Brain and behavior changes associated with an abbreviated 4-week mindfulness-based stress reduction course in back pain patients

May combine two claims.

For anxiety, both groups' mean scores were below the clinically significant cutoff mark of 40, although the MBSR group had a mean score of 39, representing borderline clinical significance.

“For anxiety, both group's mean scores were below the clinically significant cutoff mark of 40 although the MBSR group had a mean score of 39, representing borderline clinical significance (Julian 2011).”

• cites Julian 2011Not checked yet

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May combine two claims.

There were no interactive effects of group on BOLD signal; all subsequent analyses reflect within-group changes pre- to post-intervention.

“There were also no interactive effects of group; therefore, all subsequent analyses reflect within‐group changes pre‐ to post‐intervention.”

May combine two claims.

Postintervention, the MBSR mean BDI-II score fell into the mild mood disturbance category, and the RCon mean was within the normal disturbances category.

“Postintervention, the MBSR mean BDI‐II score fell into the “mild mood disturbance” category, and the RCon mean was within the “normal disturbances” category.”

May combine two claims.

Time and ratings did not significantly change within groups from pre- to post-intervention nor differ between-groups at the preintervention scan.

“Time and ratings did not significantly change within groups from pre‐ to post‐intervention nor differ between‐groups at the preintervention scan.”

May combine two claims.

On the control task, strong BOLD signal in the visual cortex was observed with no interactive effects of group or within-group changes pre- to post-intervention.

“On the “control” task, strong BOLD signal in the visual cortex was observed with no interactive effects of group or within‐group changes pre‐ to post‐intervention.”

May combine two claims.

Despite improvement after MBSR training, both treatment and control groups remained in the moderate disability category according to Oswestry scores.

“Despite improvement after MBSR training, both treatment and control groups remained in the “moderate disability” category according to Oswestry scores (see Table S2 for number of participants within each symptom category pre‐ and post‐intervention).”

May combine two claims.

Preintervention, both groups showed elevated depression symptoms; the MBSR group was in the borderline clinical depression category and the RCon group in the mild mood disturbance category.

“Preintervention, both groups showed elevated depression symptoms based on a five‐category severity system; the mean BDI‐II score placed the MBSR group as “borderline clinical depression” while the RCon mean score was in the “mild mood disturbance” category (Kress et al. 2003).”

• cites Kress et al. 2003Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Mean scores on the Oswestry self-report of back pain placed both groups in the moderate disability category.

“Mean scores on the Oswestry self‐report of back pain placed both groups in the “moderate disability” category.”

May combine two claims.

There were no interactive effects of group; all subsequent analyses reflect within-group changes pre- to post-intervention.

“There were no interactive effects of group; therefore, all subsequent analyses reflect within‐group changes pre‐ to post‐intervention.”

May combine two claims.

42% of MBSR participants attained a 50% reduction in depression symptoms, while only 18% of the control group reached this level.

“The same pattern was observed for the BDI‐II, with more (42%) MBSR participants attaining a 50% reduction in depression symptoms while only 18% reached this level of improvement in the control group.”

May combine two claims.

The MBSR intervention led to unique improvements in back pain symptoms, as evident in the significant improvement in the MBSR group only.

“The MBSR intervention led to unique improvements in back pain symptoms, as evident in the significant improvement in the MBSR group only.”

May combine two claims. The quote only partly states this claim.

MBSR intervention uniquely led to greater activity of the sgACC while gaining conscious access to changes in emotion.

“We found that MBSR intervention uniquely led to greater activity of the sgACC and vlPFC while gaining conscious access to changes in emotion, as well as a greater relationship between activity in sgACC (associated with generating emotional reactions) and changes in self‐reported emotional states.”

May combine two claims.

Half of the MBSR participants reached the 4+ point Oswestry improvement threshold, while only 18% of the control group reached this level.

“Half of the MBSR participants reached this threshold of improvement, while only 18% reached this level of improvement in the control group.”

May combine two claims. The quote only partly states this claim.

MBSR intervention uniquely led to greater activity of the vlPFC while gaining conscious access to changes in emotion.

“We found that MBSR intervention uniquely led to greater activity of the sgACC and vlPFC while gaining conscious access to changes in emotion, as well as a greater relationship between activity in sgACC (associated with generating emotional reactions) and changes in self‐reported emotional states.”

May combine two claims.

An abbreviated MBSR course may be an effective complementary intervention that specifically improves back pain symptoms and frontal lobe regulation of emotional awareness.

“An abbreviated MBSR course may be an effective complementary intervention that specifically improves back pain symptoms and frontal lobe regulation of emotional awareness”

Probably not a substantial claim: may not pass S3 (load-bearing).

There is a clear positive relationship in severity between chronic back pain and depression.

“Approximately 50% of chronic back pain patients experience concomitant depression, and there is a clear positive relationship in severity between the two conditions (Rush et al. 2000).”

• cites Rush et al. 2000Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Approximately 50% of chronic back pain patients experience concomitant depression.

“Approximately 50% of chronic back pain patients experience concomitant depression, and there is a clear positive relationship in severity between the two conditions (Rush et al. 2000).”

• cites Rush et al. 2000Not checked yet

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May combine two claims.

Mood disturbances, particularly depression and anxiety, are both risk factors for, and the result of, chronic back pain.

“Mood disturbances, particularly depression and anxiety, are both risk factors for, and the result of, chronic back pain (Linton 2000; Rush et al. 2000; Gerhardt et al. 2011).”

• cites Linton 2000Not checked yet

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• cites Rush et al. 2000Not checked yet

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• cites Gerhardt et al. 2011Not checked yet

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May combine two claims.

Previous studies suggest that abbreviated MBSR courses improve symptoms of depression, anxiety, and quality of life in cancer patients, primary care clinicians, and an inner city population.

“Although few in number, previous studies suggest that abbreviated MBSR courses improve symptoms of depression, anxiety, and quality of life in cancer patients (Stafford et al. 2015), primary care clinicians (Fortney et al. 2013), and an inner city population (Smith et al. 2015).”

• cites Stafford et al. 2015Not checked yet

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• cites Fortney et al. 2013Not checked yet

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• cites Smith et al. 2015Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Three participants (one MBSR, two RCon) withdrew from the study prior to undergoing the postintervention assessment.

“Three participants (one MBSR, two RCon) withdrew from the study prior to undergoing the postintervention assessment.”

Probably not a substantial claim: may not pass S4 (based).

Most fMRI studies of pain regulation have focused on tasks that provoke exteroceptive pain in healthy individuals, rather than tasks involving emotional processing in patients with chronic pain.

“However, to date, most fMRI studies of pain regulation have focused on tasks that provoke exteroceptive pain in healthy individuals, rather than tasks involving emotional processing in patients with chronic pain.”

Classified as probably not a substantial claim.

Emotional and cognitive reactivity were identified as the strongest and most consistent psychological constructs to mediate mindfulness-related benefits.

“In a recent meta‐analysis across diverse populations, emotional and cognitive reactivity were identified as the strongest and the most consistent psychological constructs to mediate mindfulness‐related benefits (Gu et al. 2015).”

• cites Gu et al. 2015Not checked yet

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May combine two claims.

Complete randomization was not achieved; some participants were assigned to the MBSR group based on their ability to attend all four MBSR training sessions.

“While complete randomization was intended, study size, timing of the class, and the abbreviated nature of the class made it necessary to assign some participants to the MBSR group based on their ability to attend all four MBSR training sessions, occurring once a week for 4 weeks”

Probably not a substantial claim: may not pass S3 (load-bearing).

Patients with depression show functional changes in brain regions associated with appraising the emotional significance of one's situation (sgACC) and with perception of the bodily emotional reactions that those appraisals provoke (AI).

“patients with depression show functional changes in brain regions associated with both appraising the emotional significance of one's situation (subgenual ACC; sgACC) and with perception of the bodily emotional reactions that those appraisals provoke (AI; Price and Drevets 2012).”

• cites Price and Drevets 2012Not checked yet

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May combine two claims.

MBSR intervention studies in back pain patients show demonstrably favorable outcomes on pain severity, functional limitations due to pain, acceptance of chronic pain, physical functioning, and depression.

“Mindfulness‐based stress reduction intervention studies in back pain patients show demonstrably favorable outcomes on pain severity, functional limitations due to pain, acceptance of chronic pain, physical functioning, and depression (Morone et al. 2008; Rosenzweig et al. 2010; Schutze et al. 2014).”

• cites Morone et al. 2008Not checked yet

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• cites Rosenzweig et al. 2010Not checked yet

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• cites Schutze et al. 2014Not checked yet

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Classified as probably not a substantial claim.

These psychological processes may correspond to brain regions implicated in emotion regulation, including the ventrolateral and dorsomedial prefrontal cortices, anterior insula, anterior cingulate cortex, and subcortical regions.

“These psychological processes may correspond to brain regions implicated in emotion regulation, including the ventrolateral and dorsomedial prefrontal cortices (vlPFC and dmPFC), anterior insula (AI), anterior cingulate cortex (ACC), as well as subcortical regions (Ochsner and Gross 2005; Ochsner et al. 2012).”

• cites Ochsner and Gross 2005Not checked yet

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• cites Ochsner et al. 2012Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Both the focused attention and open monitoring aspects of meditation lead to alterations in frontal and other regions during anticipation of pain.

“Zeidan et al. (2010) reviewed brain mechanisms associated with mindfulness meditation in pain regulation, finding support that both the focused attention and open monitoring aspects of meditation lead to alterations in frontal and other regions during anticipation of pain.”

• cites Zeidan et al. (2010)Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The risk-to-benefit ratio for many surgical interventions for chronic back pain is unfavorable.

“the risk‐to‐benefit ratio for many surgical interventions is unfavorable (Chou et al. 2009).”

• cites Chou et al. 2009Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

There is no evidence that the Control Vision Task would influence findings on the Sadness Induction Task.

“All participants received this Control Vision Task first in the scanner, before the Sadness Induction Task, and there is no evidence that the Control Vision Task would influence findings on the Sadness Induction Task.”

• AssumptionThe authors state this as an assumption: The Control Vision Task is stable over time and unaffected by the intervention.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

No between-group differences in age or years of education were observed.

“No between‐group differences in age [t(21) = 0.62; P = 0.54] or years of education [t(21) = 0.08; P = 0.94] were observed.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Of the RCon group, seven participants reported reading the material.

“Of the RCon group, seven participants reported reading the material.”

Classified as probably not a substantial claim.

The sadness induction task was previously validated.

“We used a previously validated sadness induction task to focus on neural changes related to becoming aware of one's current emotional state (Smith et al. 2011, 2014b).”

• cites Smith et al. 2011Not checked yet

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• cites Smith et al. 2014bNot checked yet

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Classified as probably not a substantial claim.

Given the small sample size, Fisher's protected t-test with planned contrast was used to minimize Type I and II errors and control for family-wise error.

“Given the small sample size, we used Fisher's protected t‐test with planned contrast, based on a priori predictions, in order to minimize both Type I and II errors and control for family‐wise error (Cohen et al. 2003).”

• cites Cohen et al. 2003Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

Intention-to-treat analysis was used; participants remained in assigned groups regardless of adherence or withdrawal.

“In fitting with intention‐to‐treat (ITT) concept, participants remained in the groups to which they were assigned, regardless of their adherence to the treatment or subsequent withdrawal from the study (Gupta 2011).”

• cites Gupta 2011Not checked yet

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May combine two claims.

The MBSR group reported somewhat higher levels of depression, anxiety, and back pain, although only the between-group anxiety difference reached statistical significance.

“The MBSR group reported somewhat higher levels of depression, anxiety, and back pain, although only the between‐group anxiety difference reached statistical significance [STAI: t(21) = 5.34; P = 0.031; Fig. 1E].”

May combine two claims.

Groups were well balanced for gender and medication use to manage pain and psychiatric symptoms.

“Groups were well balanced for gender and medication use to manage pain and psychiatric symptoms (see Table S1 for complete medication list by the participant).”

Classified as probably not a substantial claim. May combine two claims.

The ROIs were selected because they showed a significant association with the sadness induction task in previous studies and because of their contributions to emotional/autonomic processing.

“The ROIs were selected because these regions showed a significant association with this sadness induction task in our previous studies (Smith et al. 2011, 2014b) and because of the contributions of these regions to afferent and efferent emotional/autonomic processing, as discussed in detail elsewhere (Smith et al. 2014a).”

• cites Smith et al. 2011Not checked yet

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• cites Smith et al. 2014bNot checked yet

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• cites Smith et al. 2014aNot checked yet

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May combine two claims.

More participants from the MBSR group did additional MBSR research and used the techniques they learned than the RCon group, and MBSR participants used the techniques at a higher frequency.

“As expected, there were consistently more participants from the MBSR group who did additional MBSR research outside of what was provided in the study and used the techniques they learned than the RCon group. MBSR participants also used the techniques at a higher frequency than the RCon group.”

Classified as probably not a substantial claim.

The lack of unique effect on cognitive aspects of depression and anxiety suggests a cumulative dose-response aspect to MBSR intervention such that neural changes and coping with pain occur prior to changes in more enduring symptoms.

“which suggests that there may be a cumulative dose–response aspect to MBSR intervention such that neural changes and coping with pain occur prior to changes in more enduring symptoms such as cognitive aspects of depression and anxiety, or that the intense focus on pain in these patients made changes to this symptom more evident.”

Classified as probably not a substantial claim. May combine two claims.

The sgACC has been implicated in the representation of emotional valence, appraising the emotional significance of one's current situation, and automatically generating emotional somatic marker responses to guide decision-making.

“The sgACC has been implicated in the representation of emotional valence (Grimm et al. 2006), appraising the emotional significance of one's current situation (Roy et al. 2012), and automatically generating emotional “somatic marker” responses to guide decision‐making (Gupta et al. 2011).”

• cites Grimm et al. 2006Not checked yet

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• cites Roy et al. 2012Not checked yet

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• cites Gupta et al. 2011Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Previous studies of the neural substrates associated with pain perception have utilized pain paradigms to determine whether MBSR alters pain tolerance as elicited by heat, cold, or electrical stimulation.

“Previous studies of the neural substrates associated with pain perception have utilized pain paradigms to determine whether MBSR alters pain tolerance as elicited by either heat, cold, or electrical stimulation (Zeidan et al. 2010).”

• cites Zeidan et al. 2010Not checked yet

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May combine two claims.

MBSR has been effective in alleviating symptoms in anxiety disorders, but results regarding the reduction of anxiety in back pain patients have been mixed.

“Although MBSR has been effective in alleviating symptoms in anxiety disorders, results regarding the reduction of anxiety in back pain patients have been mixed.; Schutze et al. (2014) reported no change, but Rosenzweig et al. (2010) reported reduced anxiety.”

• cites Schutze et al. (2014)Not checked yet

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• cites Rosenzweig et al. (2010)Not checked yet

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May combine two claims.

The mechanism by which MBSR changes perceived pain is quickly acquired, but also likely linked to a state effect of increased awareness, such that longer exposure to MBSR techniques provides a foundation necessary for long-term benefits of symptom improvements.

“Our findings of improved symptoms and neural changes associated with current use suggest that the mechanism by which MBSR changes perceived pain is quickly acquired, but also likely linked to a state effect of increased awareness, such that longer exposure to MBSR techniques provides a foundation that is necessary for long‐term benefits of symptom improvements.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The intense focus on pain in these patients made changes to cognitive aspects of depression and anxiety more evident.

“which suggests that there may be a cumulative dose–response aspect to MBSR intervention such that neural changes and coping with pain occur prior to changes in more enduring symptoms such as cognitive aspects of depression and anxiety, or that the intense focus on pain in these patients made changes to this symptom more evident.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

Zeidan et al. (2010) hypothesized that MBSR plays a role in altering expectancy of pain by increasing the training of reduced- or non-appraisal of nociceptive information.

“These past studies therefore focus on the anticipatory aspects of pain regulation, and Zeidan et al. (2010) hypothesized that MBSR plays a role in altering expectancy of pain by increasing the training of “reduced‐ or non‐appraisal of nociceptive information.””

• cites Zeidan et al. (2010)Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

The MBSR group likely had expectation to improve in symptoms.

“The MBSR group likely had expectation to improve in symptoms.”

May combine two claims.

Interpretations from this pilot study are limited by the sample size and the pseudorandom design.

“Interpretations from this pilot study are limited by the sample size and the pseudorandom design that was necessary to ensure that all MBSR participants were able to attend sufficient sessions in this abbreviated program.”

May combine two claims.

Findings from this study converge with conclusions from a recent meta-analysis and review that short-term mindfulness training is associated with increased top-down emotion regulation, while increased bottom-up emotion regulation is more likely to be observed in long-term practitioners.

“Taken together, findings from this study converge with conclusions from a recent meta‐analysis and review, that short‐term mindfulness training is associated with increased “top‐down” emotion regulation, while increased “bottom‐up” emotion regulation is more likely to be observed in long‐term practitioners (Chiesa et al. 2013; Tang et al. 2015).”

• cites Chiesa et al. 2013Not checked yet

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• cites Tang et al. 2015Not checked yet

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Classified as probably not a substantial claim.

Kerr et al. (2013) postulated that over time, attentional control may become generalized to other cognitive processes subserved by regions of the prefrontal cortex.

“Using magnetoencephalography, Kerr et al. (2013) found that the introductory technique of MBSR, the body scan, trains one to control the “attentional spotlight” within the somatosensory cortex, and postulated that over time, this attentional control may become generalized to other cognitive processes subserved by regions of the prefrontal cortex.”

• cites Kerr et al. (2013)Not checked yet

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May combine two claims.

In this pilot study, we did not match participants on demographic variables, control for medication use, or control for other changes in behavior during the study.

“In this pilot study, we did not match participants on demographic variables, control for medication use, or control for other changes in behavior that participants engaged in during the study.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Farb et al. (2010) found MBSR training to be related to increased involvement of sgACC when depressed and anxious patients observed sad movie clips.

“Consistent with this finding, Farb et al. (2010) also found MBSR training to be related to increased involvement of sgACC when depressed and anxious patients observed sad movie clips.”

• cites Farb et al. (2010)Not checked yet

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May combine two claims.

The groups do appear somewhat dissimilar, which is a possible problem with a small sample.

“Although groups were not statistically significantly different in preintervention analyses for back pain, depression symptoms, or neuroimaging measures, the groups do appear somewhat dissimilar, which is a possible problem one can encounter with a small sample.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In healthy participants, increased blood flow in sgACC was coupled with self-reported transient sadness.

“Others have reported this phenomenon, noting that in healthy participants increased blood flow in sgACC was coupled with self‐reported transient sadness (Mayberg et al. 1999).”

• cites Mayberg et al. 1999 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The control group was aware they were being compared to an in-person MBSR training group, which may have created the expectation that they would experience worsening symptoms.

“Further, the control group was aware of the fact that they were being compared to an in‐person MBSR training group, which may have created the expectation that, by comparison, they would experience worsening symptoms.”

May combine two claims.

Demographic variables and medication use were strikingly equivalent between groups.

“Demographic variables and medication use, however, were strikingly equivalent between groups (Table 1).”

May combine two claims.

The attentional control gained through the body scan may be particularly relevant to chronic pain patients by refocusing pain to a specific body region, rather than as an overwhelming feeling of generalized pain, which in turn may free up pain-focused attentional resources.

“The attentional control gained through the body scan may be particularly relevant to chronic pain patients by refocusing pain to a specific body region, rather than as an overwhelming feeling of generalized pain, which in turn may “free up pain‐focused attentional resources” (Kerr et al. 2013).”

• cites Kerr et al. 2013Not checked yet

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May combine two claims.

Our findings support the hypothesis that back pain patients who received MBSR training showed reductions in perceived pain and a concomitant increase in regional prefrontal neural activity reflecting a gain in cognitive access to one's own emotional state.

“Our findings support this hypothesis in that back pain patients who received MBSR training showed reductions in perceived pain and a concomitant increase in regional prefrontal neural activity reflecting a gain in cognitive access to one's own emotional state.”

May combine two claims.

Groups were not statistically significantly different in preintervention analyses for back pain, depression symptoms, or neuroimaging measures.

“Although groups were not statistically significantly different in preintervention analyses for back pain, depression symptoms, or neuroimaging measures, the groups do appear somewhat dissimilar, which is a possible problem one can encounter with a small sample.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Holzel et al. (2013) found a similar increased coupling of vlPFC in generalized anxiety disorder patients whose anxiety was alleviated by MBSR.

“Holzel et al. (2013) found a similar increased coupling of vlPFC in generalized anxiety disorder patients whose anxiety was alleviated by MBSR.”

• cites Holzel et al. (2013)Not checked yet

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May combine two claims.

MBSR participants were very consistent in their back pain improvement, thus the restricted range and small sample size were not conducive to detecting a significant correlation.

“MBSR participants were very consistent in their back pain improvement, thus the restricted range and small sample size were not conducive to detecting a significant correlation.”

May combine two claims.

Reassignment of groups based on exit survey factors did not better account for improvements in symptoms than participation in the MBSR group, making it unlikely that there were other mediating variables in symptom improvement over and above MBSR.

“Reassignment of groups based on any of these factors did not better account for improvements in symptoms than participation in the MBSR group, making it unlikely that there were other mediating variables in symptom improvement over and above MBSR.”

Classified as probably not a substantial claim.

MBSR focuses on increasing awareness of present moment experiences.

“From a therapeutic standpoint, MBSR focuses on increasing awareness of present moment experiences (Kabat‐Zinn 1990); therefore, increased coupling between sgACC activity and self‐reported emotional transitions may relate to core aspects of MBSR training.”

• cites Kabat‐Zinn 1990Not checked yet

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