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Mindfulness Meditation-Related Pain Relief: Evidence for Unique Brain Neuroscience Letters 520 (2012) 165–173 Contents lists available at SciVerse ScienceDirect Neuroscience Letters jou rnal homepage: www.elsevier.com/locate/neulet Review Mindfulness meditation-related pain relief: Evidence for unique brain mechanisms in the regulation of pain a,∗ b c a a F. Zeidan , J.A. Grant , C.A. Brown , J.G. McHaffie , R.C. Coghill a Wake Forest School of Medicine, Department of Neurobiology and Anatomy, Winston-Salem, NC, United States b Max Planck Institute for Human, Cognitive and Brain Sciences, Department of Social Neuroscience, Stephanstraße 1A, 04103 Leipzig, Germany c University of Manchester, Human Pain Research Group, Clinical Sciences Building, Salford Royal NHS Foundation Trust, Salford M6 8HD, Manchester, England, United Kingdom a r t i c l e i n f o a b s t r a c t Article history: The cognitive modulation of pain is influenced by a number of factors ranging from attention, beliefs, Received 18 February 2012 conditioning, expectations, mood, and the regulation of emotional responses to noxious sensory events. Received in revised form 21 March 2012 Recently, mindfulness meditation has been found attenuate pain through some of these mechanisms Accepted 27 March 2012 including enhanced cognitive and emotional control, as well as altering the contextual evaluation of sensory events. This review discusses the brain mechanisms involved in mindfulness meditation-related Keywords: pain relief across different meditative techniques, expertise and training levels, experimental procedures, Mindfulness and neuroimaging methodologies. Converging lines of neuroimaging evidence reveal that mindfulness Meditation Pain meditation-related pain relief is associated with unique appraisal cognitive processes depending on Neuroimaging expertise level and meditation tradition. Moreover, it is postulated that mindfulness meditation-related pain relief may share a common final pathway with other cognitive techniques in the modulation of pain. © 2012 Elsevier Ireland Ltd. All rights reserved. Contents 1. What is mindfulness? ..... 166 2. Mindfulness meditation practices: focused attention and open monitoring . 166 3. Mindfulness meditation and health ..... 166 4. Mindfulness meditation and pain . 166 5. Behavioral studies of meditation-related pain relief . 167 6. The neural substrates of mindfulness meditation-related pain relief. 167 7. Trait effects of prior meditation practice on pain . 167 8. State effects of active meditation during pain . 168 9. An integrated perspective on meditation-based pain relief. 170 10. Common final pathway to the cognitive modulation of pain . 171 Acknowledgment . 172 References . 172 The advent of contemporary neuroimaging techniques has con- increased brain activity in a set of regions including the anterior tributed greatly to our understanding of the neural mechanisms cingulate cortex (ACC), anterior insula and sensory areas such as underlying pain perception and, importantly, how pain can be mod- primary and secondary somatosensory cortices (SI/SII), thalamus ulated. Increases in experienced pain are reliably associated with and posterior insula [1,13,14,19,56]. A variety of factors are now known to either increase or decrease pain-related brain activation, including: predictive cues [3], dis- traction [5,58], attention [52,58,63] expectation [41,55], beliefs ∗ Corresponding author at: Wake Forest School of Medicine, Department of Neu- [68], placebo [54,67], hypnosis [57], stress, anxiety, mood and emo- robiology, Medical Center Blvd., Winston-Salem, NC 27157, United States. tional state [51,65]. Many of these factors, however, are difficult for Tel.: +1 704 578 1271; fax: +1 336 716 4534. an individual to engage in a self-directed and volitional fashion. By E-mail addresses: [email protected] (F. Zeidan), mchaffi[email protected] (J.G. McHaffie), [email protected] (R.C. Coghill). contrast, there is growing evidence that mindfulness meditation, a 0304-3940/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.neulet.2012.03.082 166 F. Zeidan et al. / Neuroscience Letters 520 (2012) 165–173 volitionally initiated cognitive act, can significantly attenuate the emphasis on refraining from appraisal or elaboration. Unlike FA, subjective experience of pain. Although mindfulness meditation which likely involves reappraisal, OM ultimately would involve a has only recently been the subject of scientific investigation, the complete lack of higher order appraisal. Traditionally it is taught emerging data indicate that it shares important common neural that training in focused attention, prior to open monitoring, sta- substrates engaged by other cognitive factors known to modulate bilizes one’s attention and emotions allowing insight, into the pain. Nevertheless, some facets of mindfulness meditation-related changeability of experience, to occur during OM practice. pain relief appear to engage brain mechanisms distinct from those engaged by other cognitive factors and thus may provide novel insights into how the subjective experience of pain is produced 3. Mindfulness meditation and health and modulated. Mindfulness meditation has been found to improve a wide spectrum of cognitive and health outcomes [29]. Training in mind- 1. What is mindfulness? fulness meditation improves anxiety [25,38], depression [6,61], stress [2,10,11,39], and cognition [33,42–44,70]. Mindfulness- Mindfulness has been described as a “non-elaborative, non- related health benefits are associated with enhancements in judgmental awareness” of present moment experience [36]. cognitive control, emotion regulation, positive mood, and accep- Operational definitions of mindfulness expand on this description tance, each of which have been associated with pain modulation by regarding it as including: (a) regulated, sustained attention to the [29]. Thus, it seems reasonable to hypothesize that mindfulness moment-to-moment quality and character of sensory, emotional meditation itself would attenuate pain through some of these and cognitive events, (b) the recognition of such events as momen- mechanisms. tary, fleeting and changeable (past and future representations of those events being considered cognitive abstractions), and (c) a consequent lack of emotional or cognitive appraisal and/or reac- 4. Mindfulness meditation and pain tions to these events. This latter aspect highlights the assumption that our normal experiences are typically, but perhaps unnecessar- For thousands of years, contemplatives have reported that the ily, framed as enduring due to insufficient mindfulness and thus practice of mindfulness meditation attenuates the experience of augmenting mindfulness could have significant positive effects. pain by modulating expectations, the nature and orientation of Taken together, mindfulness is simultaneously a process of cog- attention toward the experience, and the corresponding emotional nitive control, emotional reappraisal or reduced judgment, and response [7]. In 1980, Clark and Clark reported that “devout Bud- existential insight. Although there are individual differences in trait dhist” porters from Nepal exhibited higher pain tolerance and lower mindfulness [15,20], this characteristic can be developed by mental subjective pain reports when compared to other, age-matched, eth- training such as meditation. nic groups [12]. Although these researchers suggested that religious practices (i.e., meditation) were associated with greater pain tol- 2. Mindfulness meditation practices: focused attention and erance, it was not clear if mindfulness-based practice itself could open monitoring reduce pain [12]. In the early 1980s, clinical studies of mindfulness began with There are a variety of different meditative practices that are sub- Jon Kabat-Zinn’s seminal work with chronic pain patients. It was sumed under the general rubric of “mindfulness”. This ambiguity has hypothesized that training in mindfulness would attenuate pain by lead to confusion within the literature because the specific medi- altering emotional responses to pain and enhancing acceptance- tation technique being employed is not always adequately defined related coping strategies [35,37]. Over the course of a five year and operationalized [20,42,59]. Because the mechanisms involved study, it was found that chronic pain patients who completed an in meditation-induced pain-related changes may be dependent on eight-week Mindfulness-Based Stress Reduction (MBSR) program the specific technique being investigated (see below), it is critical significantly improved their pain symptoms and overall quality of that the specifics of the practice being taught or employed be recog- life, even up to four years after completion of this initial training. nized. In general, mindfulness techniques can be divided into two In other work, eight weeks of mindfulness training was shown to styles, namely, focused attention and open monitoring [42] (see improve pain acceptance in lower back pain patients [47]. More Lutz et al. [42] for a comprehensive review). recently, [64] administered a dot-probe task of pain-related threat Focused attention (FA), also known as Samatha or Shamatha words to fibromyalgia (FM) patients. Increased engagement to (from Sanskrit), is associated with maintaining focus on a specific pain-related threat, as measured by dot-probe performance, is object, often the changing sensation or flow of the breath or an associated with slower response times to a neutral probe where external object [42]. When attention drifts
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