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Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: A systematic review and network meta-analysis
Open accessAbstract
Question: This review compares mindfulness-based stress reduction (MBSR) to cognitive-behavioural therapy (CBT) in its ability to improve physical functioning and reduce pain intensity and distress in patients with chronic pain (CP), when evaluated against control conditions. Study selection and analysis: Ovid MEDLINE, EmbaseClassic+Embase, PsycINFO and the Cochrane Library were searched to identify randomised controlled trials. The primary outcome measure was physical functioning. Secondary outcomes were pain intensity and depression symptoms. We used random and fixed effects (RE and FE) network meta-analyses (NMA) to compare MBSR, CBT and control interventions on the standardised mean difference scale. Findings: Twenty-one studies were included: 13 CBT vs control (n=1095), 7 MBSR vs control (n=545) and 1 MBSR vs CBT vs control (n=341). Of the 21 articles, 12 were determined to be of fair or good quality. Findings from RE NMA for change in physical functioning, pain intensity and depression revealed clinically important advantages relative to control for MBSR and CBT, but no evidence of an important difference between MBSR and CBT was found. Conclusions: This review suggests that MBSR offers another potentially helpful intervention for CP management. Additional research using consistent measures is required to guide decisions about providing CBT or MBSR.
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“Our findings are reassuring that patients with CLBP, regardless of these baseline characteristics examined to date, could reasonably expect to benefit from either CBT or MBSR.44”
From Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain (2023) · cites this paper as [44]
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“As in previous research in chronic pain (Veehof et al., 2016; Hilton et al., 2017; Khoo et al., 2019), compared to TAU, MBI produced a significant reduction at post-treatment in depressive symptoms, in one out of two studies (De Jong et al., 2018), and an increase in emotional awareness and self-regulation, in the one study that addressed this (De Jong et al., 2016).”
From A systematic review of cognitive behavioral therapy-based interventions for comorbid chronic pain and clinically relevant psychological distress (2023) · cites this paper as Khoo et al., 2019
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“There is some evidence for specific effects of different forms of meditation practice on both the brain and behavior with longer and more intensive practice163–167.”
From A common factors perspective on mindfulness-based interventions (2022) · cites this paper as [167]
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“An active control was selected because recent systematic reviews have mentioned the lack of studies with ‘head- to- head’ comparisons between MBIs and cognitivebehavioural therapies (Khoo et al., 2019); and this is an important knowledge gap to be addressed.”
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“One systematic review and meta-analysis (31) evaluated group-based MBSR and CBT for managing and treating chronic pain; however, no meta-analysis has compared MBIs and CBT for anxiety symptoms.”
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“91 Another meta-analysis found that psychological interventions that used cognitive behavioral techniques (eg, cognitive restructuring, cognitive coping skills) led to reductions in pain and emotional distress, and that the use of group-based interventions resulted in greater improvements compared…”
BackgroundThe psychophysiology of music-based interventions and the experience of pain
Arnold, C. A., Bagg, M. K., & Harvey, A. R. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1361857 · Cited by 68
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“…pain and distress processes (Maurel et al., 2021; Zeidan et al., 2010), which is beneficial for some chronic pain conditions (Ball et al., 2017); however, there is no Randomized Controlled Clinical Trial (RCT) in the particular context of chronic pelvic pain and endometriosis (Khoo et al., 2019).”
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“Available evidence in other areas such as chronic pain research suggest that mindfulness interventions are as effective as cognitive–behavioural interventions (Khoo et al. 2019).”
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Overall and differential attrition in mindfulness-based interventions: A meta-analysis
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“…Q between (1) = 1.848, p = .174; Type: Q between (1) = .007, p = .929. low back pain, d = 0.41 (Hoffman et al., 2007); MBSR for chronic pain, g = 0.49 (Khoo et al., 2019); exercise training, d = 0.30 (Herring et al., 2012); and MBSR d = 0.26 (Bohlmeijer et al., 2010) for chronic disease samples.”
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ResultStieger, A., Asadauskas, A., Luedi, M. M., & Andereggen, L. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14103427 · Cited by 31
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A synthesis of meta-analyses of mindfulness-based interventions in pain
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“This fi nding is consistent with fi ndings in recent reviews that compare the ef fi cacy between MBSR and CBT in chronic pain (Khoo et al., 2019) and mental health outcomes of anxiety, depression and sleep quality (Li et al., 2021a).”
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Mindfulness and Chronic Musculoskeletal Pain: An Umbrella Review
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“In some instances, MBI were no better than other interventions (such as CBT), as highlighted by Khoo et al.36 In one review, Eccleston et al19 found that internet-delivered psychological therapies, which included MBI, reduced headache pain and non-headache related pain with a small effect size, although it was reporte…”
MethodMindfulness vs Cognitive Behavioral Therapy for Chronic Low Back Pain Treated With Opioids
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How to Distinguish Non-Inflammatory from Inflammatory Pain in RA?
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“Therefore, mindfulness-based therapies could be offered additionally to CBT for improving pain severity and reducing pain interference and psychological distress in in patients with RA [124, 126].”
BackgroundEffects of mindfulness-based cognitive therapy for chronic pain: A multicenter study
Pardos-Gascón, E. M., Narambuena, L., Leal-Costa, C., Ramos-Morcillo, A. J., Ruzafa-Martínez, M., & van-der Hofstadt Román, C. J. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18136951 · Cited by 20
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“Our results also found that the statement related to relaxation or meditation as a means of distancing oneself from pain and reducing suffering is in line with the results of studies on cognitive therapy and mindfulness-based stress reduction (MBSR), which comprises a state of awareness that has been characterized as…”
ResultWarth, M., Koehler, F., Aguilar‐Raab, C., Bardenheuer, H. J., Ditzen, B., & Keßler, J. (2020) · European Journal of Cancer Care · doi:10.1111/ecc.13249 · Cited by 17
Zhu, M., Wong, S. Y. S., Zhong, C. C., Zeng, Y., Xie, L., Lee, E. K. P., Chung, V. C., & Sit, R. W. S. (2025) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2025.112061 · Cited by 16
Meditation for adults with non-specific low back pain: a systematic review and meta-analysis
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“, irritable bowel syndrome, chronic pain) (Khoo et al., 2019; Lakhan & Schofield, 2013).”
BackgroundAdewumi, A. D., Maravilla, J. C., Alati, R., Hollingworth, S., Hu, X., Loveday, B., & Connor, J. P. (2020) · International Journal of Clinical Pharmacy · doi:10.1007/s11096-020-01079-0 · Cited by 14
“Facilities that may improve health (and pain) outcomes such as specialist supervised exercise [28], cognitive-behavioural therapy [29] and mindfulness-based stress reduction [30], which are often available in affluent locations may be lacking in lower socioeconomic status areas [31].”
BackgroundEvaluation of the Empower Veterans Program for Military Veterans With Chronic Pain
Uche (2022) · Journal of Clinical Outcomes Management · doi:10.12788/jcom.0089 · Cited by 8
Shifting the perspective: how positive thinking can help diminish the negative effects of pain
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Mapping the associations of daily pain, sleep, and psychological distress in a U.S. sample
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“This study makes use used to treat pain and its related factors with some success (Feliu-Soler et al., 2018 ; Khoo et al., 2019 ).”
BackgroundMethodFeasibility of an online health intervention for Latinas with chronic pain.
Pagan‐Ortiz, M. E., & Cortés, D. E. (2020) · Rehabilitation Psychology · doi:10.1037/rep0000341 · Cited by 12
Sud, A., Lai, K. S. P., Cheng, D. K.-Y., Chung, C., Pico-Espinosa, O. J., & Rice, D. B. (2020) · Pain Physician · doi:10.36076/ppj.2021.24.61-72 · Cited by 12
Self-citationMindful Walking in Patients with Chronic Low Back Pain: A Randomized Controlled Trial
Rotter, G., Ortiz, M., Binting, S., Tomzik, J., Reese, F., Roll, S., Brinkhaus, B., & Teut, M. (2022) · Journal of Integrative and Complementary Medicine · doi:10.1089/jicm.2021.0361 · Cited by 12
“Reviews and systematic reviews report mindful interventions’ beneficial impact.(16,20,21) A systematic review and meta-analysis of 30 randomized controlled trials (RCTs) investigating chronic pain showed improvement in chronic pain management after mindfulness meditation interventions.”
Gascón, E. M. P., Narambuena, L., Leal‐Costa, C., Ramos‐Morcillo, A. J., Ruzafa‐Martínez, M., & Román, C. J. V.-D. H. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm10163544 · Cited by 12
“These results are contradictory to previous literature [11], which indicates a similar efficacy.”
ResultFernández‐Castilla, B., & Noortgate, W. V. D. (2022) · Behavior Research Methods · doi:10.3758/s13428-022-01905-5 · Cited by 11
López-Ramón, M. F., Campos, V. M., Alonso-Esteban, Y., Navarro‐Pardo, E., & Marín, F. A. (2023) · Mindfulness · doi:10.1007/s12671-023-02234-0 · Cited by 14
“For instance, Khoo et al. (2019) found that MBSR training can enhance physical functioning and reduce pain intensity and distress in patients with chronic pain.”
BackgroundCommunity-Based Yoga for Women Undergoing Substance Use Disorder Treatment
Galantino, M. L., Turetzkin, S., Lawlor, S., Jones, L., & Brooks, J. C. (2021) · International Journal of Yoga · doi:10.4103/ijoy.ijoy_103_20 · Cited by 10
“[40] One meta‐analysis suggests that mindfulness‐based interventions offer potentially helpful skills for persistent pain management, which has implications for women in recovery.[41] If persistent pain complicates addiction, using multifaceted mind‐body interventions, including yoga in overall sustainable recovery, w…”
BackgroundVidanage, K., Noor, N. M. M., & Sathsara, S. (2024) · International Journal of Information Technology · doi:10.1007/s41870-024-01900-3 · Cited by 10
“T h i s ca n b e u tili ze d a s e n r i c h e d i npu t f o r t h e CB T a n a l y s i s C ogn iti v e B e h a v i o r a l T h e r a py ( CB T ) [ 51 ] G o l d s t a nd a r d p s y c ho t h e r a p e u ti c t r ea t m e n t s t r a t e gy u tili ze d t o c l a ss i f y t h e i n t e r n a l s e l…”
Bijker, L., de Wit, L. M., Cuijpers, P. J., Poolman, E. Y., Scholten-Peeters, G. G. M., & Coppieters, M. W. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-050808 · Cited by 13
McCallion, E. A., Robinson, C. S. H., Clark, V. P., & Witkiewitz, K. A. (2020) · Mindfulness · doi:10.1007/s12671-020-01323-8 · Cited by 11
Kovacevic, M., Montes, M., Tirone, V., Pridgen, S., Smith, D. L., Burns, J. W., & Held, P. (2023) · Journal of Traumatic Stress · doi:10.1002/jts.22979 · Cited by 8
“…such as mindfulness and yoga, have previously been found to be helpful in addressing pain (Cramer et al., 2013, 2017; Goldstein et al., 2019; Khoo et al., 2019; Lee & Ernst, 2011; Shires et al., 2020; Veehof et al., 2016), it is unclear whether combining evidence-based treatments for PTSD…”
Liu, Z., Wan, J., & Liu, S. (2026) · Cancer Letters · doi:10.1016/j.canlet.2026.218318 · Cited by 8
Feasibility of Mindfulness-Based Intervention for Veterans Managing Chronic Pain
Chen, S., Liu, H.-T., Appelt, J. C., Klassen, B. L., Liu, L., Smith, J. L., & Cruz, A. M. (2023) · Canadian Journal of Occupational Therapy · doi:10.1177/00084174231156276 · Cited by 10
“In the past two decades, mindfulness-based interventions (MBIs) have been evaluated and have demonstrated positive outcomes in multiple domains for individuals with chronic pain (Bawa et al., 2015; Creswell, 2017; Hilton et al., 2017; Khoo et al., 2019; Veehof et al., 2016).”
BackgroundPresti, S. L., Origlia, S., Gianelli, C., & Canessa, N. (2023) · Human Brain Mapping · doi:10.1002/hbm.26312 · Cited by 7
“…connectivity (Brewer et al., 2011) and cortical thickness (Afonso et al., 2020; Grant et al., 2010), which, based on the role of this region in pain processing (Russo & Sheth, 2015), might support the greater pain tolerance compared with naïve subjects (Khoo et al., 2019; Zeidan & Vago, 2016).”
Chen, S., Gao, X., Shi, T., Zuo, X., Hong, C., Zhang, Y., You, B., Li, F., Jackson, T., & He, Y. (2023) · Pain and Therapy · doi:10.1007/s40122-023-00551-9 · Cited by 8
“MBSR and CBT were found to be significantly more effective than no treatment in reducing physical impairment and depressive symptoms, but not in pain severity [9].”
BackgroundSud, A., Nelson, M. L. A., Cheng, D. K.-Y., Armas, A., Foat, K., Greiver, M., Hosseiny, F., Katz, J. D., Moineddin, R., Mulsant, B. H., et al. (2020) · Trials · doi:10.1186/s13063-020-04243-z · Cited by 7
Shift in Valence Bias Associated with Decrease in Trait Anxiety and Depression Symptoms
Harp, N. R., Blair, J., & Neta, M. (2023) · Cognitive Therapy and Research · doi:10.1007/s10608-023-10437-x · Cited by 7
“The cultivation of mindfulness through MBIs is a well-known method for improving both physical (e.g., chronic pain, neurogenic inflammation; Khoo et al., 2019; Rosenkranz et al., 2013) and mental health outcomes (e.g., depression, anxiety; Querstret et al., 2020), as well as psychological…”
MethodScholten, S., Herzog, P., Glombiewski, J. A., & Kaiser, T. (2024) · Pain · doi:10.1097/j.pain.0000000000003363 · Cited by 9
Miller-Matero, L. R., Gavrilova, L., Hecht, L. M., Autio, K., Tobin, E. T., Braciszewski, J. M., Maye, M. P., Felton, J. W., & Ahmedani, B. K. (2022) · Pain Practice · doi:10.1111/papr.13134 · Cited by 9
“and these various options appear to be similarly effective.(14,27) Combining strategies from each of these interventions could offer a variety of evidence- based components in a single intervention while also allowing for delivery of the treatment in a brief format.”
BackgroundReynolds, K., Sommer, J. L., Roy, R., Kornelsen, J., Mackenzie, C. S., & El-Gabalawy, R. M. (2024) · Pain Management Nursing · doi:10.1016/j.pmn.2024.04.002 · Cited by 5
Salaberría, K., Ruiz‐Iriondo, M., Pérez, J. I., Barandiarán, A., & Iruín, Á. (2022) · PsyCh Journal · doi:10.1002/pchj.617 · Cited by 6
Yay-Pence, A., Aslan, S., Çöldür, M., Atalay, Z., Beba, B., Sayın, C. C., Aydin, E., Gumus, Z., Uckan, A. S., Sahinoglu, E. N., et al. (2025) · Psychiatry Research · doi:10.1016/j.psychres.2025.116632 · Cited by 7
Venturin, D., Battimelli, A., di Cara, G., & Poser, A. (2024) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2024.2336099 · Cited by 6
“…effectiveness in reducing stress and enhancing an individual’s capacity to cope positively with the distressing and disabling sensation of pain, ultimately leading to an improvement in associated disability (Hughes et al., 2017; Khoo et al., 2019; Krause et al., 2021; Smith and Langen, 2020).”
Misje, M., Ask, T., Skouen, J. S., Anderson, B., & Magnussen, L. H. (2023) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2023.2227967 · Cited by 5
“Stress management training, CBT and MBSR have previously been found to be beneficial in the treatment of chronic pain and fibromyalgia (Cash et al., 2015; Karlsson, Burell, Anderberg, and Svärdsudd, 2015; Khoo et al., 2019) supporting the findings of the present study.”
Garreta-Catala, I., Planas, R., Abouzari, R., Carnaval, T., Solé, J. M. N., Videla, S., Agulló, J.-L., the EN-FORMA study group, Calvis-Garcia, P., Carmezim, J., et al. (2023) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-023-06763-6 · Cited by 8
Designing voice interfaces to support mindfulness-based pain management
Mendu, S., Fosco, S. L. D., Lanza, S. T., & Abdullah, S. (2023) · Digital Health · doi:10.1177/20552076231204418 · Cited by 5
“24,11 MBSR has also been shown to signi fi cantly reduce the perception of pain intensity and functional limitations.”
BackgroundCherkin, D. C. (2020) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2020.7081 · Cited by 5
Pauly, T., Nicol, A., Lay, J. C., Ashe, M. C., Gerstorf, D., Graf, P., Linden, W., Madden, K. M., Mahmood, A. N., Murphy, R. A., et al. (2023) · Canadian Journal on Aging / La Revue canadienne du vieillissement · doi:10.1017/s0714980823000326 · Cited by 4
“Mindfulness is a mental state that has been shown to affect various types of chronic pain (Hilton et al., 2017; Khoo et al., 2019).”
BackgroundPerspective on salutogenic approaches to persistent pain with a focus on mindfulness interventions
Paley, C. A., & Johnson, M. I. (2023) · Frontiers in Pain Research · doi:10.3389/fpain.2023.1188758 · Cited by 6
Moreira, M. D. F., Gamboa, O. L., & Oliveira, M. A. P. (2024) · Mindfulness · doi:10.1007/s12671-024-02381-y · Cited by 3
“For instance, there was no improvement for fibromyalgia (Lauche et al., 2013) and low back pain (Pardos-Gascón et al., 2021), but a small effect size was observed for mixed chronic pain populations (Khoo et al., 2019).”
Rocca, G. L., Orlando, V., Galieri, G., Mazzucchi, E., Pignotti, F., Cusumano, D., Bazzu, P., Olivi, A., & Sabatino, G. (2024) · Journal of Personalized Medicine · doi:10.3390/jpm14090917 · Cited by 3
Managing Older Adults' Chronic Pain: Lower-Risk Interventions
Arnstein, P. M., Shade, M. Y., Herr, K., Young, H. M., & Fishman, S. M. (2023) · AJN American Journal of Nursing · doi:10.1097/01.naj.0000919740.00088.93 · Cited by 3
Metadata
- Authors
- Khoo, E.-L., Small, R., Cheng, W., Hatchard, T., Glynn, B., Rice, D. B., Skidmore, B., Kenny, S., Hutton, B., & Poulin, P. A.
- Affiliations
- Ottawa Hospital Research Institute (CA)
- Memorial University of Newfoundland (CA)
- University of Ottawa (CA)
- Corresponding author
- Poulin, Patricia A
- ORCID
- Venue
- Evidence Based Mental Health
- Publisher
- BMJ
- Published
- 2019-01-31
- Volume
- 22
- Issue
- 1
- Pages
- 26-35
- ISSN
- 1362-0347 (ISSN-L)
- 1468-960X
- PMC
- PMC10270397
- OpenAlex
- W2913124466
- Cited by
- 175
- References
- 40
- Citations by year
- 2026: 10 · 2025: 16 · 2024: 16 · 2023: 39 · 2022: 39 · 2021: 23 · 2020: 25 · 2019: 5
- FWCI
- 3.63
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Evidence-Based Mental Health (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Funders
- Canadian Institutes of Health Research
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Keywords
- mindfulness-based stress reduction, cognitive behavioral therapy, chronic pain, physical function, pain intensity, depression, group intervention, psychological pain management
- MeSH terms
- Humans, Psychotherapy, Group, Stress, Psychological, Cognitive Behavioral Therapy, Outcome Assessment, Health Care, Chronic Pain, Mindfulness
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