventions.
Follow-up effects
Thirteen studies assessed long-term effects. Follow-up periods ranged from 2 months to
6 months after completing treatment. Wong et al. (2011) reported follow-up results at both
3 and 6 months. In this case, we included the longest follow-up period. Ten studies assessed
the effects on pain intensity, 10 on depression, four on anxiety, two on pain interference,
five on disability, and seven on quality of life. Pooled SMDs and the results of the tests for
heterogeneity and overall effect are presented in Table 3. The effect on pain increased but
remained small with a mean SMD of .41 (95% CI = .14, .68). The effects on depression and
quality of life (slightly) increased and became moderate with mean SMDs of respectively .
53 (95% CI = .24, .82) and .66 (95% CI = .06, 1.26). The effect on pain interference increased
and became large with a mean SMD of 1.05 (95% CI = .55, 1.56). The effects on anxiety and
disability remained moderate with mean SMDs of respectively .59 (95% CI = .14, 1.04) and
.39 (95% CI = .11, .67). All effects were statistically significant.
Subgroup analyses
Results of the subgroup analyses are presented in Table 4. Significant differences in mean
SMDs were found between some subgroups. ACT interventions reported a statistically
significant higher mean effect on depression (SMD .82 vs. .18) and anxiety (SMD .64 vs.
−.01) than mindfulness-based interventions. Furthermore, studies using a (M)TAU group
as the control group (SMD .85) showed a higher mean effect on anxiety than studies using
an education/support group as an active control group (SDM .07). Finally, medium quality
studies (SMD .17) showed a lower mean effect on quality of life than the low (SMD 1.01)
and high (2.33) quality studies.
Table 4. Subgroup analyses on outcome measures at post-treatment.

Outcome
measure Criteria Subgroup n SMD [95% CI] Test for subgroup differences
Pain Quality Low 5 .27(−.06, .60) χ2 = 1.33, df = 2 (p = .52), I2 = 0%
Medium 12 .13 (−.06, .32)
High 5 .39 (−.08, .85)
Intervention ACT 9 .38 (.00, .76) χ2 = 1.23, df = 1 (p = .27), I2 = 18.8%
Mindfulness 13 .15 (−.01, .30)
Control group Education/support 8 .13 (−.08, .34) χ2 = 1.11, df = 1 (p = .29), I2 = 9.8%
(M)TAU/waitlist 14 .31 (.06, .57)
Pain type Chronic pain 10 .19 (.01, .38) χ2 = .15, df = 3 (p = .98), I2 = 0%
Fibromyalgia 5 .23 (−.34, .80)
Specific-site pain 6 .27 (−.06, .59)
Rheumatoid arthritis 1 .22 (−.26, .69)
Attrition rate <25% 11 .38 (.12, .63) χ2 = 3.16, df = 1 (p = .08), I2 = 68.3%
>25% 11 .08 (−.14, .29)
Depression Quality Low quality 1 .60 (−.49, 1.70) χ2 = .34, df = 2 (p = .84), I2 = 0%
Medium quality 9 .34 (.16, .51)
High quality 6 .45 (−.13, 1.02)
Intervention ACT 7 .82 (.30, 1.33) χ2 = 5.36, df = 1 (p = .02), I2 = 81.3%
Mindfulness 9 .18 (.03, .34)
Control group Education/support 5 .21 (.00, .41) χ2 = 2.66, df = 1 (p = .10), I2 = 62.4%
(M)TAU/waitlist 11 .56 (.19, .93)
Pain type Chronic pain 7 .35 (.15, .55) χ2 = 6.56, df = 3 (p = .09), I2 = 54.3%
Fibromyalgia 6 .54 (−.02, 1.11)
Specific-site pain 1 1.09 (.13, 2.05)
Rheumatoid arthritis 2 .00 (−.34, .34)
Attrition rate <25% 10 .46 (.07, .84) χ2 = .20, df = 1 (p = .66), I2 = 0%
>25% 6 .36 (.13, .58)
Anxiety Quality Low quality 1 1.40 (.17, 2.62) χ2 = 2.74, df = 2 (p = .25), I2 = 27.1%
Medium quality 3 .33 (−.02, .67)
High quality 2 .47 (−.48, 1.42)
Intervention ACT 5 .64 (.24, 1.05) χ2 = 5.09, df = 1 (p = .02), I2 = 80.4%
Mindfulness 1 −.01 (−.40, .38)
(M)TAU/waitlist 4 .85 (.53, 1.16)
Pain type Chronic pain 3 .25 (−.25, .76) χ2 = 2.76, df = 2 (p = .25), I2 = 27.7%
Fibromyalgia 2 .81 (.39, 1.23)
Specific-site pain 1 .62 (−.29, 1.53)
Rheumatoid arthritis 0
Attrition rate <25% 5 .43 (.01, .84) χ2 = 2.16, df = 1 (p = .14), I2 = 53.82%
>25% 1 1.40 (.17, 2.62)
Disability Quality Low quality 2 .41 (.05, .77) χ2 = 1.81, df = 2 (p = .41), I2 = 0%
Medium quality 7 .57 (.00, 1.14)
High quality 1 .35 (−.04, .75)
Intervention ACT 5 .75 (−.10, 1.61) χ2 = 1.42, df = 1 (p = .23), I2 = 29.7%
Mindfulness 5 .21 (−.05, .47)
Control group Education/support 2 .34 (−.01, .68) χ2 = .12, df = 1 (p = .73), I2 = 0%
(M)TAU/waitlist 8 .45 (−.09, .98)
Fibromyalgia 1 −.19 (−.85, . 47)
Specific-site pain 5 .81 (.03, 1.59)
Attrition rate <25% 7 .36 (.13, .58) χ2 = .14, df = 1 (p = .70), I2 = 0%
>25% 4 .59 (.60, 1.78)
Quality of life Quality Low quality 1 1.01 (−.14, 2.16) χ2 = 61.50, df = 2 (p < .00001),
I2 = 96.7%
Medium quality 9 .17 (−.02, .37)
High quality 1 2.30 (1.80, 2.80)
Intervention ACT 6 .77 (−.13, 1.67) χ2 = 1.74, df = 1 (p = .19), I2 = 42.4%
Mindfulness 5 .14 (−.10, .39)
(M)TAU/waitlist 9 .53 (−.09, 1.16)
Fibromyalgia 5 .67 (−.19, 1.52)
Specific-site pain 2 .52 (−.28, 1.32)
Attrition rate <25% 7 .60 (−.09, 1.28) χ2 = 1.35, df = 1 (p = .25), I2 = 26.0%
>25% 4 .11 (−.32, .54)
(Continued)
Table 4. Subgroup analyses on outcome measures at post-treatment.

Outcome
measure Criteria Subgroup n SMD [95% CI] Test for subgroup differences
Pain interfer- Quality Low quality 0 χ2 = .03, df = 1 (p = .86), I2 = 0%
ence
Medium quality 2 .64 (.23, 1.06)
High quality 2 .56 (.28, 1.40)
Intervention ACT 2 .64 (−.23, 1.06) χ2 = .03, df = 1 (p = .86), I2 = 0%
Mindfulness 2 .56 (−.28, 1.40)
Control group Education/support 2 .76 (−.34, 1.18) χ2 = .34, df = 1 (p = .56), I2 = 0%
(M)TAU/waitlist 2 .48 [−.37, 1.32)
Pain type Chronic pain 3 .56 (.09, 1.03) χ2 = .72, df = 1 (p = .40), I2 = 0%
Fibromyalgia 0
Specific-site pain 1 1.02 (.07, 1.96)
Attrition rate <25% 2 .64 (.23, 1.06) χ2 = .03, df = 1 (p = .86), I2 = 0%
>25% 2 .56 (−.28, 1.40)
Notes: SMD, standardized mean difference; 95% CI, 95% confidence interval; ACT, acceptance and commitment therapy; (M)
TAU, (medical) treatment as usual.
Comparison with active treatments

In two of the 25 studies, a comparison was made with both a waitlist or education/support
group and an active intervention such as CBT (Zautra et al., 2008) or relaxation (Schmidt
et al., 2011). Three additional studies made only a comparison with an active intervention
like CBT (Wetherell et al., 2011), MDT (Wicksell et al., 2009) or relaxation (Thorsell et al.,
2011). The results of these studies were pooled in a meta-analysis to compare the effects of
acceptance- and mindfulness-based interventions with the effects of other active treatments.
Pooled SMDs and the results of the tests for heterogeneity and overall effect are presented in
Table 5. Small effects were found on depression, pain interference and disability, in favour
of CBT compared to acceptance- and mindfulness-based interventions. Moderate to large
effects were found on pain, depression, pain interference, disability and quality of life in
favour of acceptance- and mindfulness-based interventions compared to MDT/relaxation.
None of these differences in pooled SMDs were significantly different.
Discussion
Main findings
The increased number of studies on the effectiveness of acceptance- and mindfulness-based
interventions for people with chronic pain enabled a more robust assessment of their effects
on the physical and mental health of patients. Twenty-five randomized controlled trials
(RCTs) were included in this meta-analysis. At post treatment, small effects were found for
pain intensity, depression, disability and quality of life; and moderate effects for anxiety and
pain-interference. These results confirm the findings of the former meta-analysis (Veehof
et al., 2011). The larger effect size for pain interference is congruent with acceptance- and
mindfulness-based treatment models, mainly because pain interference, as opposed to pain
intensity, is a more proximate indicator of the aim of acceptance- and mindfulness-based
interventions, i.e. for patients to go along with life even in the face of pain. Disabilities
caused by chronic pain as experienced by patients also depend on the degree to which the
patients allow pain sensations to interfere with their daily life. Increased acceptance of pain
sensations instead of fighting them, may be related to a larger decrease of pain interference.
Table 5. Comparison of acceptance-based treatments with CBT and MDT/relaxation at post-treatment.

Outcome Pooled SMD Test for overall
measures n Studies Heterogeneity (95% CI) effect
Comparison with CBT
Pain 2 Wetherell et al., 2011; χ2 = 6.04, df = 1 −.02 (−.74, .70) Z = .05 (p = .96)
Zautra et al., 2008 (p = .01); I2 = 83%
Depression 2 Wetherell et al., 2011; χ2 = 1.29, df = 1 −.25 (−.58, .08) Z = 1.48 (p = .14)
Zautra et al., 2008 (p = .26); I2 = 22%
Anxiety 0
Pain interference 1 Wetherell et al., 2011 n.a. −.23 (−.60, .14) Z = 1.24 (p = .21)
Disability 1 [109] n.a. −.22 (−.58, .15) Z = 1.15 (p = .25)
Quality of life 0
Comparison with MDT/relaxation
Pain 3 Schmidt et al., 2011; χ2 = 27.09, df = 2 .94 (−.16, 2.04) Z = 1.68 (p = .09)
Thorsell et al., 2011; (p < .00001);
Wicksell et al., 2009 I2 = 93%
Depression 3 Schmidt et al., 2011; χ2 = 51.94, df = 2 .83 (−.70, 2.37) Z = 1.06 (p = .29)
Thorsell et al., 2011; (p < .00001);
Wicksell et al., 2009 I2 = 96%
Anxiety 1 Thorsell et al., 2011 n.a. .00 (−.42, .42) Z = .00 (p = 1.00)
Pain interference 1 Wicksell et al., 2009 n.a. .69 (−.03, 1.41) Z = 1.89 (p = .06)
Disability 2 Thorsell et al., 2011; χ2 = 49.90, df = 1 2.54 (−1.20, 6.29) Z = 1.33 (p = .18)
Wicksell et al., 2009 (p < .00001);
I2 = 98%
Quality of life 2 Schmidt et al., 2011; χ2 = 63.08, df = 1 1.56 (−1.31, 4.43) Z = 1.07 (p = .29)
Thorsell et al., 2011 (p < .00001);
I2 = 98%
Note: SMD, standardized mean difference; 95% CI, 95% confidence interval; df, degrees of freedom; n.a., not applicable.
Only four studies, however, included pain interference as an outcome measure. To ensure
conformity, comparability and especially, consistency with theory, we advise for future
acceptance- and mindfulness-based intervention trials to apply pain interference or pain
disabilities as the primary outcome.
At two to six months after treatment, the effect sizes for depression, anxiety and quality
of life were moderate. The effect size for pain interference was large. These (in general)
larger effects at follow-up indicate that patients, even in the presence of enduring pain,
in the long term manage to apply the principles of acceptance- and mindfulness-based
treatments in their daily lives.
The effect sizes for pain intensity were small, both at post-treatment and follow-up. This
confirms the findings of a recent systematic review of mindfulness-based interventions and
ACT in mixed samples (Reiner, Tibi, & Lipsitz, 2013). Given the chronic nature of pain, it
is doubtful whether psychological treatments can achieve larger effects on pain intensity.
Pain control and reduction are not the primary aims of acceptance- and mindfulness-based
interventions, but some impact on pain intensity may be reached because mindfulness skills
have been found to influence brain mechanisms that may alter the pain experience (Zeidan
et al., 2011). In addition, acceptance- and mindfulness-based interventions can have indirect
effects on pain intensity since increased acceptance may buffer the degree to which pain
sensations are experienced as stressful events to be immediately avoided (Shapiro, Carlson,
Astin, & Freedman, 2006).
Subgroup analyses showed that the effect sizes of ACT were higher in comparison to
MBSR and MBCT for all outcome measures and significantly higher for depression and
anxiety. The difference on depression remained after excluding an ACT study that found
large effects on depression and anxiety (Luciano et al., 2014) . The explicit formulation of
life values and the emphasis on committed action of the ACT-model may install hope and
increase behavioral change and thereby explain the larger effects of ACT when compared
to MBSR and MBCT. The smaller effects of MBSR and MBCT in this meta-analysis corrob-
orate with a recent meta-analysis of the effects of mindfulness on anxiety and depression
(Hofmann, Sawyer, Witt, & Oh, 2010). For fibromyalgia, none or small effects of MBSR or
MBCT were found in (randomized) controlled studies (Lakhan & Schofield, 2013; Lauche,
Cramer, Dobos, Langhorst, & Schmidt, 2013).
Except for quality of life, the quality of the studies was not found to moderate outcomes.
For quality of life, studies of medium quality were found to have significant lower effect.
However, this result needs to be interpreted with caution since the number of high- and
low-quality studies were only one study each.
Overall, the effect sizes found in this study were at least comparable to those found in a
recent meta-analysis of CBT for chronic pain patients (Williams et al., 2012). Williams and
co-workers found small post treatment effect sizes on pain intensity, disability and mood
in their meta-analysis of sixteen RCTs, in which CBT was compared to TAU or a waiting
list. However, only the effect size of mood was maintained at follow-up (Williams et al.,
2012). This finding is in contrast to those of the current meta-analysis which showed that
the effects on all outcomes, except pain intensity, increased at follow-up.
The subgroup analysis on control group showed that (M)TAU and waitlist did not differ
from the active control conditions of support groups or education, apart from a significant
difference in favour of (M)TAU on anxiety. Pain education as developed by Moseley and his
colleagues has been shown to have beneficial effects as a treatment on its own (Moseley &
Butler, 2015). This pain education program, however, differs fundamentally form the pain
management education used in most of the studies in this meta-analysis, by the important
role for explanation of the biological basis of pain. It thereby offers alternative and more
helpful conceptualisations of pain and of inadequate (catastrophic) cognitions patients may
be fused with. Five studies compared acceptance- and mindfulness-based interventions
to active treatments such as CBT (Wetherell et al., 2011; Zautra et al., 2008), relaxation
(Schmidt et al., 2011; Thorsell et al., 2011) or MDT (Wicksell et al., 2009). Small effects were
found in favour of CBT, and moderate to large effects were found in favour of acceptance-
and mindfulness-based treatments compared to relaxation or MDT. However, the number of
studies is small and none of differences were found to be significant in the pooled analyses.
Study limitations and strengths

The number of studies on acceptance- and mindfulness-based interventions has increased
considerably since our former systematic review and meta-analysis. Therefore, we were able
to restrict ourselves to the more rigorous test of RCTs. However, this study also contains a
number of limitations. First, the average quality of studies has not improved over the past six
years. Although the number of high quality studies has increased compared to our previous
search up to 2009, a number of studies of low quality have still been recently published. The
rating of quality may be an underestimation since we rated a criterion as not-fulfilled if it
was not reported in the article. It is also plausible that mean quality would be enhanced if all
researchers would routinely report on their randomization procedures and the training of
therapists. Second, we combined studies of ACT with mindfulness-based studies. This allows
for a comparison of the recent results with the results of the former systematic review and
meta-analysis. However, the ACT and mindfulness based treatments can only be compared
at post-treatment, since the number of studies were too small to perform subgroup analyses
at follow-up. As studies continue to increase, future meta-analyses may differentiate between
acceptance- and mindfulness-based interventions to understand their unique effects. Third,
a small number of studies were represented in some of the subgroup analyses.
The data extraction of this study revealed a great number of qualitative, narrative or sys-
tematic reviews. By now, the field is saturated with reviews. The meta-analytic approach of
this study and the reported effect sizes not only offer insight into the strength of effects, but
can also be used to benchmark pre- to post-treatment as well as follow-up measurements
in daily practice (Morley, 2011).
Conclusions and recommendations

To conclude, acceptance- and mindfulness-based interventions for chronic pain are, on
the whole, moderately effective on a number of beneficial outcomes, especially in the long
term. Nevertheless, there is room for progress and treatment improvement.
It is necessary to study whether interventions work in accordance to their underlying
theoretical basis. In CBT, the main hypothesized working mechanism is the changing of
the content of thoughts such as catastrophizing cognitions and of emotions such as kinesi-
ophobia (Crombez, Eccleston, Van Damme, Vlaeyen, & Karoly, 2012). In acceptance- and
mindfulness-based treatments, mindfulness and psychological flexibility are hypothesized
to be the main process of change (McCracken & Morley, 2014). In a MBSR study among
adults with problematic stress resulting from chronic pain, chronic disease or other life
circumstances, increases in mindfulness preceded decreases in perceived stress (Baer
et al., 2012). A meta-analysis of samples with a mix of mental and physical health prob-
lems, showed that ACT seemed to work through its proposed mechanism of change while
CBT did not (Ruiz, 2012). In a mediation analysis within a sample of patients with chronic
whiplash-associated disorders, psychological inflexibility was identified as a mediator on
pain-related disability and life satisfaction, but kinesiophobia was not (Wicksell et al., 2010).
The mediating role of psychological inflexibility was also found in individuals with pain
that finished an online ACT program, but there were indications that catastrophizing, a
putative mediating variable in a CBT model, was also an independent mediator on pain
interference (Trompetter, Bohlmeijer, Fox, & Schreurs, 2015). Therefore, it is recommended
to include variables from the CBT, mindfulness, as well as from the psychological flexibility
model in future studies.
Knowledge on mechanisms of change can help to enhance or integrate our existing
theoretical models of chronic pain, thereby progressing opportunities for more effective
treatment. More than one measurement moment must be scheduled during the interven-
tion phase to discern how processes unfold over time. But the scheduling of more intensive
measurement is advisable to really grasp time-varying processes in relation to specific
intervention characteristics and subsequent changes in outcome. We suggest that the appli-
cation of intensive measurements once per day, or even more times per day by the use of
mobile technology gives real insight into unfolding processes over time within individuals
(Richardson & Reid, 2013). When scheduling the intensity and timing of measurements
during interventions, however, we must not merely measure mechanisms just for the sake of
measuring. Timing and spacing of measurements needs to be well thought out and be related
to theory and intervention characteristics. It must be scheduled in such a way that one is
most certain to catch unfolding of processes one is interested in (Selig & Preacher, 2009).
Furthermore, outcomes could also be improved if treatments are matched to the char-
acteristics of patients. In general, sample sizes of current RCTs are too small to answer
questions on what works for whom; therefore, studies should be designed to investigate
specific hypotheses.
Finally, clinicians and researchers should invest in treatment integrity. In this meta-
analysis, only seven studies performed a treatment integrity check. Clearly, this is a
challenging criterion that is still too liberally applied in this and other meta-analyses since
the mere report of an integrity check already receives credit. If we want to improve the
effects of interventions, it is absolutely necessary to ensure that interventions are provided
as intended.
Overall, we can conclude that individuals with pain, in general, respond rather well to
acceptance- and mindfulness-based interventions and that beneficial effects are retained
after treatment. ACT seems to be more effective in treating depression and anxiety in indi-
viduals with pain than mindfulness-based treatments.
Note
1. Information on the quality assessment per study is obtainable from the corresponding author.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
M. M. Veehof http://orcid.org/0000-0003-3907-3322
H. R. Trompetter http://orcid.org/0000-0003-4518-6999
E. T. Bohlmeijer http://orcid.org/0000-0002-7861-1245
K. M. G. Schreurs http://orcid.org/0000-0002-1229-0151
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Appendix 1. Search strategy Pubmed (OVID)

(“attention”[MeSH Terms] OR “attention”[All Fields]) OR (“mindfulness”[MeSH Terms] OR “mind-
fulness”[All Fields]) OR vipassana[All Fields] OR (“meditation”[MeSH Terms] OR “meditation”[All
Fields]) OR MBSR[All Fields] OR MBCT[All Fields] OR “mindfulness-based stress reduction”[All
Fields] OR “mindfulness-based cognitive therapy”[All Fields] OR “acceptance based”[All Fields]
OR “acceptance-based”[All Fields] OR (acceptance[All Fields] AND (“Commitment”[Journal] OR
“commitment”[All Fields]))
AND
((“chronic pain”[MeSH Terms] OR (“chronic”[All Fields] AND “pain”[All Fields]) OR “chronic
pain”[All Fields]) OR (“fibromyalgia”[MeSH Terms] OR “fibromyalgia”[All Fields]) OR “chronic
fatigue syndrome”[All Fields] OR “whiplash associated disorder”[All Fields] OR WAD[All Fields]
OR “repetitive strain injury”[All Fields] OR RSI[All Fields] OR dystrophy[All Fields] OR (com-
plaints[All Fields] AND (“arm”[MeSH Terms] OR “arm”[All Fields]) AND (“neck”[MeSH Terms]
OR “neck”[All Fields]) AND (“shoulder”[MeSH Terms] OR “shoulder”[All Fields])) OR CANS[All
Fields] OR “complex regional pain syndrome”[All Fields] OR CRPS[All Fields])
AND
(hasabstract[text]
AND
(“2009/01/01”[PDAT] : “2013/12/31”[PDAT])
AND
English[lang])

Acceptance and Mindfulness Based Interventions For The Treatment of Chronic Pain - A Meta Analytic Review

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Cognitive Behaviour Therapy

ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: https://www.tandfonline.com/loi/sbeh20

Acceptance- and mindfulness-based interventions

M. M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs

To cite this article: M. M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs (2016)

To link to this article: https://doi.org/10.1080/16506073.2015.1098724

© 2016 The Author(s). Published by Informa Published online: 28 Jan 2016.

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Acceptance- and mindfulness-based interventions for the

ABSTRACT ARTICLE HISTORY

CONTACT K. M. G. Schreurs k.m.g.schreurs@utwente.nl Department of Psychology, Health & Technology,

study, therefore, was to conduct a meta-analysis to assess the effectiveness of acceptance-

Selection procedure and eligibility criteria

Table 1. Methodological quality criteria.a

1393 records identified

1393 records screened

1133 records excluded

260 records identified

163 records identified

87 full-text articles 76 full-text (systematic) no additional relevant

8 studies from previous

Figure 1. Flow chart of the selection procedure.

Characteristics of included studies

Table 2. Characteristics of included studies.

Figure 2. Funnel plot for depression.

Table 3. Effects at post-treatment and follow-up.

Table 4. Subgroup analyses on outcome measures at post-treatment.

Table 4. Subgroup analyses on outcome measures at post-treatment.

Comparison with active treatments

Table 5. Comparison of acceptance-based treatments with CBT and MDT/relaxation at post-treatment.

Study limitations and strengths

Conclusions and recommendations

Appendix 1. Search strategy Pubmed (OVID)

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