Brief Mindfulness Findings and Cancer Related Pain

Objective: To report for the first time preliminary findings of mindfulness intervention 1) at the three-week point, and 2) on the novel factors of psychological flexibility, pain self-efficacy and expressive suppression in women with cancer pain. Methods: Data were collected on 46 women with breast cancer after three weeks of the eight-week intervention. Results: Pain self-efficacy and expressive suppression scores improved significantly after three-weeks. Limitations include lack of previous research for comparison and lack of generalizability to other cancer populations. Conclusion: These preliminary findings are limited and must be considered with caution. This initial exploration adds to the mindfulness intervention literature in malignant pain and populations whose health status is compromised by persistent pain.


Introduction
While biological and neuropathic pain etiologies are common in cancer, cognitive or psychological and affective aspects can more strongly contribute to pain ratings than sensory aspects [1].Thus, the objective purpose of the present study here was to report investigate exploratory three-week effects of a traditional eightweek mindfulness intervention on the cognitive and emotional factors of pain psychological inflexibility, pain self-efficacy, and expressive suppression in women with breast cancer and related pain.Pain intensity ratings also were collected as a standard secondary pain measure.This exploratory data collection was initiated out of consideration for participant health status that was not robust.

Psychological Flexibility, Pain Self-Efficacy, and Expressive Suppression Psychological Flexibility
An important cognitive factor in the treatment literature of chronic nonmalignant pain is Psychological Flexibility (PF), yet no study to date has investigated the effects of a mindfulness intervention on PF in women with cancer.Psychological flexibility is conceptualized as a process of being in the present moment without avoidance and judgment, and acting in adaptable healthy ways to achieve goals; psychological maladaptive inflexibility is associated with internal and behavioral avoidance [2][3].Distress is viewed as related to fused cognitions, where thoughts and previous experience become paired until merely the thought evokes the same inflexible emotional reaction as the actual experience.

Pain Self-Efficacy
According to Bandura's social cognitive theory, self-efficacy is conceptualized as a reflection of a "resilient self-belief system" in the face of obstacles, or the confidence to successfully perform or engage in specific behavioral activities or tasks [4].Pain selfefficacy as a form of behavioral regulation refers to the confidence one has to live meaningfully while managing pain [5], which is also known as pain management self-efficacy.Indeed, pain self-efficacy is viewed as critical to a patient's ability to manage the challenges unique to cancer [6].Surprisingly literature is not availble in this area, women with cancer.

Expressive Suppression
The avoidance of internal experience when negatively emotionally aroused can manifest as expressive suppression [7].Historically, emotional suppression and related concepts are associated with cancer patients; also, it is associated with emotional distress, depression and anxiety, and quality of life [8][9].No study has examined the effects of a mindfulness intervention on this major factor by using Gross' well-known Emotion Regulation Questionnaire (ERQ) [10].Indeed, several researchers suggest that interventions should target reducing emotional suppression so as to help breast cancer patients cope with chemotherapy side effects [11].

Mindfulness Meditation
According to Kabat-Zinn, the founder of the Mindfulness-Based Stress Reduction (MBSR) program, mindfulness is the disciplined practice of ''paying attention in a particular way, on purpose, in the present moment, and non-judgmentally'' [12].Mindfulness encourages being in the present moment with detached, nonjudging awareness, which provides one with a strategy for selfmonitoring and self-regulation of one's arousal [12].Few MBSR studies have investigated pain-related factors in malignant populations or women with breast cancer [13][14][15][16].Therefore, the aim here was to report preliminary three-week findings of a mindfulness intervention on psychological pain inflexibility, pain self-efficacy, expressive suppression, and pain intensity ratings in women with cancer-related pain.

Design
One group pre-test/post-test design was used to investigate changes in the factors of interest to this study.Here, data were collected before (pre) and at the end of three-weeks of the traditional eight week MBSR.Pain intensity ratings also were assessed as a standard secondary measure in those suffering with pain [13,[15][16].Statistical analyses consisted of paired t-test analyses that were conducted to assess pre-and-post three-week changes for each outcome variable.SPSS software was used for analyses.

Participants and Procedures
Following human subjects approval committee (IRB00000276), forty-six women served as participants, among them 36 women in stage II (78%) and 10 (22%) in stage III.Majority of participants were Caucasian (93%), Protestant (90%), married (86%), with a modal family income between $ 22,500 and $ 69,110 (85%).The mean age for this sample was 56.9 years.Most of them are educated beyond high school (77%), 8 women were working part-time (17%), and 20 women (43%) indicated a family history of cancer (Table 1).Cancer pain was confirmed by the oncologist.Cancer diagnosis time ranged from 16-months to 3.5 years.Participants maintained standard medical care throughout the intervention program.

Intervention
The MBSR program was held in a hospital counseling center for 1.5 hours/week for eight-weeks.Participants received training in the primary mindfulness practices of the body scan, sitting meditation and hatha yoga as condition permitted.Mindfulness strategies were substituted as needed for more physically demanding activities such as yoga or walking in those persons whose physical health was compromised.As described elsewhere [13][14][15][16] the body scan is a journey through the physical body.It involves a gradual sweeping of attention through the entire body, focusing non-critically on sensations or feelings in body regions with breath awareness, acceptance, and relaxation suggestions.Hatha yoga involves stretches and postures (asanas) designed to strengthen the body and increase flexibility; indeed, yoga is viewed as "meditation in motion," wherein body awareness of movement is coordinated with breathing.Sitting meditation involves attention to the breath with non-judging awareness of distractions that flow through the mind.The women received for small guidance and compact discs for daily homework of techniques learned in the weekly sessions.

Outcome measures
Data were collected on standardized measures at baseline, the end of three-weeks, and will be collected at the end of the program (eight-weeks).All measures have good psychometric properties with empirical support, and were chosen for this reason.
The Psychological Inflexibility in Pain Scale (PIPS) [17] was used to assess psychological flexibility.This 12-item measure focuses on psychological flexibility as it pertains to pain experiences.The PIPS measures the tendency to engage in behavior that serves to avoid pain and assesses the frequency of pain-related thoughts likely to lead to avoidant behavior.The PIPS contains the subscales of avoidance and cognitive fusion, with higher scores indicating greater psychological inflexibility (range 12-84).The total score was used.Nicholas' well-known10-item Pain Self-Efficacy Questionnaire (PSEQ) was used to measure pain self-efficacy or pain management self-efficacy, which is based on Bandura's concept of self-efficacy [5].The PSEQ, indicating behavioral regulation in the context of pain, is widely used in clinical and research.The PSEQ assesses the confidence that people with persistent pain have in successfully performing activities.Items are summed for a total score (range 0 -60); higher scores indicate greater pain self-efficacy.The Emotion Regulation Questionnaire (ERQ) was used to measure emotional suppressive tendencies [10].The ERQ has been used over 200 publications and translated into multiple languages.The four-item Expressive Suppression subscale (range 4 -28) was used [10].Items are rated on a 7-point Likert scale; higher scores indicate greater use of this emotion regulation strategy.The pain rating index of the standard McGill Pain Questionnaire, short form (MPQ-SF), was used to measure pain intensity [18].This well-known measure has been used in cancer populations.Pain intensity is determined by the sum of 15 items (range 0 -45), with higher scores indicating greater pain.

Results
Statistical analyses consisted of paired t-test analyses that were conducted to assess pre-and-post three-week changes for each outcome variable (Table 2).

Psychological Inflexibility
This first exploratory factor showed decreasing scores from baseline (M = 60.05,SD = 14.22), however, these changes were not significant after three-weeks (M = 59.35,SD = 13.73).Thus, while there was a reduced tendency to engage in cognitive avoidance and cognitive fusion, results did not reach significance.

Pain Self-Efficacy
Results revealed significant changes from the pre-to-post period.Scores for pain self-efficacy prior to the program (M = 20.61,SD = 11.47)increased significantly at the end of the third intervention week (M = 22.00, SD = 10.24)(t = 2.97 p < 0.05).

Expressive Suppression
The third exploratory investigation revealed significant differences from scores before the intervention (M = 22.77, SD = 7.75) to after three full weeks of the intervention (M = 21.33,SD = 8.11) (t = 2.88 p < 0.05).

ISSN: 2470-1017 Pain Intensity
The last factor of pain ratings showed a trend of reduced scores from before (M = 33.67,SD = 8.48) to after three weeks, yet did not reach significance (M = 33.21,SD = 8.37).

Discussion
The purpose here is to report for the first time three-week data of a mindfulness intervention exploring psychological flexibility in pain, pain self-efficacy and expressive suppression in a malignant pain population.This is salient because no previous research exists in cancer pain populations compared to non-malignant pain populations.Pain self-efficacy and expressive suppression scores improved significantly after three-weeks.While the trend of improvement for all factors is encouraging, no suggestions can be made beyond these data.It is hoped that brief mindfulness interventions may be able to produce beneficial effects and enhance quality of life in populations whose health and vigor are compromised.

Table 2 :
Means and Standard Deviations of Dependent Variables.