Neurobiological Aspects of Mindfulness in Pain Autoregulation: Unexpected Results from a Randomized-Controlled Trial and Possible Implications for Meditation Research
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fnhum-10-00674 January 24, 2017 Time: 17:52 # 1 ORIGINAL RESEARCH published: 26 January 2017 doi: 10.3389/fnhum.2016.00674 Neurobiological Aspects of Mindfulness in Pain Autoregulation: Unexpected Results from a Randomized-Controlled Trial and Possible Implications for Meditation Research Tobias Esch1,2,3, Jeremy Winkler4, Volker Auwärter5, Heike Gnann5, Roman Huber6 and Stefan Schmidt4,7* 1 Division of Integrative Health Promotion, Coburg University of Applied Sciences, Coburg, Germany, 2 School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany, 3 Institute for General Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany, 4 Department of Psychosomatic Medicine, Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany, 5 Institute of Forensic Medicine, Forensic Toxicology, Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany, 6 Center for Complementary Medicine, Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany, 7 Institute for Transcultural Health Studies, European University Viadrina, Frankfurt (Oder), Germany Background: Research has demonstrated that short meditation training may yield higher pain tolerance in acute experimental pain. Our study aimed at examining underlying mechanisms of this alleged effect. In addition, placebo research has shown Edited by: that higher pain tolerance is mediated via endogenous neuromodulators: experimental Stephane Perrey, inhibition of opioid receptors by naloxone antagonized this effect. We performed a University of Montpellier, France trial to discern possible placebo from meditation-specific effects on pain tolerance and Reviewed by: Fei Luo, attention. Institute of Psychology (CAS), China Objectives: It was proposed that (i) meditation training will increase pain tolerance; (ii) Wolf E. Mehling, University of California, naloxone will inhibit this effect; (iii) increased pain tolerance will correlate with improved San Francisco, USA attention performance and mindfulness. *Correspondence: Methods: Randomized-controlled, partly blinded trial with 31 healthy meditation-naïve Stefan Schmidt [email protected] adults. Pain tolerance was assessed by the tourniquet test, attention performance was measured by Attention Network Test (ANT), self-perceived mindfulness by Freiburg Received: 11 October 2016 Mindfulness Inventory. 16 participants received a 5-day meditation training, focusing Accepted: 19 December 2016 Published: 26 January 2017 on body/breath awareness; the control group (N D 15) received no intervention. Citation: Measures were taken before the intervention and on 3 consecutive days after the Esch T, Winkler J, Auwärter V, training, with all participants receiving either no infusion, naloxone infusion, or saline Gnann H, Huber R and Schmidt S (2017) Neurobiological Aspects infusion (blinded). Blood samples were taken in order to determine serum morphine of Mindfulness in Pain Autoregulation: and morphine glucuronide levels by applying liquid chromatography-tandem mass Unexpected Results from spectrometry analysis. a Randomized-Controlled Trial and Possible Implications Results: The meditation group produced fewer errors in ANT. Paradoxically, increases for Meditation Research. Front. Hum. Neurosci. 10:674. in pain tolerance occurred in both groups (accentuated in control), and correlated doi: 10.3389/fnhum.2016.00674 with reported mindfulness. Naloxone showed a trend to decrease pain tolerance in Frontiers in Human Neuroscience | www.frontiersin.org 1 January 2017 | Volume 10 | Article 674 fnhum-10-00674 January 24, 2017 Time: 17:52 # 2 Esch et al. Meditation and Pain Regulation both groups. Plasma analyses revealed sporadic morphine and/or morphine metabolite findings with no discernable pattern. Discussion: Main objectives could not be verified. Since underlying study goals had not been made explicit to participants, on purpose (framing effects toward a hypothesized mindfulness-pain tolerance correlation were thus avoided, trainees had not been instructed how to ‘use’ mindfulness, regarding pain), the question remains open whether lack of meditation effects on pain tolerance was due to these intended ‘non-placebo’ conditions, cultural effects, or other confounders, or on an unsuitable paradigm. Conclusion: Higher pain tolerance through meditation could not be confirmed. Keywords: meditation, mindfulness, pain tolerance, attention, morphine, opioids, placebo INTRODUCTION patients with chronic low back pain, though effects were similar to those of cognitive behavioral approaches, leaving the question Pain as an unpleasant sensory and emotional experience has open as to the specificity of effects in mindfulness training. Kabat- a multidimensional nature, which means it is sensitive to Zinn (2003, p. 145) defines mindfulness as “the awareness that diverse manipulations, implicating there are many starting emerges through paying attention on purpose, in the present points for pain relief. Keeping in mind that, for example, moment, and non-judgmentally to the unfolding of experience chronic pain patients cost about 38 billion Euros per year in moment by moment.” Mindfulness has been suggested to be Germany (Zimmermann, 2004), reliable therapeutic concepts are effective via four mechanisms (Hölzel et al., 2011): attention desperately needed. A better understanding of the notion of pain regulation, body awareness, emotion regulation, and changes in is mandatory. perspective on the self. This study was planned and conducted in light of recent Pain Manipulation through Mindfulness evidence demonstrating, indeed, that meditation alters pain and Meditation perception (e.g., reduction of subjective pain ratings in healthy When observing the phenomenon of pain it appears that there adults), and that pain tolerability for experimental pain is are several dimensions involved, from which the affective and elevated – since, for example, a short mindfulness training cognitive dimension are two: the affective dimension reflecting has been shown to increase pain tolerance in novices (Kabat- the emotional and motivational relevance of the stimuli and the Zinn, 1982; Kabat-Zinn et al., 1985; Kingston et al., 2007; cognitive dimension relating to how aspects of cognition can Zeidan et al., 2010, 2011, 2012; MacCoon et al., 2012); however, sculpt one’s experience (Melzack and Casey, 1968). It seems quite some of these early experimental studies on pain modulation logical that manipulation on these two dimensions would lead to through meditation training didn’t involve proper controls or an altered pain experience. Meditation, understood as a mental randomization procedures. The postulated phenomenon has training that shapes the brain/mind in highly specific ways, is a recently been called ‘meditative analgesia’ by some authors relatively new approach in the field of pain modulation (Benson (Grant, 2014), also discussing various or ‘specific’ forms of et al., 1974; Hoffman et al., 1982; Kabat-Zinn, 1982, 2003; Kabat- meditation that are particularly linked to the presumed potential Zinn et al., 1985; Lazar et al., 2000; Esch et al., 2003; Salamon et al., of affecting pain. 2006; Zeidan et al., 2010, 2011, 2012; Schmidt et al., 2011) and In addition, there is evidence for a modification of the could be one of such starting points among others to manipulate subjective interpretation of pain via meditation in patients the affective and cognitive dimensions of pain. dealing with chronic pain (cf. Schmidt et al., 2011). However, Meditation lies at the core of mindfulness-based stress little is known about underlying neurobiological mechanisms. reduction (MBSR). MBSR, since its development for chronic For example, the involvement of dopamine or dopaminergic pain and stress-associated disorders in the late 1970s, is under brain pathways in meditation (Bujatti and Biederer, 1976; Kjaer intensive research (Kabat-Zinn, 1982; Kabat-Zinn et al., 1985; et al., 2002), and the production of endogenous opioids/opiates Bishop et al., 2004; Grossman et al., 2004; Ernst et al., 2009; via dopamine (Zhu et al., 2005; Kream and Stefano, 2006; Stefano Zeidan et al., 2010, 2011, 2012; cf. Bazarko et al., 2013; and Kream, 2007, 2010; Stefano et al., 2007, 2012; Mantione Katterman et al., 2014), and now frequently used in clinical et al., 2008; Zhu and Stefano, 2009; Esch, 2014), have been practice. Evidence, however, for the clinical effectiveness of discussed. An activation of these pathways could, theoretically, MBSR programs in improving pain intensity or disability, e.g., in influence pain modulation. Also, it has been speculated that pain chronic low back pain patients, is still inconclusive, with limited attenuation through mindfulness might involve unique brain evidence that MBSR can improve pain acceptance (Cramer et al., mechanisms that are in sharp contrast to established models, e.g., 2012). A recent randomized clinical trial by Cherkin et al. (2016) comprising increased sensory processing and decreased cognitive concluded that MBSR may be an effective treatment option for control (Gard et al., 2011). Accordingly, a search for modulators Frontiers in Human Neuroscience | www.frontiersin.org 2 January 2017 | Volume 10 | Article 674 fnhum-10-00674 January 24, 2017 Time: 17:52 # 3 Esch et al. Meditation and Pain Regulation and key neurotransmitters, or autoregulatory indicators, of this (e.g., dorsolateral prefrontal cortex) and insular cortices (among proposed shift has begun. others: e.g., amygdala,