Fall semester of 2013 Study programme for professional psychologists Master thesis, 30hp Supervisor: Michael Rönnlund

Online mindfulness training for chronic pain

- a randomized controlled trial

Jessica Henriksson and Emma Vasara Möller

Tack!Vivill tackavårhandledareMichaelRönnlund föralltengagemangochallvägledning.Tackäven tillallapåMindfulnesscentersommöjliggjordedettaexamensarbete.SärskilttacktillOlaSchenströmfördetentusiasmerandestödetochtillSusanneSahlénNybergfördenovärderligatekniskaassistansen.Tack även till alla vid smärtrehabiliteringen på Norrlands universitetssjukhus för all hjälp underterminens gång och för assistans med rekrytering av deltagare. För detta vill vi även tacka allainblandade från primärvården i Västerbottens läns landsting. Slutligen vill vi tacka alla övrigainblandadeunderresansgångochriktaettextrastorttacktillalladeltagareiprojektetutanvilkadettaexamensarbeteintehadevaritmöjligt.

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ONLINEMINDFULNESSTRAININGFORCHRONICPAIN‐ARANDOMIZEDCONTROLLEDTRIAL

JessicaHenrikssonandEmmaVasaraMöller

Mindfulnessisawayofmanagingchronicpainanditsconsequencesas it fostersanacceptingapproachtopainthatcanbebeneficialinseveralaspectsoflifeaffectedbypain.Thisstudysoughttoexaminewhetheranonlinemindfulnesstrainingprogramcouldreducetheexperienceofpain,increaseacceptanceofpain,andincreasequalityof life in a group of individuals suffering from chronic pain. The study was arandomizedcontrolledtrialwithapartlyactivecontrolgroup.Initially52participantswererandomizedtotheinterventiongroupand55tothecontrolgroup.Thedropoutrateswerehigh,21participantsfromtheinterventiongroupand40participantsfromthe control group completed post measurement. Increased levels of mindfulness,reducedpain relateddistress, andheightenedpain acceptance, aswell as increasedqualityof life,wasobserved in the interventiongroup.Astrongtendencytowardsaperceivedreductionofpain intensitywasalsoevident in the interventiongroup.Asthemindfulnessprogramhadpositiveeffectsontheoverallexperienceofpainitmayserveasacost‐effectiveandusefulmethodofdealingwithchronicpain.Mindfulnessärettsättatthanterakronisksmärtaochdesskonsekvenserdådetlärutenaccepterandeinställningtillsmärtasomkanvaratillhjälpifleraaspekteravlivetpåverkade av smärta. Denna studie undersökte huruvida ett online‐baseratmindfulnessprogramkundeminskaupplevelsenavsmärta,ökaacceptansavsmärtaoch öka livskvaliteten hos en grupp individer med kronisk smärta. Studien varrandomiserad och kontrollerad med en delvis aktiv kontrollgrupp. Initialtrandomiserades 52 deltagare till experimentgruppen och 55 deltagare tillkontrollgruppen. Bortfallet var högt, 21 deltagare från experimentgruppen och 40deltagare från kontrollgruppen fullgjorde eftermätningarna. Ökade nivåer avmindfulness, reducerat smärtrelaterat lidande, ökad acceptans av smärta såväl somökad livskvalitet återfanns i experimentgruppen. En stark tendens till minskadupplevd smärtintensitet var också tydlig hos experimentgruppen. Dåmindfulnessprogrammethadepositiva effekterpådenövergripandeupplevelsenavsmärta kan det fungera som en kostnadseffektiv och användbarmetod att hanterakronisksmärta.

Keywords: Mindfulness, chronic pain, persistent pain, Internet‐based treatment, Breathworks,acceptance‐basedtreatment

Conditionsinvolvingchronicpaincauseindividualsufferingaswellassubstantialsocial costs (SBU, 2006). The International Association for the Study of Pain(International Association for the Study of Pain, 2013) defines pain as “Anunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,ordescribedintermsofsuchdamage”.Thisisthemostwidespreaddefinition of pain. The experience of pain is affected by factors such as theindividual’semotions,context,historicalandculturalbackground,aswellastheindividualsappraisalsofthesymptoms(Turk&Okifuji,2002). Chronic pain is oftendefined as pain that has persisted longer than three or sixmonths(e.g.Breivik,Collett,Ventafridda,Cohen&Gallacher,2006;Gerdle,Björk,Henriksson&Bengtsson,2004)andmaybedistinguishedfromacutepainwhich

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hasashorterduration.Chronicpain,however,isnotthesameasprolongedacutepain. Instead, it could be described as an experience of a disabling disease(Chapman & Gavrin, 1999). The diagnosis is non‐uniform with differences indistribution,states,severityandfunctionalimpact(Bergmanetal.,2002).Oncethepain has been established as chronic, the chances of becoming pain free arerelatively small (e.g. Andersson, 2004; Bergman, Herrström, Jacobsson &Petersson,2002). Chronicpainisarelativelycommoncondition.TheprevalenceofmoderatetoseverechronicpaininaSwedishsamplehasbeenestimatedto18%(Breiviketal.,2006).Otherstudieshaveshownprevalenceratesforchronicpainingeneralatabout50%(Gerdle,Björk,Henriksson&Bengtsson,2004;Jakobsson,2010). Inregardtoeffectsofchronicpainonothersubjectvariables, ithasbeenshownthat individuals suffering from chronic pain are less satisfied with their livescomparedtocontrols.Thelargestdifferencesinlifesatisfactionwerefoundinthedomains of physical and psychological health (Silvemark, Källmén, Portala &Molander,2008).Thisisinaccordancewithresultsfromotherstudiesassociatingchronicpainwithdecreasedqualityof life(e.g.Breiviketal.,2006;Lamé,Peters,Vlaeyen,Kleef&Patijn,2005). Chronic pain has, in addition, been shown to affect aspects of life such as sleep,BMI,fatigue,andmobilitynegatively(Jakobsson,2010).Asthesesymptomsoftenaccompany the pain it could result in feelings of sickness, exhaustion andimpairment. This state of suffering resembles depression but is different fromdepressionasitisawiderconcept,notnecessarilypsychopathological.Incasesofchronic pain, the individual is more focused on suffering in the future than onnegativeaffecttowardstheself(Chapman&Gavrin,1999). Chronicpainishardtotreateffectively.Themostcommontreatmentforchronicpainisavarietyofpainreductiontreatmentssuchasanalgesicandopioiddrugs.Thiskindoftreatmentonlyreducespainby30‐40%inabouthalfofthepatients.Surgery forchronicpainconditions,especiallychronicbackpain, is commonbutdoes not remove the pain to a satisfactory level (Turk, 2002). Multimodalrehabilitation is used for chronic pain for patients with extensive and complexneeds.Thistypeofrehabilitationincludescontributionfromdifferentlinessuchaspsychology,physiotherapy,medicineetcetera.Multimodalrehabilitationprovidesbetter long term results on aspects of life such as return to work than lessextensiveinterventionsdo(SBU,2006). Cognitive Behavioral Therapy (CBT) has shown to mainly be associated withimprovementsinqualityoflife.CBTalsoappeartohavesomeeffectonpainandpsychologicaldistress.Inparticular,copingskillstrainingwithafocusoncognitiveskilldevelopmentandpracticeseemstobeeffective(Eccleston,Morley&Williams,2013).Given that the foregoing methods for reducing pain have some drawbacks (e.g.with regard to costs, time consumption et cetera, an increased interest inalternativemeans to reducepainhasbeenseen in recentyears.Recent research

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has also focused on mindfulness‐based interventions (MBIs) for chronic pain(Reiner,Tibi&Lipsitz,2013),thatalsoservedasabasisforthepresentstudy. Mindfulness has been described as “paying attention in a particular way; onpurpose, in the presentmoment, andnonjudgmentally” (Kabat‐Zinn, 1994, p. 4).Bishopetal.(2004)proposedanoperationaldefinitionofmindfulnessconsistingoftwocomponents:self‐regulationofattentionandorientationtoexperience.Self‐regulation of attention involves skills in sustained attention and attentionswitchingaswellasinhibitionofelaborativeprocessing.Orientationtoexperienceinvolvescuriosity,opennessandacceptancetowardsthecurrentexperience.Theseattitudes provide a non‐elaborative awareness to the experience as well as adecentered and more insightful perspective on thoughts and feelings. By thisdefinition,mindfulness is ametacognitive process as it requires both control ofcognitiveprocessesandtheabilitytomonitorthestreamofconsciousness(Bishopetal.,2004). Brown and Ryan (2003) found positive relationships between mindfulness andseveral health benefits such as life satisfaction and optimism. Beingmindful hasalso been found to exhibit a negative relationship with depression, anxiety andself‐consciousness (Brown&Ryan,2003).Thus,mindfulness seems topositivelyinfluence psychological well‐being. It has become a popular element inpsychological treatments (Baer, 2009) and is considered a powerful andwidelyapplicableinterventionincounseling(Brown,Marquis&Guiffrida,2013). MBIs have been used in treatment of patients with chronic pain. Unfortunately,there is no consensus regarding the effects MBIs have on pain intensity. Morespecifically, two reviews (Chiesa & Serretti, 2011; Veehof, Oskam, Schreurs &Bohlmeijer, 2011) show inconclusive results regarding MBIs on pain intensitywhile a third review (Reiner et al., 2013) concluded thatMBIshaveaneffect onpainintensity.Partiallyduetothelackofhighqualityrandomizedandcontrolledstudies it is therefore difficult to conclude anything absolute regarding theeffectivenessofMBIstoreduceperceivedpainintensitybasedonthosestudies.DespitetheuncertaintyofMBIspossibleeffectsonpainintensitythereismoreofconsensus regarding the effects on psychological and secondary outcomemeasures.MBIs increasepainacceptanceandtolerance(Chiesa&Serretti,2011)andalsoappeartohavepositiveeffectsonpsychological featuresrelatedtopainsuch as decreased levels of depressive symptoms and increased levels of lifequality(Chiesa&Serretti,2011;Veehofetal.,2011).AlthoughChiesaandSerretti(2011)didnotfindthatMBIsnecessarilyweremoreefficientintreatingpainthaneducationorothertypesofcontrols,theystillproposedawayofwhichtheeffectsof mindfulness on pain can be understood. In accordance to the operationaldefinitionofmindfulness,ChiesaandSerrettihypothesized thatMBIsaltershowpsychologicalprocessesandcontentsareexperiencedratherthanalteringthepainitself. Veehof et al. (2011) also questioned whether pain intensity is a validoutcome measure for patients with chronic pain since MBIs do not intend tochangethepainitselfbutratherpromoteacceptanceofpain.Reineretal.(2013)who concluded that MBIs can reduce pain intensity also hypothesized that the

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reduction in pain intensity could be an effect of reduced pain avoidance andincreasedengagementinvaluableactivities.Whether the effect is on the pain itself or via secondary measures such asincreasedqualityof lifeorreducedpainavoidance,mindfulnessseems tohaveapositiveeffectontheexperienceofpain.Astudyexaminingmoreacutepainfounddecreases in pain and anxiety ratings when exposed to experimentally inducedpain after only three days ofmindfulness training (Zeidan, Gordon,Merchant &Goolkasian, 2010). Liu,Wang, Chang, Chen, and Si (2013) also found significantpositiveeffectsofbriefmindfulnesstrainingonpaintoleranceanddistresswhenexposedtoexperimentallyinducedpain.Immediateeffectsofasinglemindfulnessexerciseonchronicpainhavealsobeenobservedinaclinicsetting(Ussheretal.,2012).Studies on brief onlinemindfulness training programs indicate thatmindfulnessprogramscanbesuccessfullyadministeredonline(Cavanaghetal.2013;Glück&Maercker,2011).Onlinemindfulness trainingprogramsareeasilyaccessibleandcouldbeapowerfulcomplementtopaintreatmentandrehabilitationprogramsasit is a cost‐effective means of adding to, or administrating a mindfulnesscomponentinthetreatment.To our knowledge, there are noprevious studies on onlinemindfulness trainingprograms for chronic pain. A study on mindfulness for chronic pain taught viavideoconference showed positive results in parity to face‐to‐face training(Gardner‐Nix,Backman,Barbati&Grummitt,2008)butwasmoreinteractivethanthe program used in the present study as it included personal contact with aninstructor.Tworecentstudies(Krusche,Cyhlarova&Williams,2013;Morledgeetal., 2013) have investigated the feasibility and effects of longer mindfulnessprogramswithoutpersonalcontactandfoundpromisingeffectsbutnoneoftheminvestigatedprogramsdirectedtowardspain. Thepresent study servedasapilot‐studyonanonlinemindfulnessprogram forchronicpain.Theoverallpurposewastoexaminewhetheranonlinemindfulnesstraining program reduced the experience of pain in individuals suffering fromchronicpain.Morespecifically,wesetout to investigatewhether thisweb‐basedmindfulness program has an effect on experience of pain, quality of life andacceptance of pain. To this end a randomized controlled design with an activecontrol group with access to an online discussion forumwas adopted, a designthat, as noted, seldom has been used in past research on MBIs, despite itsadvantagesinregardtocontrolofpotentialconfoundingfactors.

Method

ParticipantsTheparticipantswere recruitedonline aswell as in primary care settings and apainclinic.262agreedtoaconsentformandfilledoutthefirstroundofquestions.

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Inclusionandexclusioncriteria Tobe includedinthepresentstudyparticipantshadtobeover18yearsoldandsufferfrompainatanintensityoffouroutoftenthathadpersistedforatleastsixmonths.ParticipantswereexcludediftheyscoredoversixoreightonAUDIToriftheirDUDITscoreindicatedanyillicitdruguse.AsshowninFigure1,participantswerealsoexcludedonthebasisoftheirHADSresults.Cut‐offscoresof10forthedepressionsubscaleand16fortheanxietysubscalewereused.As shown in Figure 1 the present study finally included 107 participants. 93%(n=100)were female and the average agewas 51 years. 48% (n=51)were on asick‐leave due to their pain, and the mean length of absence from work was 8years.Thelargestpart(36%,n=39)oftheparticipantsreportedthatthemainlocationofpain varies. Other responses were divided fairly equally amongst specific bodyparts. 46% of the participants reported at least some previous experience ofmindfulness.

Figure1.Flowchartofparticipants:exclusionanddecidednottoparticipate.

Completed the screening (n=262)

Excluded before pre-intervention

measurements (total n=94)

High levels of anxiety or depression (n=44)

Potentially hazardous alcohol- or drug use (n=31)

Low pain intensity (n=14) Incomplete data (n=3) Duration of pain < six months (n=2)

Decided not to participate (n=61)

Completed the pre-interventionmeasurement and were randomized to

the mindfulness program or the

discussion forum (n=107)

Mindfulness program (n=52)

Completed the program and the post-measurement (n=21)

Waiting list (n=55)

Completed the post-measurement (n=40)

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MaterialAlcoholUseDisordersIdentificationTest(AUDIT)

AUDITisaten‐questionquestionnaireusedasascreeningmeasureforhazardousalcohol use (Fiellin, Reid & O’Connor, 2000) and alcohol dependence (Hulse,Saunders,Roydhouse,Stockwell,andBasso,2000).TheSwedishversionofAUDIThasbeenshowntohavegoodspecificityandsensitivityformeasuringhigh‐volumedrinking and dependencewhenusing a cutoff score at 8 (Selin, 2006). The bestspecificity and sensitivity regarding heavy‐drinking among middle‐aged womenarereachedwhenusingacutoffscoreat6(Aalto,Tuunanen,Sillanaukee&Seppa,2006).Hence,thecut‐offscoresusedinthepresentstudywere8formenand6forwomen. AUDIT has shownmoderate concurrent validity to the alcohol problemseverity domain of the Addiction Severity Index (ASI‐6) and an internalconsistency (Cronbach’s alpha) at .89 (Durbeej, Berman, Gumpert, Palmstierna,Kristiansson&Alm,2010).

DrugUseDisordersIdentificationTest(DUDIT)DUDITmeasuresdruguseandconsequencesofthatuseoverthepastyear(Voluse,Gioia,Sobell,Dum,Sobell,&Simco,2012).TheSwedishversionofDUDIThasbeenfound to have an internal consistency (Cronbach’s alpha) at .94. The instrumenthasfurthermorebeendemonstratedtohavegoodconcurrentvalidityasreflectedby a substantial relationship the drug problem severity domain of the ASI‐6(Durbeejetal.,2010). For the purpose of this study the DUDIT was primarily used as a measure forcurrentdruguse.Participantswhoexhibitedcurrentdrugusewereexcludedfromthestudy.Theparticipantswereallowedtoscoreabove0ontwoquestionswhichmeasureddrug‐relatedsocial consequencesduring the lastyear, if theyscored0ontheotheritemsregardingcurrentdruguse.

HospitalAnxietyandDepressionScale(HADS)Both of the anxiety and the depression subscale in the Swedish version of theHADShave exhibitedadequate internal consistency,withCronbach’s alpha= .84forHAD‐A,α=.82forHAD‐D(Lisspers,Nygren,&Söderman,1997). Thecut‐offscoresforthisstudyweredifferentforthedepressionsubscaleandtheanxiety subscale. For the depression subscale a cutoff score at 10 was used tocaptureparticipantswithevenmildcasesoffdepression.Fortheanxietysubscaleacutoffscoreat16wasusedtoonlyincludethosewithsevereanxiety.Thecutoffscore for thesepurposes is recommendedby thedevelopers (Snaith&Zigmond,1994 inCrawford,Crombie&Taylor, 2001).Whenadministeredon the Internetthe HADS has shown to provide meaningful and valid data (Andersson, Kaldo‐Sandström,Ström&Strömgren,2003).

ChronicPainAcceptancequestionnaire(CPAQ)CPAQisaninstrumentmeasuringacceptanceinrelationtoperceivedpain.Ithasbeen used in several studies on mindfulness and pain (e.g. McCracken & Zhao‐O’Brien,2010;Cusens,Duggan,Thorne&Burch,2010).Its20itemsaredividedintotwosubscales:activitiesengagementandpainwillingness(Vowles,McCracken,

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McLeod & Eccleston, 2008). Higher scores indicate higher levels of pain relatedacceptance,withpossiblescoresrangingfrom0to120.Thepossiblescoreonthesubscaleactivitiesengagementrangesfrom0to66andthescoreonthesubscalepainwillingnessrangesfrom0to54.CPAQ is regarded as a valid instrument for measuring pain related acceptance(McCracken, 2004), even when administered online (Fish, McGuire, Hogan,Morrison, & Stewart, 2010). The Swedish version of the instrument has showngood psychometric properties with regard to internal consistency with aCronbach’salphareaching.91(Wicksell,Olsson&Melin,2009).

BriefscreeningversionoftheMultiplePainInventoryThe brief screening version of the multiple pain inventory is a screeninginstrumentforchronicpainwhichconsistsofeightquestionsfromthefirstsectionof theSwedishversionof themultiplepain inventory(MPI‐S) (Jakobsson,2009).The original version of the MPI was designed to measure pain from amultidimensional perspective, considering not only pain severity but also otherfactors such as affective distress and support from others (Turk, 2005). EventhoughthebriefscreeningversionoftheMPI‐Sdoesnotincludeasmanyaspectsof pain as the full version, it still provides more information regarding theexperienceofpainthanunidimensionalmeasuresandcanbeconsideredabetteroption when measuring pain. The brief screening version is comprised of foursubscales: pain severity, interference, life control and affective distress. In thisstudy the scoring method used calculates the mean score of each subscale assuggestedbyJakobsson,2009.Scorescanrangefrom0to6 ,wherehigherscoreindicatehigherimpactoftheaspectsthatthesubscaleissupposedtomeasure.WithCronbach’salpharangingfrom.68to.93forthedifferentscales,theSwedishbrief screening version of the instrument has been found to show acceptablereliability and validity in all age groups, except for the oldest old. A standardscoringmethodfortheinstrumentdoesnotexistanditcanonlydetectcaseswithseveredysfunction(Jakobsson,2009).

NumericalRatingScale(NRS)Twonumericalratingscalesareusedinthepresentstudy.Onewhereparticipantsareaskedtoratetheiraverageamountofpainduringthepastweekandanotherinwhichparticipantsareaskedtoratetheamountofsufferingtheirpainhadcausedthemduringthepastweek.Thescalesrangefrom0to10,where0indicates"nopain/distress"and10"pain/distressasbadasitcouldbe".

FiveFacetMindfulnessQuestionnaire(FFMQ)TheFFMQprovidesamultifacetedwayofmeasuringthetendencytobemindfulindaily life (Christopher, Neuser, Michael & Baitmangalkar, 2012). MeasuringmindfulnessasamultifacetedconstructisrecommendedbyBaer,Smith,Hopkins,KrietemeyerandToney(2006)sinceitcanprovideinsightintothecomponentsofmindfulness and its relationships with other variables. The five subscales are:observing,describing,actingwithawareness,nonreactivityandnonjudging(Baeret al., 2006). Possible scores on the full scale on FFMQ ranges from 29 to 145,

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wherehigherscores indicatehighermindfulness levels.Allof thesubscaleshavebeen found to show acceptable validity and reliability (Christopher et al., 2012)andthisappliestotheSwedishversionoftheinstrumentaswellwithCronbach’salphaof.81(Liljaetal.,2011).

LifeSatisfation(LiSat‐11)Lifesatisfactionwasmeasuredbythelifesatisfactionchecklist(LiSat‐11).LiSat‐11is an 11 item questionnaire measuring global‐ as well as domain‐specific lifesatisfaction. The score is receivedby calculating themean value of the answers,with possible scores ranging from 1 to 6. Higher scores indicate higher lifesatisfaction. It has been found to show acceptable construct validity as well asinternal reliabilitywith aCronbach’s alpha at .82 (Silvemark,Källmén,Portala&Molander,2008). Themindfulnessprogram The mindfulness program “Mindfulness ‐ living with pain” is a program thatintendstohelppeoplewithchronicpaintofindnewwaysofdealingwiththepainand has a strong emphasis on acceptance of pain. The program was originallydevelopedVidyamalaBurchandBreathworksandwasthenadaptedtoanonlineSwedishversionbyMindfulnesscenterAB(Breathworks,2013).Theprograminitsoriginalformhasbeenevaluatedshowingpositivechangesonseveralpain‐relatedhealth problems such as pain catastrophizing and pain acceptance even thoughpain intensity ratings remained the same even after completing the program(Cusens,Duggan, Thorne&Burch, 2010). Themain components in the programaremindfulnessexercises,whichtheparticipantsaretoperformtwicedaily.Thedurationofeachexerciseisabouttenminutesandtheexercisesfolloweightsteps,oneforeachweekoftheprogram. The steps were labeled: 1) The breathing body, 2) Dwelling in the body, 3)Mindfulness of moving and living, 4) Acceptance and self‐compassion, 5) Thetreasureofpleasure,6)Beingwhole,7)Turningoutwards‐compassionforothers,and 8) The journey continues ‐ living with choice. Each step includes a fewexercisesspecifictothatstepeventhoughsomeexercisesarerepeatedinseveralsteps(Breathworks,2013). Thediscussionforum Theparticipantsinthecontrolgroupwereprovidedananonymousandmonitoredonlinediscussionforum.Eachweekanewdiscussiontopicwasintroducedbytheauthorsandthediscussionswerethenheldamongsttheparticipantswithoutanyinputfromtheauthors.Thediscussiontopicswerenotrelatedtomindfulnessanddidnothaveatherapeuticcharacter.Thetopicsincludedwereforexample:“Howis chronic pain presented in themedia?”, “Is it helpful tomeet other individualswithchronicpain?”and“Whatexperiencedoyouhaveofthehealthcaresystem?”.Before entering the discussion forum the participants were asked to readinformation regarding anonymity in the forum. They were also informed of apreviousstudyofLorigetal.(2002)whofoundpositiveeffectsonpain,disability,role function, and health distress in subjects with chronic back pain afterparticipationinaninternet‐baseddiscussion.42participantscreatedauserforthe

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discussion forumwhich enabled them to participate as well as take part in thediscussions. 27 users posted commentswhile the remaining 15 participants didnot post comments but could havebeen active as readers. Therewasnowayofcontrolling for their activity in the forum. Therefore the discussion forum wasdefinedasapartlyactivecontrolcondition.DesignThe design of the present study was a between groups, randomized controlledtrial.ProcedureParticipantswereinformedofthestudyandwereaskedtofilloutaconsentformviaawebpage.TheycompletedascreeningprocedureinvolvingadministrationofHospital Anxiety and Depression Scale (HADS), Alcohol Use DisordersIdentification Test (AUDIT), Drug Use Disorders Identification Test (DUDIT),togetherwithquestions concerningdemographicsandquestions concernedwithpain. Participants who met the inclusion criteria were sent pre‐interventionquestionnaires a week before the program started. The questionnaires that theparticipantsweretoanswerwereChronicPainAcceptanceQuestionnaire(CPAQ),brief screening version of the Multiple Pain Inventory (MPI), Five FacetMindfulnessQuestionnaire(FFMQ)andLifeSatisfactionQuestionnaire‐11(LiSat‐11).ThesequestionnaireswerecomplementedbyanNumericRatingScale(NRS)regarding the distress caused by their current pain and questions about theirexperienceofmindfulness.Theywerealsoaskedto filloutanNRSregardingthecurrentseverityoftheirpainthedaybeforetheprogramstarted. After submitting the final NRS the participants were randomly assigned to acontrol‐ and a intervention group. The randomization was conducted using anonline randomizer (www.randomizer.org). Next, the participants receivedinformation on whether they were to begin by participating in the discussionforum or the mindfulness program. On the fourth week of the program,encouraginge‐mailsweresenttotheparticipantsintheexperimentalgroup. Program completion was defined as having completed at least six weeks of themindfulness program. 21 individuals completed the program. Of the remainingparticipants, 13 were on the first step of the program while the other 15participantsweredividedamongstthefivestepsinbetweenthefirstandthefinaltwo. Once the mindfulness program was completed, participants in both groupsreceived post‐intervention questionnaires. The participants in the control groupwere given access to the mindfulness program when they completed the post‐interventionquestionnaires. EthicalconsiderationsThe intervention was defined as a pedagogic program which is equated withreadingaself‐helpbook.Hence, themindfulnessprogramwasnotconsideredastreatment,thuseliminatingtheneedforrecordkeepinginaccordancetoSwedish

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regulations. To identify the participants their e‐mail addresseswere used. As e‐mail addresses are unique but not necessarily coupled with personal data orinformationtheywereusedas identifying informationthroughoutthestudy.Theparticipantswereaskedtofillinaconsentformwithinformationaboutthestudybeforethestudybegan.Byagreeingtotheconsentformtheparticipantsvalidatedthattheyhadreadandagreedtotheinformationandconditionsofthestudy.Theconsent form included information regarding confidentiality of the results andmadeitclearthatallparticipationwasvoluntary.

Results

Thefirstanalysesaddressedpotentialeffectsassociatedwithattrition,ordrop‐out.Next,analysesofvariance(ANOVAs)wereconductedtocomparethemean–levels(pre‐ vs. post‐intervention) on the following variables: mindfulness level, painintensityandpainexperience,acceptanceofpain,distresscausedbypainandlifesatisfaction.Effectsizesforallthesignificantresultswerecalculatedusingpartialeta square ( 2

p ). Within group effect sizes for the intervention group were

calculatedusingCohen’sd.Cohen (1992)defineda smalleffect sizeasd>0.2, amediumeffectsizeasd>0.5andalargeasd>0.8. Drop‐outanalysisAnalysesofthedrop‐outwasconductedbyt‐tests(forindependentgroups)onthefollowingvariables:age,levelofmindfulness,painintensity,sick‐leaveduetopain,potentialpaindiagnosis,potentialmedicationforpain,durationofpainandqualityof life.No significant differences between theparticipantswhodroppedout andthe returnees were observed. Thus, the two groups may be regarded ascomparableattimeofentryinthestudy. Toanalyze thedata2 x2mixedANOVAswere conducted.More specifically, thegroup factor (intervention vs. control) was a between‐subjects factor and timevariedwithinsubjects(repeatedmeasures). MindfulnesslevelsTocomparemindfulnesslevelsbetweentheinterventiongroupandcontrolgroupthetotalscoreonFFMQwasusedasdependentvariable.Figure2showsmeansoftheFFMQinthetwogroupsandaswecanseethemeansreveal littlechangeforthe control group but a substantial mean increment for the intervention group.The ANOVA results substantiated this impression by showing a significantmaineffectoftimeF(1,59)=7.90,MSE=198.44,p<.05, 2

p =.12reflectingthefactthat

thetotalscoreonFFMQwashigheronthesecondtimeofmeasurement.ThemaineffectofgroupwasontheotherhandnotsignificantF(1,59)=3.49,MSE=187.22,p>.05.Mostcritical,theinteractioneffectwashighlysignificantF(1,59)=12.05,p< .001, 2

p = .17. The intervention group exhibited higher levels of mindfulness

than the control group after having completed the mindfulness program. Theintervention group exhibited significantly higher end results than the control

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groupwhichdid not significantly differ between the two times ofmeasurement.Theeffectsizewithintheinterventiongroupwaslargeandcalculatedtod=1.53.

Figure2.PreandpostmeasurementmeansontheFFMQfortheinterventionandcontrolgroup.FFMQwasnextanalyzedatthesubscalelevel.TheresultsoftheANOVAsonthesesubscalesweresimilartotheresultofthetotalscoreonFFMQ,suggestingthatnospecificsubscaleisresponsiblefortheresultontheANOVAofthetotalscore. PainmeasurementsFor comparison on pain intensity ratings, the scores on NRS were used as adependentvariable.ThemaineffectoftimewassignificantF(1,59)=10.80,MSE=1.76, p < .05, 2

p = .13, reflecting a lower score on pain in the second time of

measurement.As for themaineffectofgroup theresult showednodifference inscoredpainintensitybetweenthegroupsF(1,59)=2.08,MSE=5.40,p>.05.Theinteraction effect of time and group on the NRS score exhibited no significantdifferenceF(1,59)=3.25,p>.05.Eventhoughchangesinpainintensitymeasuredwith an NRS did not reach significance a tendency towards less pain for theinterventiongroupwasevident. Asanalternativemeasureof theexperienceofpain, thesubscalesofMPI‐Sbriefscreening version were used. Pain intensity was measured by using the painseveritysubscaleasthedependentvariable.MeansarepresentedinFigure3.TheANOVArevealedsignificantmaineffectsontimeF(1,59)=7.53,MSE=0.26,p<.01, 2

p = .11, indicating that the scores were lower at the second time of

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measurement.NosignificantmaineffectofgroupwasobservedF (1,59)=2.98,MSE = 0.80,p >.05. The results of the interaction effect of group and timeweresignificantF (1,59)=5.57,p < .05, 2

p = .09which implies that themindfulness

programhasaneffectonpainintensitywhenmeasuredwithMPI‐Sbriefscreeningversion.Theeffectsizewithintheinterventiongroupwasmeasuredtoamediumlevel(d=0.59).

Figure3.PreandpostmeasurementmeansfortheinterventionandcontrolgrouponthepainseveritysubscaleoftheMPI. TocomparethegroupsonthesecondsubscaleinthebriefscreeningversionoftheMPI‐Stheinterferencesubscalewasusedasdependentvariable.MeansareshowninFigure4.AsignificantmaineffectoftimewasobservedF(1,59)=18.86,MSE=0.80, p < .001, 2

p = .24, as the scores were lower on the second time of

measurementcomparedtothefirst.TherewasnomaineffectofgroupF(1,59)=2.46,MSE=3.99,p>.05butwhentimeandgroupinteractsitrevealsasignificantinteractioneffectF(1,59)=8.67,p<.01, 2

p =.13.Theinterventiongroupscored

significantlyloweroninterferenceonthesecondtimeofmeasurementwhiletherewas no significant difference between the two times of measurements in thecontrolgroup.Theeffectsizewithintheinterventiongroupwaslarge(d=0.74).

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Figure4.PreandpostmeasurementmeansfortheinterventionandcontrolgroupontheinterferencesubscaleoftheMPI.Theperceivedlifecontrolinrelationtopainwasmeasuredwiththethirdsubscaleof the brief screening version of the MPI‐S. The subscale was used as thedependentvariableinthisANOVA,whereamaineffectoftimewasobservedF(1,59)=9.61,MSE=0.98,p< .01 2

p = .14.At thesecondtimeofmeasurementthe

perceived life controlwashigher.Therewasnomaineffect of groupF (1, 59)=3.28,MSE=2.48,p>.05.NosignificantinteractioneffectappearedF(1,59)=2.48,p > .05 meaning that the difference between the scores at the second time ofmeasurement in the interventiongroupand control groupwasnot significant inrelationtothescoresatthefirsttimeofmeasurement. Tocompareexperiencesofaffectivedistressinregardtopainthefourthandlastsubscale in MPI‐S brief screening version was used as dependent variable. InFigure5themeanscanbeviewed.AsignificantmaineffectoftimeF(1,59)=8.26,MSE=0,93,p< .01, 2

p = .12was revealed, thescoreswere lowerat thesecond

timeofmeasurement.NosignificantmaineffectofgroupwasobservedF(1,59)=3.63,MSE=2.46,p>.05.Theinteractioneffect,ontheotherhand,wassignificantF(1,59)=9.48,p<.01, 2

p =.14.Theinterventiongroupdecreasedsignificantlyin

measuredaffectdistressfromthefirsttothesecondtimeofmeasurementbutnosuch difference could be observed in the control group. The effect size for theinterventiongroupwascalculatedtod=0.82,alargeeffectsize.

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Figure5.PreandpostmeasurementmeansfortheinterventionandcontrolgroupontheaffectivedistresssubscaleoftheMPI. AcceptanceofpainCPAQmeasures acceptance of pain and can be divided into two subscales: painwillingness and activities engagement. For comparison of painwillingness, thissubscalewasusedasadependentvariable.Asignificantmaineffectontimewasrevealed,F (1, 59) = 21.43,MSE = 14.46,p < .001, 2

p = .27. indicating that the

participants rated their pain willingness higher at the second time ofmeasurement.TherewasnosignificantmaineffectofgroupF(1,59)=0.53,MSE=14.46,p>.05.TheinteractioneffectwasnotsignificanteitherF(1,59)=1.83,p>.05.Comparisons of activities engagement, used this subscale as the dependentvariable.Means are presented in Figure 6. A significantmain effect of timewasobservedF(1,59)=17.01,MSE=20.14,p<.001, 2

p =.22,butnotofgroupF(1,

59)=1.20,MSE=157.31,p>.05,indicatingthatthatthemeanscorewashigheratthesecondtimeofmeasurement.TheinteractioneffectwassignificantF(1,59)=7.73,p < .01, 2

p = .03. Thismeans that the intervention group exhibited higher

levels of activities engagement after the intervention when compared to thecontrolgroup.Theeffectsizewithintheinterventiongroupwasatamediumlevel(d=0.62).

15

Figure6.PreandpostmeasurementmeansfortheinterventionandcontrolgroupontheactivitiesengagementsubscaleoftheCPAQ. For comparisons on total score of CPAQ, this was set as a dependent variable.MeansarepresentedinFigure7.TheANOVArevealedasignificantmaineffectoftimeF(1,59)=29.26,MSE=44.57,p<.001, 2

p =.33meaningthattheacceptance

levelswerehigheron the second timeofmeasurement.Nomain effect of groupwasobservedF(1,59)=1.12,MSE=359.13,p>.05.WhenthevariablestimeandgroupinteractsasignificantinteractioneffectisrevealedF(1,59)=6.95,p<.05,

2p =.11,thissuggeststhattheinterventiongrouphadincreasedtheirscorefrom

thefirstmeasurementtothesecondmeasurementwhencomparedtothecontrolgroup.Theeffectsizefortheinterventiongroupwasatamediumlevel(d=0.71).

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Figure7.PreandpostmeasurementmeansfortheinterventionandcontrolgrouponthetotalCPAQscores.DistresscausedbypainToevaluatewhetherthemindfulnessprogramdecreasedthedistressthatfollowsthepain anANOVAwithanNRS fordistressasdependentvariablewas created.ThemeansareexhibitedinFigure8.TheresultshowedsignificantmaineffectsofbothtimeF (1,59)=22.29,MSE=2.31,p< .001, 2

p = .27andgroupF (1,59)=

5.83,MSE=6.22,p<.05, 2p =.09.Therateddistresswasloweratthesecondtime

ofmeasurementandintheinterventiongroupcomparedtothecontrolgroup.TheinteractioneffectoftimeandgroupwassignificantF(1,59)=11.15,p<.001, 2

p =

.16. After completing themindfulness program the intervention group exhibitedsignificantly loweredscoresofsufferingwhiletherewasnosignificantdifferenceamongthecontrolgroupbetweenthetwotimesofmeasurement.Theeffectsizewithintheinterventiongroupwasd=1.32,whichisconsideredalargeeffectsize.

17

Figure8.PreandpostmeasurementmeansfortheinterventionandcontrolgroupontheNRSmeasuringdistresscausedbypain. LifeSatisfactionForcomparisononlifesatisfactionLiSat‐11wasusedasadependentvariable.ThemeanscoresdifferencesareshowninFigure9and indicateequivalentratingsatthe firstmeasurementbetween the twogroupsbutappear tobemuchhigher inthe interventiongroupatthesecondtimeofmeasurement.Thisobservationwasconfirmed by using an ANOVAwhich revealed amain effect of time F (1, 59) =12.01,MSE=0.13,p<.001, 2

p =.17thescoreswerehigheratthesecondtimeof

measurement.NomaineffectofgroupwasobservedF(1,59)=0.71,MSE=0.93,p>.05.TheinteractioneffectoftimeandgroupwassignificantF(1,59)=4.53,p<.05, 2

p = .07 which means that the increase in the ratings on LiSat‐11 in the

intervention group between the first and second time of measurement wassignificantandsignificantlylargerthanthechangeinratingsinthecontrolgroup.Theeffectsizefortheinterventiongroupwasatamediumlevelatd=0.55.

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Figure9.PreandpostmeasurementmeansfortheinterventionandcontrolgroupontheLiSat‐11.

Discussion

Thepurposeofthisstudywastoexaminewhetheranonlinemindfulnesstrainingprogramcouldservetoreducetheexperienceofpaininindividualssufferingfromchronic pain. After completing the program the participants showed decreasedpain intensity and reduced levels of interference of pain in their everyday lives.They also exhibited less affectivedistress aswell as greater acceptanceof and adecreased level of distress caused by pain. Furthermore, their quality of lifeimproved and as expected, they showed increased levels of mindfulness. Bycontrast, the control group did not exhibit higher levels of mindfulness whichindicatethattheimprovementsintheinterventiongroupwereinfactderivedfromthe mindfulness training. Thus, the mindfulness training program wasdemonstrated to be effective both in regard to reduction of the pain‐relatedexperiences and to improve aspects of life that could be negatively affected bypain. Thedecreasesinpainwerenotcompletelyunanimous,though.Whenmeasuredbyasingleitemaskingforanaverageofpainduringthepastweektheresultdidnotshow significantly lower levels of pain intensity in the intervention group eventhoughastrongtendency(p=0.77)towardsreducedpainwasfound.Inpreviousresearch there is no agreement regarding the effect mindfulness has on painintensity.IntheirreviewReineretal.(2013)foundthatmindfulnesshasaneffectonpainintensitywhileChiesaandSerretti(2011)wereunabletoconfirmthisin

19

their review. The reviews differed inwhat kind of painmeasures they included.Chiesa and Serretti as well as Veehof et al. used both multidimensional andunidimensionalmeasuresofpainwhileReineretal.onlyreviewedstudiesthathadusedunidimensionalmeasuresofpain. WhenmeasuredbythepainseveritysubscaleofthebriefscreeningversionoftheMPI‐Sasignificantdecreaseinpainintensityatamediumeffectsizewasrevealed.Thesubscaleconsistsofacompositeoftwoquestions,oneregardingaveragepainduring the last week and one regarding current pain. We hypothesize that theinclusionofanitemregardingcurrentpaincouldberelatedtothelowerresultsonthe pain ratings compared to the unidimensional NRS. The emphasis on thepresentmoment that is central inmindfulness could be an important aspect toconsider when understanding this result. An active component in mindfulnesstrainingforchronicpainaccordingtoReineretal.(2013)couldbedetachmentofcognitiveandemotionalpaincomponents(Reineretal.,2013).Theexperienceofpaininthepresentmomentwouldthennotbeaggravatedbythoughtsandfeelingsaboutit.The other subscales in the brief screening version of MPI‐S measures otherimportant aspects of chronicpain, such as its effect on everyday life (Jakobsson,2009). The scores on the two subscales affective distress and interferenceimproved significantly in the intervention group compared to the control groupindicatingthatthemindfulnessprogramhasapositiveeffectontheexperienceofpain.Nosignificantimprovementsinthesubscalelifecontrolwerefound.The lack of significant improvement on the single item regarding average painduringthepastweekgoesinlinewiththeresultsofCusens,Duggan,ThorneandBurch(2010)whoalsofailedtofindasignificantdecreaseinpainintensityratings.TheyhypothesizedthatthiscouldberelatedtotheBreathworks’programasithasanemphasisonacceptanceandabsenceofexplicitattempts todecreasepain.Asthe mindfulness program used in the present study is an adaptation of theBreathworks’programthesameexplanationcouldapplyhereaswell.Veehofetal.(2011)concludedthatininterventionsforchronicpainthepain,duetoitschronicnature,isunlikelytodecreasemuch. Therefore,otheraspectsthanpain intensityarealsorelevantwhenassessingtheexperienceof chronicpain.Acceptanceof chronicpainhasbeen associatedwithseveralhealthbenefitssuchaslessdisabilityandbetterworkstatus(McCracken&Eccleston,2003).Afterprogramcompletion,acceptanceofpainincreasedfortheparticipants in the intervention group. As the mindfulness program largely isdirected towards increasing acceptance of pain through mindfulness this is notsurprising. After completing the program participants showed increases in bothoverallacceptanceandactivitiesengagement. Increased engagement in activities can be valuable for individuals with chronicpainastheconditionoftenisassociatedwithwithdrawal frompreviouslyvaluedactivities (Vlaeyen & Linton, 2012). McCracken, Vowles and Eccleston (2004)suggestthatanimportantcomponentofacceptanceofchronicpainisengagement

20

inpositive everyday activities evenwhenexperiencingpain.Thus, acceptanceofchronicpainisnotonlylimitedtomentalprocesses.Anothercomponentofchronicpainacceptanceistherealizationthatavoidanceof,orattemptstocontrolpainareineffective ways of coping as they do not decrease pain (McCracken, Vowles &Eccleston, 2004). The participants in the present study did not show significantchange in painwillingness though. Both intervention and control group reachedsignificantly highermeans in the postmeasurements but the interaction effectswerenotsignificant.However,themeanscoresderivedfromthepainwillingnesssubscale are relatively high in both pre andpostmeasurement compared to thereportedmeansinpreviousstudies(e.g.Vowles,McCracken,McLeod&Eccleston,2008),constitutingforanevenresultwhenconsideredinrelationtotheactivitiesengagementsubscale. Aftercompletingthemindfulnessprogramtheparticipantsexhibitedsignificantlyreducedlevelsofdistresscausedbypain.Thisisanimportantfindingasdecreasesin distress due to pain can be viewed as an indicator of the impact of themindfulness training on the individuals’ everyday lives.Basedon the findings inthe present studywe hypothesize that decreases in distress due to pain can berelatedtoincreasedqualityof life, thusaffectingtheoverallexperienceof lifeforthe individual. The reduction in distress could also be related to the increase inacceptance of pain that the participants exhibited in the present study. AsproposedbyMcCrackenandO’Brien(2009),peoplewithchronicpainmight feelless distress when they are able to experience unpleasant sensations withoutattemptingtocontrolthem.Mindfulnesstrainingcouldleadtosuchanattitudeasitiseducatinganonjudgmentalandacceptingpositiontowardspain. As chronic pain is associatedwith decreased quality of life (Breivik et al., 2006;Lamé,Peters,Vlaeyen,Kleef&Patijn,2005) it isan importantaspect toconsiderwhen evaluating an intervention for chronic pain. In the present study, theinterventiongroupincreasedtheirlifesatisfactioncomparedtothecontrolgroup.Thisisinaccordancewithpreviousresearch(Chiesa&Serretti,2011).TheeffectsizewasatamediumlevelwhichisthesameasVeehofetal.(2011)foundintheirmeta‐analysis. Theuseofadiscussionforumforthecontrolconditioncanbeconsideredasaformofactivecontrolgroup,whichispreferabletoasimplewaiting‐listcondition(Boot,Simons,Stothart&Stutts,2013).Itisalsoneededinresearchonmindfulnessandchronic pain (Reiner et al., 2013). The participants in the control group wereinformed that a previous study (Lorig et al., 2002) had shown that a discussionforumcanhaveapositiveeffectontheexperienceofpain,thusgivingthemsomeexpectationofpositiveeffects.Providing thecontrolgroupwith informationthatmight increase their expectations to benefit from the control condition isrecommended by Boot, Simons, Stothart and Stutts (2013) as it is considered awayofremovingpotentialplaceboeffects.Wedidnotmeasureexpectationsinthepresent study however, thus making it difficult to clearly state that the controlgrouphadequalexpectationsastheinterventiongroup.

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Some limitations of the current study should be noted. Many participants hadprevious mindfulness experience which may have affected the results. If theparticipants alreadyweremindful before participating in the present study theycouldalreadyexhibithighlevelsoftheskillsthataretrainedinmindfulness.Thus,generalizability of the findings needs to be further investigated in pain groupswithoutpreviousmindfulnessexperience.However,theconstitutionofthesamplealsohassomestrength,sinceitdoesnotonlyconsistofchronicpainpatientstheresults are not limited to this group. This is lacking in some previous studiesaccording to Reiner et al. (2013). Turk and Okifuji (2002) also point out theimportanceofinvestigatingtreatmentsforchronicpainonindividualsthatdonotseekhelpsincetreatmenteffectmaynotbethesameintheseindividuals.As we excluded participants with high levels of depression which is a commoncomorbiddiagnosistochronicpainthegeneralizabilityofthepresentstudycouldbecompromised.However, even thoughmindfulness isconsideredanapplicablemethod of preventing depression it has been considered less useful in patientswith current depression as they might exhibit cognitive deficits due to theirdepressive state making it difficult to acquire the skills taught through training(Segal, Williams & Teasdale, 2002). The participants’ ability to complete theprogram can also be negatively affected by a depressive state. More recentresearchhasfoundpositiveeffectsondepressionaftermindfulnesstrainingonline(Krusche,Cyhlarova&Williams,2013),butthisisnotyetsufficientlyresearched. Thedropoutratesinthisstudywerehigh(60%),duetowhichsomecautionwheninterpreting the results is needed. Thehighdropout rates impliesdifficulties incompletingtheprogramfortheparticipants.LargedropoutratesarecommoninInternet‐based studies in which none or little personal contact is included(Melville,Casey&Kavanagh,2010).Wehypothesizethatmoreparticipantswouldhavecompletedtheprogramifsomeformofpersonalsupportorcontacthadbeenprovidedoriftheparticipantshadbeenabletoparticipateinadiscussionforumrelatedtopainandmindfulnessduringtheintervention.Itcanbenotedthat71%of the 21 participants who completed the program reported no previousmindfulnessexperience.Thereforeitcanbeassumedthat,inordertocompletethemindfulnessprogram,nopreviousexperienceofmindfulness isneeded.The factthat 93%of the participantswere female is noteworthy even thoughwe do notbelievethatthisaffectedtheresultsinanyparticularway.Aplausible explanation to the largedropout in the intervention group couldbethat theparticipantsdidnot experience improvements in the early stagesof theprogramandthereforediscontinuedtheprogram.Ontheotherhand,experiencesofearlyimprovementcouldresultinprematuredropoutastheparticipantsmightnotfeeltheneedtocontinuetheprogram.Furthermore,thelargedropratecouldtosomeextentbeduetotechnicalproblemswiththemindfulnessprogram,which,for a few days, made the participants unable to progress in their mindfulnesstraining.

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Acceptance seems to be an important aspect of the mindfulness program indecreasing pain related suffering. In order to gain further understanding of theconnection between mindfulness and pain, future research should focus oninvestigating whether certain components in mindfulness training, such asacceptance, carries specific importance for reducing pain and pain‐relatedproblems. The goal in acceptance based interventions for chronic pain is not specificallyreducedpainbutratheranewwayofdealingwithpain.Ourresultssupport thenotion that individuals suffering fromchronicpaincanbenefit frommindfulnesstraining.Inconclusion,themindfulnessprogramusedinthepresentstudyseemstobeaneffectivewayof increasing levelsofmindfulnessaswell aspain relatedacceptanceand, to someextent, alsodecreasepain.As themindfulnessprogramwasadministeredonline,withoutanypersonalcontactitisacost‐effectiveoptionor complement to other types of treatments for the disabling disease that ischronicpain.

References

Aalto, M., Tuunanen, M., Sillanaukee, P., & Seppa, K. (2006). Effectiveness of structuredquestionnaires for screening heavy drinking in middle‐aged women. Alcoholism: Clinical andExperimentalResearch,30,1884–1888.Andersson,G.,Kaldo‐Sandström,V., Ström,L.,&Strömgren,T. (2003). Internet administrationofthehospitalanxietyanddepressionscaleinasampleoftinnituspatients.JournalOfPsychosomaticResearch,55,259‐262. Andersson,H.I.(2004).Thecourseofnon‐malignantchronicpain:A12‐yearfollow‐upofacohortfromthegeneralpopulation.EuropeanJournalofPain,8,47‐53. Baer, R. A. (2009). Self‐focused attention and mechanisms of change in mindfulness‐basedtreatment.CognitiveBehaviourTherapy,38,15‐20. Baer,R.A.,Smith,G.T.,Hopkins,J.,Krietemeyer,J.,&Toney,L.(2006).Usingselfreportassessmentmethodstoexplorefacetsofmindfulness.Assessment,13,27‐45. Bergman,S.,Herrström,P., Jacobsson,L.T.&Petersson, I.F. (2002).Chronicwidespreadpain:Athreeyearfollow‐upofpaindistributionandriskfactors.JournalofRheumatology,29,818–25. Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., ... Devins, G. (2004).Mindfulness:Aproposedoperationaldefinition.ClinicalPsychology:ScienceAndPractice,11,230‐241. Boot,W.R.,Simons,D. J.,Stothart,C.,&Stutts,C.(2013).Thepervasiveproblemwithplacebosinpsychology:Whyactivecontrolgroupsarenotsufficienttoruleoutplaceboeffects.PerspectivesOnPsychologicalScience,8,445‐454.Breathworks, online mindfulness for health course (2013). Retrieved December 31 2013 at:http://www.breathworks‐mindfulness.org.uk/online‐courses/mindfulness‐for‐health‐online

23

Breivik,H.,Collett,B.,Ventafridda,V.,Cohen,R.,&Gallacher,D. (2006).Surveyofchronicpain inEurope:Prevalence,impactondailylife,andtreatment.EuropeanJournalofPain,10,287–333. Brown,A.P.,Marquis,A.,&Guiffrida,D.A.(2013).Mindfulness‐basedinterventionsincounseling.JournalOfCounseling&Development,91,96‐104. Brown, K.W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role inpsychologicalwell‐being.JournalOfPersonalityAndSocialPsychology,84,822‐848. Cavanagh, K., Strauss, C., Cicconi, F., Griffiths, N., Wyper, A., & Jones, F. (2013). A randomisedcontrolledtrialofabriefonlinemindfulness‐basedintervention.BehaviourResearchAndTherapy,51,573‐578. Chapman, C. R., & Gavrin, J. (1999). Suffering: The contributions of persistent pain. Lancet, 353,2233‐2237. Chiesa, A., & Serretti, A. (2011). Mindfulness‐based interventions for chronic pain: A systematicreviewoftheevidence.TheJournalofAlternativeandComplementaryMedicine,17,83‐93. Christopher, M. S., Neuser, N. J., Michael, P. G., & Baitmangalkar, A. (2012). Exploring thepsychometricpropertiesoftheFiveFacetMindfulnessQuestionnaire.Mindfulness,3,124‐131. Cusens, B., Duggan, G. B., Thorne, K., & Burch, V. (2010). Evaluation of the Breathworksmindfulness‐basedpainmanagementprogramme:Effectsonwell‐beingandmultiplemeasuresofmindfulness.ClinicalPsychology&Psychotherapy,17,63‐78. Durbeej, N., Berman, A. H., Gumpert, C. H., Palmstierna, T., Kristiansson, M., & Alm, C. (2010).ValidationofthealcoholusedisordersidentificationtestandthedrugusedisordersidentificationtestinaSwedishsampleofsuspectedoffenderswithsignsofmentalhealthproblems:Resultsfromthementaldisorder, substanceabuseandcrimestudy. JournalofSubstanceAbuseTreatment,39,364–377. Eccelston,C.,Morley,S.J.,&Williams,A.C.deC. (2013).Psychologicalapproaches tochronicpainmanagement:Evidenceandchallenges.BritishJournalofAnaesthesia,111,59–63. Fiellin,D.A.,Reid,M.C.,&O’Connor,P.G.(2000).Screeningforalcoholproblemsinprimarycare:Asystematicreview.ArchivesofInternalMedicine,160,1977–1989.Fish,R.A.,McGuire,B.,Hogan,M.,Morrison,T.G.,&Stewart,I.(2010).Validationofthechronicpainacceptance questionnaire (CPAQ) in an Internet sample and development and preliminaryvalidationoftheCPAQ‐8.Pain,149,435‐443.Gardner‐Nix, J.,Backman,S.,Barbati, J.,&Grummitt, J. (2008).Evaluatingdistanceeducationofamindfulness‐basedmeditationprogramme for chronicpainmanagement. JournalOfTelemedicineAndTelecare,14,88‐92.Gerdle,B.,Björk,J.,Henriksson.C.,&BengtssonA.(2004).Prevalenceofcurrentandchronicpainand their influences upon work and healthcare‐seeking: A population study. Journal ofRheumatology,31,1399‐406. Glück, T., & Maercker, A. (2011). A randomized controlled pilot study of a brief web‐basedmindfulnesstraining.BMCPsychiatry,11,175‐186.

24

Hulse,G.K.,Saunders,J.B.,Roydhouse,R.M.,Stockwell,T.R.,&Basso,M.R.(2000).Screeningforhazardousalcoholuse anddependence inpsychiatric in‐patientsusing theAUDITquestionnaire.DrugandAlcoholReview,19,291–298.International Association for the Study of Pain (2013). Retrieved December 31, 2013 at:http://www.iasp‐pain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm Jakobsson,U.(2010).Theepidemiologyofchronicpaininageneralpopulation:ResultsofasurveyinsouthernSweden.ScandinavianJournalofRheumatology,39,421–429. Jakobsson,U.(2009).Psychometrictestingofthebriefscreeningversionofmultidimensionalpaininventory(Swedishversion).ScandinavianJournalOfCaringSciences,23,171‐179.Kabat‐Zinn,J.(1994).Whereveryougo,thereyouare:Mindfulnessmeditationineverydaylife.NewYork:Hyperion.Krusche,A.,Cyhlarova,E.,&Williams,J.(2013).Mindfulnessonline:Anevaluationofthefeasibilityof a web‐based mindfulness course for stress, anxiety and depression. BMJ Open, 3,doi:10.1136/bmjopen‐2013‐003498 Lamé,I.E.,Peters,M.L.,Vlaeyen,J.S.,Kleef,M.v.,&Patijn,J.(2005).Qualityoflifeinchronicpainismoreassociatedwithbeliefsaboutpain,thanwithpainintensity.EuropeanJournalOfPain,9,15‐24. Lilja, J.L.,Frodi‐Lundgren,A.,Hanse, J., Josefsson,T.,Lundh,L.,Sköld,C., ...Broberg,A.G. (2011).Five facets mindfulness questionnaire ‐ Reliability and factor structure: A Swedish version.CognitiveBehaviourTherapy,40,291‐303. Lisspers,J. J.,Nygren,A.A.,&Söderman,E.(1997).HospitalAnxietyandDepressionScale(HAD):SomepsychometricdataforaSwedishsample.ActaPsychiatricaScandinavica,96,281‐286. Liu, X.,Wang, S., Chang, S., Chen,W.,& Si,M. (2013). Effect of briefmindfulness interventionontolerance and distress of pain induced by cold‐pressor task. Stress & Health: Journal Of TheInternationalSocietyForTheInvestigationOfStress,29,199‐204. Lorig,K., Laurent,D.,Deyo,R.,Marnell,M.,Minor,M.,&Ritter,P. (2002).Canabackpaine‐maildiscussiongroupimprovehealthstatusandlowerhealthcarecosts?:Arandomizedstudy.ArchivesOfInternalMedicine,162,792‐796. McCracken,L.M.&Eccleston,C.(2003).Copingoracceptance:Whattodoaboutchronicpain?.Pain,105,197‐204. McCracken, L.M., Vowles K.E., & Eccleston, C. (2004). Acceptance of chronic pain: componentanalysisandarevisedassessmentmethod.Pain,107,159‐166. McCracken, L.M., Zhaao‐O’Brien, J. (2010). General psychological acceptance and chronic pain:Thereismoretoacceptthanthepainitself.EuropeanJournalofPain,14,170‐175. Melville,K.M.,Casey,L.M.,&Kavanagh,D. J. (2010).Dropout from Internet‐based treatment forpsychologicaldisorders.BritishJournalOfClinicalPsychology,49,455‐471.Morledge,T.,Allexandre,D.,Fox,E.,Fu,A.,Higashi,M.,Kruzikas,D.,&...Reese,P.(2013).FeasibilityofanOnlineMindfulnessProgramforStressManagement‐ARandomized,ControlledTrial.AnnalsOfBehavioralMedicine,46,137‐148.

25

Reiner,K.,Tibi,L.,&Lipsitz,J.D.(2013).Domindfulness‐basedinterventionsreducepainintensity?Acriticalreviewoftheliterature.PainMedicine,14,230‐242. Segal, Z.V., Williams, J.M.G., & Teasdale, JD. (2002). Mindfulness‐based cognitive therapy fordepression:anewapproachtopreventingrelapse.TheGuilfordPress:NewYork. Silvemark, A.K., Källmén, H., Portala, K., &Molander, C. (2008). Life satisfaction in patientswithlong‐termnon‐malignantpain:Relation todemographic factorsandpain intensity.Disabilityandrehabilitation,30,1929‐1937.Turk, D. C. (2002). Clinical effectiveness and cost‐effectiveness of treatments for patients withchronicpain.TheClinicalJournalofPain,18,355–365. Turk,D.C.(2005).Thepotentialoftreatmentmatchingforsubgroupsofpatientswithchronicpain:Lumpingversussplitting.TheClinicalJournalOfPain,21,44‐55. Turk, D. C., & Okifuji, A. (2002). Psychological factors in chronic pain: Evolution and revolution.JournalOfConsultingAndClinicalPsychology,70,678‐690. Ussher,M.,Spatz,A.,Copland,C.,Nicolaou,A.,Cargill,A.,Amini‐Tabrizi,N.,&McCracken,L.(2012).Immediateeffectsofabriefmindfulness‐basedbodyscanonpatientswithchronicpain.JournalOfBehavioralMedicine.doi:10.1007/s10865‐012‐9466‐5Veehof, M. M., Oskam, M., Schreurs, K. G., & Bohlmeijer, E. T. (2011). Acceptance‐basedinterventionsforthetreatmentofchronicpain:Asystematicreviewandmeta‐analysis.Pain,152,533‐542.Vlaeyen,J.,&Linton,S.(2012).Fear‐avoidancemodelofchronicmusculoskeletalpain:12yearson.Pain,153,1144‐1147.Voluse,A.,Gioia,C.,Sobell,L.,Dum,M.,Sobell,M.,&Simco,E.(2012).Psychometricpropertiesofthedrugusedisordersidentificationtest(DUDIT)withsubstanceabusersinoutpatientandresidentialtreatment.AddictiveBehaviors,37,36‐41. Vowles, K., McCracken, L., McLeod, C., & Eccleston, C. (2008). The Chronic Pain AcceptanceQuestionnaire:Confirmatoryfactoranalysisandidentificationofpatientsubgroups.Pain,140,284‐291.Wicksell,R.K.,Olsson,G.L.,&Melin,L.(2009).Thechronicpainacceptancequestionnaire(CPAQ)‐furthervalidationincludingaconfirmatoryfactoranalysisandacomparisonwiththeTampascaleofkinesiophobia.EuropeanJournalofPain,13,760‐768.Zeidan, F., Gordon, N.S., Merchant, J., & Goolkasian, P. (2010). The effect of brief mindfulnessmeditationtrainingonexperimentallyinducedpain.TheJournalofPain,11,199‐209.