A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain

Omfattende studie om kronisk smerte som kommer med reelle tiltak for å bedre tilstanden hos pasientene. Nevner spesielt en at en holdningsendring må skje hos legene og sykepleierene hvor man inkluderer pasientes subjektive opplevelse. Nevner grunnlaget for dagens medisin og objektifisering av pasienten: «Foucault412 described the paradoxical position of the clinical encounter, in which the doctor aims to diagnose a disease rather than understand the person’s experience: ‘If one wishes to know the illness from which he is suffering, one must subtract the individual, with his [or her] particular qualities’  »


Conclusion: Our model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care. 

As part of a person’s struggle we described the fragmentation of body and self, and suggested that moving forward with pain involves a process of reintegrating the painful body. 

Under conditions of health, we perform actions automatically and remain unaware of our body until something goes wrong with it. Health presupposes that we remain unaware of our bodies.396 When in pain, the body emerges as an ‘alien presence’;
it ‘dys-appears’. I no longer am a body but have a body,388 and my body becomes an ‘it’ as opposed to an

I’. Wall399 describes this dualism as epitomised by the expression ‘my foot hurts me’ as if in some way the foot is apart from myself (p. 23). It is because ‘the body seizes our awareness particularly at times of disturbance, [that] it can come to appear “other” and opposed to the self’ (p. 70).388 This fragmentation of ‘mind trapped inside an alien body’ means that our bodies become mistrusted and ‘forgotten as a ground of knowledge’ (p. 86).388 Our concept ‘integrating my painful body’ implies an altered therapeutic relationship with the body in which the dualism of mind and body are broken down.

We do not know why certain patients can accept and redefine their sense of self and others cannot.
It may be related to the degree of disruption to self that is caused by pain. The enmeshment model developed by Pincus and Morley406 proposes that, if a person regards their ideal self as unobtainable in the presence of pain, they are less likely to accept chronic pain. The enmeshment model incorporates self-discrepancy theory,407 which proposes that the extent to which pain disrupts our lives depends on the meaning that it holds for us. In self-discrepancy theory meaning incorporates three constructs: (1) actual self – ‘your representation of the attributes that someone (yourself or another) believes you actually possess’; (2) ideal self – ‘your representation of the attributes that someone (yourself or another) would like you, ideally, to possess’; and (3) ought self – ‘your representation of the attributes that someone (yourself or another) believes you should or ought to possess’ (p. 320–1).407

However, it is ‘pathos’, the feeling of suffering and powerlessness, of ‘life going wrong’, that precedes a person’s visit to the doctor (p. 137).396 Our model suggests that central to the therapeutic relationship is the recognition of ‘pathos’; the patient is a subject rather than an ‘object’ of investigation. This concept is central to models of patient-centred care.413

We described a need for a person in pain to feel that the health-care professional is alongside them with their pain. Affirming a person’s experience and allowing an empathetic interpretation of their story is not an adjunct, but integral to health care.395

Our model also suggests possibilities that might help patients to move forward alongside their pain:

  • an integrated relationship with the painful body
  • redefining a positive sense of self now and in the future
  • communicating to, rather than hiding from, others the experience of pain
  • knowing that I am not the only one with pain (but I am still valued)
  • regaining a sense of reciprocity and social participation
  • recognising the limitations of the medical model
  • being empowered to experiment and change the way that I do things without the sanction of the health-care professional.

Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation

En studie som gir en tydelig beskrivelse av hvor mye mindfulness demper smerte. De fant ingen korrelasjon mellom pustefrekvens og smertereduksjon, men det kan være flere faktorer som spiller inn der.  I denne studien gjorde de f.eks. kun 20 min meditasjon i 4 dager, med mennesker som ikke har meditert først. De andre studiene inkluderer mennesker som har meditert lenge. I tillegg kan man tydelig se at etter 4 dager med meditasjon så blir pustefrekvensen lavere når man blir påført vond varme, noe som tyder på at de begynner å bruke pusten som smertereduksjon. Det var motsatt før de hadde fått instruksjon i meditasjon.


After 4 d of mindfulness meditation training, meditating in the presence of noxious stimulation significantly reduced pain unpleasantness by 57% and pain intensity ratings by 40% when compared to rest.

Meditation-induced reductions in pain intensity ratings were associated with increased activity in the anterior cingulate cortex and anterior insula, areas involved in the cognitive regulation of nociceptive processing. Reductions in pain unpleasantness ratings were associated with orbitofrontal cortex activation, an area implicated in reframing the contextual evaluation of sensory events. Moreover, reductions in pain unpleasantness also were associated with thalamic deactivation, which may reflect a limbic gating mechanism involved in modifying interactions between afferent input and executive-order brain areas. Together, these data indicate that meditation engages multiple brain mechanisms that alter the construction of the subjectively available pain experience from afferent information.

Mindfulness-based mental training.

Mindfulness-based mental training was performed in four separate, 20 min sessions conducted by a facilitator with >10 years of experience leading similar meditation regimens. Subjects had no previous meditative experience and were informed that such training was secular and taught as the cognitive practice of Shamatha or mindfulness meditation. Each training session was held with one to three participants.

On mindfulness meditation training day 1, subjects were encouraged to sit with a straight posture, eyes closed, and to focus on the changing sensations of the breath occurring at the tips of their nostrils. Instructions emphasized acknowledging discursive thoughts and feelings and to return their attention back to the breath sensation without judgment or emotional reaction whenever such discursive events occurred. On training day 2, participants continued to focus on breath-related nostril sensations and were instructed to “follow the breath,” by mentally noting the rise and fall of the chest and abdomen. The last 10 min were held in silence so subjects could develop their meditative practice. On training day 3, the same basic principles of the previous sessions were reiterated. However, an audio recording of MRI scanner sounds was introduced during the last 10 min of meditation to familiarize subjects with the sounds of the scanner. On the final training session (day 4), subjects received minimal meditation instruction but were required to lie in the supine position and meditate with the audio recording of the MRI sounds to simulate the scanner environment. Contrary to traditional mindfulness-based training programs, subjects were not required to practice outside of training.

Subjects also completed the Freiburg Mindfulness Inventory short-form (FMI), a 14-item assessment that measures levels of mindfulness, before psychophysical pain training and after MRI session 2. The FMI is a psychometrically validated instrument with high internal consistency (Cronbach α = 0.86) (Walach et al., 2006). Statements such as “I am open to the experience of the present moment” are rated on a five-point scale from 1 (rarely) to 5 (always). Higher scores indicate more skill with the mindfulness technique.

Decreases in respiration rate have been reported previously to predict reductions in pain ratings (Grant and Rainville, 2009Zautra et al., 2010). In the present data (MRI session 2; n = 14), no significant relationship between the decreased respiration rates and pain intensity (p = 0.22, r = −0.35), pain unpleasantness (p = 0.41, r = −0.24), or FMI ratings (p = 0.42, r = 0.24) was found.

CBF Respiration rate Heart rate
Session 1
    Rest: neutral 74.12 (3.01) 19.97 (1.29) 72.53 (2.33)
    Rest: heat 71.51 (2.93) 20.45 (1.11) 74.79 (2.39)
    ATB: neutral 70.69 (3.56) 17.05 (1.00) 70.46 (1.79)
    ATB: heat 67.90 (3.08) 19.32 (1.33) 74.07 (2.19)
Session 2
    Rest: neutral 68.57 (3.17) 16.72 (0.82) 74.82 (3.08)
    Rest: heat 66.82 (2.59) 17.12 (0.93) 77.32 (2.95)
    Meditation: neutral 65.09 (3.59) 11.55 (0.74) 73.62 (2.77)
    Meditation: heat 65.47 (3.86) 9.47 (0.67)a 75.38 (2.70)

In the present investigation, meditation reduced all subjects’ pain intensity and unpleasantness ratings with decreases ranging from 11 to 70% and from 20 to 93%, respectively.

Meditation likely modulates pain through several mechanisms. First, brain areas not directly related to meditation exhibited altered responses to noxious thermal stimuli. Notably, meditation significantly reduced pain-related afferent processing in SI (Fig. 5), a region long associated with sensory-discriminative processing of nociceptive information (Coghill et al., 1999). Executive-level brain regions (ACC, AI, OFC) are thought to influence SI activity via anatomical pathways traversing the SII, insular, and posterior parietal cortex (Mufson and Mesulam, 1982Friedman et al., 1986;Vogt and Pandya, 1987). However, because meditation-induced changes in SI were not specifically correlated with reductions in either pain intensity or unpleasantness, this remote tuning may take place at a processing level before the differentiation of nociceptive information into subjective sensory experience.

Second, the magnitude of decreased pain intensity ratings was associated with ACC and right AI activation (Fig. 6). Activation in the mid-cingulate and AI overlapped between meditation and pain, indicating a likely substrate for pain modulation. Converging lines of evidence suggest that these regions play a major role in the evaluation of pain intensity and fine-tuning afferent processing in a context-relevant manner (Koyama et al., 2005Oshiro et al., 2009;Starr et al., 2009). Such roles are consistent with the aspect of mindfulness meditation that involves reducing appraisals that normally impart significance to salient sensory events.

Third, OFC activation was associated with decreases in pain unpleasantness ratings (Fig. 6). The OFC has been implicated in regulating affective responses by manipulating the contextual evaluation of sensory events (Rolls and Grabenhorst, 2008) and processing reward value in the cognitive modulation of pain (Petrovic and Ingvar, 2002). Meditation directly improves mood (Zeidan et al., 2010a), and positive mood induction reduces pain ratings (Villemure and Bushnell, 2009). Therefore, meditation-related OFC activation may reflect altered executive-level reappraisals to consciously process reward and hedonic experiences (e.g., immediate pain relief, positive mood) (O’Doherty et al., 2001Baliki et al., 2010Peters and Büchel, 2010).

Mindfulness starts with the body: somatosensory attention and top-down modulation of cortical alpha rhythms in mindfulness meditation

Studie som nevner at Mindfulness øker alpha-bølger i hjernen, som bidrar til reduksjon i smerte.


Using a common set of mindfulness exercises, mindfulness based stress reduction (MBSR) and mindfulness based cognitive therapy (MBCT) have been shown to reduce distress in chronic pain and decrease risk of depression relapse. These standardized mindfulness (ST-Mindfulness) practices predominantly require attending to breath and body sensations.

Based on multiple randomized clinical trials, there is good evidence for the efficacy of these ST-Mindfulness programs for preventing mood disorders in people at high risk of depression (Teasdale et al., 2000a,bMa and Teasdale, 2004Segal et al., 2010Fjorback et al., 2011Piet and Hougaard, 2011), improving mood and quality of life in chronic pain conditions such as fibromyalgia (Grossman et al., 2007Sephton et al., 2007Schmidt et al., 2011) and low-back pain (Morone et al., 2008a,b), in chronic functional disorders such as IBS (Gaylord et al., 2011) and in challenging medical illnesses, including multiple sclerosis (Grossman et al., 2010) and cancer (Speca et al., 2000). ST-Mindfulness has also been shown to decrease stress in healthy people undergoing difficult life situations (Cohen-Katz et al., 2005), such as caring for a loved-one with Alzheimer’s disease (Epstein-Lubow et al., 2006).

Numerous behavioral and neural mechanisms have been proposed to explain these positive outcomes. Proposed mechanisms include changes in neural networks underlying emotion regulation (Holzel et al., 2008), illustrated by findings showing decreased amygdala response after ST-Mindfulness in social anxiety patients exposed to socially threatening stimuli (Goldin and Gross, 2010). Other neural mechanisms highlighted in recent reviews include changes in self-processing (Vago and Silbersweig, 2012) based on multiple studies including a report showing decreases in activation in midline cortical areas used in self-related processing in ST-Mindfulness trained subjects (Farb et al., 2007).

In the first 2 weeks of the 8-week ST-Mindfulness sequence, all formal practice is devoted to a meditative body scan practice of “moving a focused spotlight of attention from one part of the body to another.” Through this exercise, practitioners are said to learn to feel (1) how to control the attentional spotlight even when focusing on painful, aversive sensations (2) how even familiar body sensations change and fluctuate from moment to moment.

In the last 5–6 weeks of class, participants continue to use embodied practices, especially sitting meditation focused on sensations of breathing. These embodied practices are said to teach practitioners (1) how to directlyfeel when the mind has wandered from its sensory focus (2) how to use an intimate familiarity with the fluctuations of sensations of breathing (such as the up and down flow of the breath) as a template for regarding the arising and passing of distressing, aversive thoughts as “mental events” rather than as “facts or central parts of their identity.”

Specifically, we propose that body-focused attentional practice in ST-Mindfulness enhances localized attentional control over the 7–14 Hz alpha rhythm that is thought to play a key role in regulating sensory input to sensory neocortex and in enhancing signal-to-noise properties across the neocortex. Beginning with the enhanced modulation of localized alpha rhythms trained in localized somatic attention practices such as the body-scan, and then proceeding through the 8-week sequence to learn broader modulation of entire sensory modalities (e.g., “whole body attention”) practitioners train in filtering and prioritizing the flow of information through the brain.

In chronic pain situations, nearly all studies of ST-Mindfulness show relief of pain-related distress and increased mood.


A Pilot Study Evaluating Mindfulness-Based Stress Reduction and Massage for the Management of Chronic Pain

Studie på Mindfulness mot kroniske muskelsmerter som sammenlignet effekten av muskelterapi (inkl. bindevev og nevromuskulær behandling – konsepter vi behandler etter på Verkstedet). Muskelterapi var bedre enn Mindfulness mot smerte, men Mindfuness var bedre for psyken på lang sikt. Selv 1 måned etter 8-ukers programmet. Meditasjonsprogrammet vi har på Verkstedet er Verkstedet Breathing System, som gjennom pusten skaper meditative opplevelser og reduksjon av smerte.


It is feasible to study MBSR and massage in patients with chronic musculoskeletal pain. Mindfulness-based stress reduction may be more effective and longer-lasting for mood improvement while massage may be more effective for reducing pain.

Mindfulness-based stress reduction is a mind-body intervention described by Kabat-Zinn.18 The participants met weekly for eight 2½ hour sessions. Meditation and yoga techniques were practiced to foster mindfulness (present moment, nonjudgmental awareness). Audiotaped meditation exercises were assigned as daily home practice. Participants were encouraged to use these skills in moments of stress and/or pain.

One-hour massage sessions were given once per week for 8 weeks by 3 licensed massage therapists. Massage techniques were at the discretion of the therapists and included Swedish, deep-tissue, neuromuscular, and pressure-point techniques. We specifically excluded music, scented oils, and energy techniques such as Reiki or therapeutic touch.

Meditation Programs for Psychological Stress and Well-being

En metaanalyse av studier på meditasjonsprogrammer. Konkluderer med at effekten er såpass stor og viktig at leger bør prate med sine pasienter om meditasjon.


Mindfulness meditation programs had moderate evidence of improved anxiety (effect size, 0.38 [95% CI, 0.12-0.64] at 8 weeks and 0.22 [0.02-0.43] at 3-6 months), depression (0.30 [0.00-0.59] at 8 weeks and 0.23 [0.05-0.42] at 3-6 months), and pain (0.33 [0.03- 0.62]) and low evidence of improved stress/distress and mental health–related quality of life.

Clinicians should be aware that meditation programs can result in small to moderate reductions of multiple negative dimensions of psychological stress. Thus, clinicians should be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress.

Reviews to date report a small to moderate effect of mindfulness and mantra meditation techniques in reducing emotional symptoms (eg, anxiety, depression, and stress) and improving physical symptoms (eg, pain).7– 26

Among the 9 RCTs43,44,47,54,55,63,64,73,74 evaluating the effect on pain, we found moderate evidence that mindfulness-based stress reduction reduces pain severity to a small degree when compared with a nonspecific active control, yielding an ES of 0.33 from the meta-analysis. This effect is variable across painful conditions and is based on the results of 4 trials, of which 2 were conducted in patients with musculoskeletal pain,55,64 1 trial in patients with irritable bowel syndrome,43 and 1 trial in a population without pain.44 Visceral pain had a large and statistically significant relative 30% improvement in pain severity, whereas musculoskeletal pain showed 5% to 8% improvements that were considered nonsignificant.