Learning to Apply Mindfulness to Pain (LAMP): Design for a Pragmatic Clinical Trial of Two Mindfulness-Based Interventions for Chronic Pain.

BACKGROUND: Mindfulness-based interventions (MBIs) are evidence-based nonpharmacological treatments for treating chronic pain. However, the predominant MBI, mindfulness-based stress reduction, has features that pose significant implementation barriers. OBJECTIVES: This study will test two approaches to delivering MBIs for improving Veterans' chronic pain and mental health comorbidities. These two approaches address key implementation barriers. METHODS: We will conduct a four-site, three-arm pragmatic randomized controlled trial, Learning to Apply Mindfulness to Pain (LAMP), to test the effectiveness of two MBIs at improving pain and mental health comorbidities. Mobile+Group LAMP consists of prerecorded modules presented by a mindfulness instructor that are viewed in an online group setting and interspersed with discussions led by a facilitator. Mobile LAMP consists of the same prerecorded modules but does not include a group component. We will test whether either of these MBIs will be more effective than usual care at improving chronic pain and whether the Mobile+Group LAMP will be more effective than Mobile LAMP at improving chronic pain. Comparisons for the primary hypotheses will be conducted with continuous outcomes (Brief Pain Inventory interference score) repeated at 10 weeks, 6 months, and 12 months. The secondary hypotheses are that Mobile+Group LAMP and Mobile LAMP will be more effective than usual care at improving secondary outcomes (e.g., post-traumatic stress disorder, depression). We will also confirm the comparisons for the primary and secondary hypotheses in gender-specific strata. IMPLICATIONS: This trial is expected to result in two approaches for delivering MBIs that will optimize engagement, adherence, and sustainability and be able to reach large numbers of Veterans.

Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans.

INTRODUCTION: Anxiety, depression, and pain are major problems among veterans, despite the availability of standard medical options within the Veterans Health Administration. Complementary and alternative approaches for these symptoms have been shown to be appealing to veterans. One such complementary and alternative approach is mindfulness-based stress reduction (MBSR), a brief course that teaches mindfulness meditation with demonstrated benefits for mood disorders and pain. METHODS: We prospectively collected data on MBSR's effectiveness among 79 veterans at an urban Veterans Health Administration medical facility. The MBSR course had 9 weekly sessions that included seated and walking meditations, gentle yoga, body scans, and discussions of pain, stress, and mindfulness. Pre-MBSR and post-MBSR questionnaires investigating pain, anxiety, depression, suicidal ideation, and physical and mental health functioning were obtained and compared for individuals. We also conducted a mediation analysis to determine whether changes in mindfulness were related to changes in the other outcomes. RESULTS: Significant reductions in anxiety, depression, and suicidal ideation were observed after MBSR training. Mental health functioning scores were improved. Also, mindfulness interacted with other outcomes such that increases in mindfulness were related to improvements in anxiety, depression, and mental health functionality. Pain intensity and physical health functionality did not show improvements. DISCUSSION: This naturalistic study in veterans shows that completing an MBSR program can improve symptoms of anxiety and depression, in addition to reducing suicidal ideations, all of which are of critical importance to the overall health of the patients.

Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial.

Importance: Although mindfulness-based interventions (MBIs) are evidence-based treatments for chronic pain and comorbid conditions, implementing them at scale poses many challenges, such as the need for dedicated space and trained instructors. Objective: To examine group and self-paced, scalable, telehealth MBIs, for veterans with chronic pain, compared to usual care. Design, Setting, and Participants: This was a randomized clinical trial of veterans with moderate to severe chronic pain, recruited from 3 Veterans Affairs facilities from November 2020 to May 2022. Follow-up was completed in August 2023. Interventions: Two 8-week telehealth MBIs (group and self-paced) were compared to usual care (control). The group MBI was done via videoconference with prerecorded mindfulness education and skill training videos by an experienced instructor, accompanied by facilitated discussions. The self-paced MBI was similar but completed asynchronously and supplemented by 3 individual facilitator calls. Main Outcomes and Measures: The primary outcome was pain-related function using the Brief Pain Inventory interference scale at 3 time points: 10 weeks, 6 months, and 1 year. Secondary outcomes included biopsychosocial outcomes: pain intensity, physical function, anxiety, fatigue, sleep disturbance, participation in social roles and activities, depression, patient ratings of improvement of pain, and posttraumatic stress disorder. Results: Among 811 veterans randomized (mean [SD] age, 54.6 [12.9] years; 387 [47.7%] women), 694 participants (85.6%) completed the trial. Averaged across all 3 time points, pain interference scores were significantly lower for both MBIs compared to usual care (group MBI vs control difference: -0.4 [95% CI, -0.7 to -0.2]; self-paced vs control difference: -0.7 [95% CI, -1.0 to -0.4]). Additionally, both MBI arms had significantly better scores on the following secondary outcomes: pain intensity, patient global impression of change, physical function, fatigue, sleep disturbance, social roles and activities, depression, and posttraumatic stress disorder. Both group and self-paced MBIs did not significantly differ from one another. The probability of 30% improvement from baseline compared to control was greater for group MBI at 10 weeks and 6 months, and for self-paced MBI, at all 3 time points. Conclusions and Relevance: In this randomized clinical trial, scalable telehealth MBIs improved pain-related function and biopsychosocial outcomes compared to usual care among veterans with chronic pain. Relatively low-resource telehealth-based MBIs could help accelerate and improve the implementation of nonpharmacological pain treatment in health care systems. Trial Registration: ClinicalTrials.gov Identifier: NCT04526158.

Mindfulness-Based Teaching Competency Assessment: Comparing Self-Assessment With Expert Evaluation in the Veterans Administration - Compassionate Awareness Learning Module Program.

Background: Meditation, including Mindfulness-Based Interventions (MBI), is a required Complementary and Integrative Health intervention at the US Department of Veterans Affairs (VA). Training VA clinicians to provide MBI at scale must address fidelity concerns and the assessment of clinician competency. Objective: The psychometric properties of the Mindfulness-Based Intervention: Teaching Assessment Criteria (MBI:TAC), a widely used tool for assessing facilitator competence, continue to be explored. To support the dissemination of MBI, the utility of using the MBI:TAC for self-assessment for clinicians in a national training program was evaluated. Methods: In a training cohort of VA clinicians (n = 39), participant self evaluations on 2 domains of the MBI:TAC are compared to the competency scores of 2 expert evaluators as based on the observations of a 10-minute exercise. Additionally, the inter-rater reliability between the 2 experts was explored. Results: Intraclass Correlation for the 2 expert evaluators for Guiding Practice was significant (ρ = .83, P = .003), but was not significant for Embodiment of Mindfulness (ρ = .34, P = .186). Self-evaluation scores were not significantly correlated to expert rater scores such that participants rate their level of competence higher than expert scores. Conclusion: The MBI:TAC, while an essential tool in teacher training, may not produce accurate scores when used for self-assessment. Instruction from a senior teacher is needed for accurate scoring. Interrater reliability may be improved with enhanced domain operationalization and training. Implications for MBI training are explored.

Mind-Body Interventions for Rehabilitation Medicine: Promoting Wellness, Healing, and Coping with Adversity.

Physical medicine providers work to cure organic aspects of disease while simultaneously enhancing quality of life and well-being. Mind-body interventions are evidence-based, cost-effective approaches to serve these aims. This article enhances provider knowledge and acceptance of the most effective and prevalent mind-body modalities: meditation, guided imagery, clinical hypnosis, and biofeedback. The scientific evidence is strongest for mind-body applications for chronic pain, primary headache, cardiac rehabilitation, and cancer rehabilitation, with preliminary evidence for traumatic brain injury and cerebrovascular events. Mind-body interventions are well-tolerated by patients and should be considered part of standard care in physical medicine and rehabilitation settings.

A pilot study examining the effect of integrative tinnitus management (ITM) on tinnitus distress and depression symptoms in veterans.

Tinnitus, or the perception of sound in the absence of an acoustic stimulus, is a highly prevalent and distressing symptom that currently lacks an effective medical treatment. Tinnitus is highly comorbid with insomnia, depression, and anxiety and is the most common service-connected disability among veterans of the U.S. military. This article evaluates Integrative Tinnitus Management (ITM), a multidisciplinary 9-week education and skills-based program aimed at reducing distress related to tinnitus. Thirty U.S. veterans completed a course of ITM at a large, urban Veteran's Administration (VA) hospital and provided pre- and posttreatment data. Veterans completed self-report measures related to tinnitus symptoms, depression symptoms, and mindfulness at pre- and posttreatment. Results demonstrated that veterans who completed the program experienced significant decreases in self-reported distress related to tinnitus symptoms, impairment because of tinnitus symptoms, and depression symptoms. Overall, this preliminary evaluation of ITM suggests it may be an efficacious treatment for tinnitus-related distress and warrants advancement to a randomized control trial (RCT). (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Integrative Therapy Approaches for Posttraumatic Stress Disorder: A Special Focus on Treating Veterans.

Over the past decade, the use of integrative health modalities, such as mind-body interventions, art therapy, nutrition, and exercise, to treat stress-related mental health conditions, including posttraumatic stress disorder (PTSD), in military and veteran populations has been increasing. The use of integrative therapies for PTSD provides options for veterans who are not interested in traditional modalities, have limited access to traditional treatments, or are seeking a more comprehensive approach to managing their PTSD or subthreshold symptoms. These therapies show promise for improving overall well-being and comorbid conditions with PTSD, such as pain or migraines, but yield mixed data for PTSD symptoms. The aim of this article is to review the evidence for the most promising integrative health modalities for treating PTSD, with a special focus on the treatment of veterans, as well as to offer recommendations and suggestions for clinicians.

Interpreting the meaning of multiple symptom validity test failure.

While it is recommended that judgments regarding the credibility of test performance be based on the results of more than one effort indicator, and recent efforts have been made to improve interpretation of multiple effort test failure, the field currently lacks adequate guidelines for using multiple measures of effort in concert with one another. A total of 103 patients were referred for outpatient neuropsychological evaluation, which included multiple measures of negative response bias embedded in standard test batteries. Using any pairwise failure combination to predict diagnostic classification was superior (sensitivity = 83.8%, specificity = 93.9%, overall hit rate = 90.3%) to using any one test by itself and to using any three-test failure combination. Further, the results were comparable to the results of logistical regression analyses using the embedded indicators as continuous predictors. Given its parsimony and clinical utility, the pairwise failure model is therefore a recommended criterion for identifying non-credible performance; however, there are of course other important contextual factors and influences to consider, which are also discussed.