One of the most important challenges facing nursing today is providing proper pain management for patients suffering from chronic pain (1). Chronic pain ranks high as a major health problem in contemporary society and treating the chronic pain epidemic is paramount for the health care system. According to recent surveys 100 million US adults suffer from chronic pain (2) and one in five people in Europe and developing countries are affected (3). Problems associated with this epidemic are far reaching when considering the enormous social costs resulting from it, the immensurable burden borne by family members of pain sufferers, the inadequateness of opioid treatments, which too often cause addiction, and the very poor quality of life pain sufferers endure, worsened by social stigma and isolation (4).
Chronic pain is not only difficult to diagnose and to treat but becomes irreversible and often degenerative and as the body changes, psychological states are also affected (4). In order to manage this condition, opioid analgesics have been used for a long time. However, the associated side effects cannot be overlooked (e.g., nausea, vomiting, constipation, sedation, itchiness, urinary retention, cognitive impairment, hallucinations, delirium, respiratory depression, tolerance, and risk of physical and psychological dependence). These are of great concern especially when opioid analgesics are administered over prolonged periods. Furthermore, their analgesic efficacy for extreme procedural pain is limited (5). As a result of the strong psychological component of pain perception, supplemental use of non-pharmacological analgesic techniques, such as mindfulness meditation, have proved highly effective (6).
The mindfulness meditation
This literature review will describe mindfulness meditation and the areas of the brain affected by it and by the experience of pain, in an effort to show a strong correlation between these two experiences inasmuch as by manipulating sensations and emotions emerging from pain through mindfulness meditation, the pain experience itself will be altered. It will discuss the advantages of “simulated mindfulness” meditation, or Virtual Reality (VR) technology assisted, compared to more traditional forms. It will argue the importance of introducing this kind of technique to patients suffering from chronic pain as an effective therapy for self-monitoring and self-regulating their experience of pain with the purpose of enabling them to exercise an active role over their well-being. The concepts of distraction and focused attention will be emphasised with the aim of distinguishing between the use of VR technology in general in supporting the treatment of chronic pain and the use of this technology as an aid to practise meditation.
Chronic pain is defined as “pain that lasts for more than 6 months and persists beyond its putative cause and it involves neurobiological, psychological and social dimensions” (7). It is a very complex experience that affects the whole being, requiring a multidisciplinary approach to address mind, body and social issues (4). This correlates to the definition of health given by the World Health Organization, which defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (8).
Therefore, the challenges associated with such a diverse set of chronic-pain conditions and the enormous public health costs have been the catalysts for an explosion of research on persistent pain in the last decades (9). Because chronic pain is incurable, the approach is that of “managing” this condition, which includes both short-term and long-term forms of “neuroplasticity” facilitated by practices such as mindfulness meditation.
Mind-body therapies, in fact, use and increase the mind’s ability to be aware of and to self-regulate symptoms. In this regard, extensive research has shown that mindfulness meditation lowers stress, which intensifies the perception of pain, ameliorates depression, anxiety and fatigue, associated with increased pain, enhances copying ability and immune responses, and reduces pain (10-14). In fact, the goal in treating chronic pain is not to eliminate the pain but to increase patients’ quality of life (15).
According to a review of centres for pain medicine in North America meditation has in fact become a commonly recommended tool for self-managing pain. Thus, the approach to treatment in these centres is regarded as a long-term set of strategies, usually by shared efforts of multidisciplinary teams of physicians with various fields of expertise, nurses, psychologists and other healthcare practitioners (4).
Mindfulness meditation can ben defined as “a state of awareness characterized by full attention to, and awareness of, the internal and external experience of the present moment” (11, p. 2). The meditator gets into a comfortable position and the session starts with a concentration practice, by focusing attention on some concrete entity, usually the breath, followed by mindfulness practice. The meditator becomes an external witness who merely observes whatever emerges into consciousness with full awareness, without analysing or judging (11). Through self-observation presence is created, which is needed when certain situations trigger a reaction with a strong emotional charge, which in turn changes the biochemistry of the body. Presence allows to deal with difficult situations, emotional and physical pain, fear, intense negativity, anger, aggression and depression by giving focussed attention to present reactions, moods, thoughts, emotions, fears and desires, allowing the person to freely decide the way he/she is going to react, hence shaping his/her own reality in the present (16).
This process can be complicated for beginners and if they will not be able to stay focussed and present while immersing themselves in meditation, they might get discouraged and feel they are not achieving anything. Furthermore, patients might just have difficulty imaging. Therefore “simulated meditation” assisted by the use of technology helps create, guide and maintain a user’s meditation experience. Immersion and presence play an important role when combining VR and mindfulness meditation techniques for pain management (8).
It is generally recognised that technology is a useful way to enhance and reinforce meditation as the extensive use of CDs, DVDs, and online resources suggests. However, VR, integrated with biofeedback technologies, is a breakthrough since it offers something unique that enables users to see their intentional efforts to affect their continuously changing autonomic states. Using VR helps speed the learning process of meditation and allows patients to concentrate on a specific task by diverting their attention inward, to their physiological processes (8).
Studies showed that simulated coached training mediation is much more effective in helping patients create a regular practice than self-administered training using written and audio materials. The coached groups, in fact, appeared to have a higher sense of self-efficacy in establishing a regular mindfulness practice.
The virtual coach supports some non-verbal interaction, by displaying affective and conversational expressions adapting to the content of the dialogue with the user. In this way, personalised coaching affect-adaptive feedback is provided, such as smiling when the user reports success and expresses concern and verbal encouragement when the user reports a problem. Furthermore, the coach is able to support several types of pedagogical strategies necessary for effective training of mindfulness meditation and for initiating and maintaining a regular practice, such as information about techniques, associated health benefits, experiential learning, supportive and coaching interaction, intended for maintaining users’ motivation via empathic dialogue and tailored advice (11).
Another project called “Virtual Meditative Walk” (VMW) is very successful in creating a virtual environment that provides feedback to users and allows them to learn and practise mindfulness meditation to help self-manage their pain. Findings show that it improves patients’ ability to enter a meditative state by sensing and collecting biofeedback changes in real-time. The collected data then gets translated into visual and auditory feedback. For instance, galvanic skin response, which can detect arousal based on skin conductivity, controls the amount of fog patients can see in the virtual environment. When patients learn how to reduce arousal, which is correlated with stress, the fog dispels. Furthermore, using this device to learn and practise mindfulness meditation enables higher cognitive empathy, which leads to positive well-being, which ultimately may be used as a non-pharmacological alternative to chronic pain management. The VMW is able to empathise with the patient since it collects data, understands it and continuously communicates with patients. Biofeedback in this case is the empathic component in the interactive system, which enables patients to obtain an immediate response on their physiological states, proving that empathy can be embedded in technology. As a result, the real-time feedback that the system provides increases the levels of control users can learn to exert over their body. Therefore, it can be argued that by teaching mindfulness meditation to patients in this context, patients’ health can be improved over time (4,17). In this regard, some studies combined the use of VR and biofeedback technologies to determine if the immersion and biometrically-driven real-time feedback could help users achieve a meditative state. Findings confirmed that biofeedback was useful for enabling users to get real-time feedback and to gain a sense of agency or control over their heart rate, respiration, and galvanic skin response. It also indicates relative changes in physiological arousal and, after decades of testing, is considered to be a reliable indicator of attaining a meditative state (4,17).
Moreover, it has been noticed that the level of interaction affects pain tolerance because the more control patients exert on the VR environment they are in, the more “present” they feel, and thus more distracted they become from their pain. In fact, VR has been created to induce a strong feeling of “presence” and produce an experience of actually being in the simulation. How the level of presence in a VR environment influences pain reduction was the objective of a study which revealed that the degree of how “present” one feels in a virtual world and how active the interactions are within this world have a significant effect. Along this line, a study showed that it is the level of interaction allowed within a VR world that affects pain tolerance (18).
An extensive body of research demonstrated the efficacy of VR in reducing stress, anxiety and fear associated with chronic pain (19, 20) since it is an effective medium for distraction in a constructed space where the borders of reality are distorted and real life effects can be produced. Furthermore, studies confirmed that, technology can trigger behaviour changes in the long term (21) and since VR systems are also compatible with biosensors and brain imaging devices, they make a comprehensive assessment of the global effects of pain and chronic pain syndromes possible (19).
However, the key in mindfulness meditation is focused attention and acceptance instead of avoidance (22), which distinguishes this practice from other techniques employing the use of VR to create a sense of presence and induce immersion. These techniques, in fact, use distraction in an immersive context as a means of copying with chronic pain. Research confirmed, in fact, that distraction is a potent analgesic and the pain-reducing effects of distraction have been recognized for decades. Diverting attention away from a noxious stimulus can diminish self-reported pain intensity by 30 to 40% and correspondingly reduces noxious-stimulation-induced activity in pain-processing regions of the cortex by well over 50% in many studies; that is comparable to or greater than the effects of potent analgesics such as opioids. Indeed, Hoffman et al. (7) suggested that opioid analgesic medications and a powerful VR distractor task can interact to produce analgesic effects, highlighting the potential for maximizing pain relief in clinical settings applying multimodal interventions (9).
However, more extensive studies have revealed that pain distraction is not an appropriate strategy for long-term pain management and according to Hoffman et al. (7), distraction is only seen as a short-term strategy for diverting attention. In fact, pain perception is not a passive process in which the intensity of an external stimulus is coded and faithfully transmitted by peripheral fibres, through to the spinal cord and brain. Rather, pain-related sensory information is modulated at all levels of the nervous system where a variety of networks play a role in inhibiting or facilitating the perception of pain. Collectively, coping processes activate multiple modulatory networks within the brain, and these act to regulate the experience of pain (9). Therefore the goal of mindfulness meditation is not to distract patients from their experience of pain but to empower them with the necessary skills to manage attention in order to consciously and physiologically exert control over their pain through self-regulation and technology can support this process and enhance this practice and its outcomes (4). VR assisted meditation can support self-modulation by helping to relax and meditate, which are the primary ways in which chronic pain sufferers can control their own pain at will. Furthermore, one of the most often reported aspects of chronic pain that lead to depression is a sense of helplessness (4) that stems from a lack of cure and the difficulty of treating and managing this degenerative condition.
As a matter of fact, in order to experience pain conscious attention is required as demonstrated by new advancements in neuroscience, which show that the pain experience, like consciousness, is not located in one area of the brain. Instead, perception of pain is located within various complex pathways in the brain and occupies the same spaces where emotions, attention, and fear among others, are produced. It is for this reason that the subjective description of pain is highly variable and it is important to emphasize that both meditation and pain are subjective experiences. This is why the role of attention is crucial since it modulates perception by allocating finite processing resources to various internal and external events. It has therefore the potential to amplify behavioural and physiological responses to relevant events, those attended to, and to attenuate responses to those events that are not the object of attention (4, 23).
Furthermore neuroimaging studies of meditation suggest that such processes may activate the same descending pain-inhibitory pathways that are involved in distraction. For instance, a structural MRI study revealed that expert meditation practitioners showed increased thickness in regions of the prefrontal cortex, an important centre of descending pain-inhibitory processes (9). Moreover, fMRI research revealed that they also showed about 50% less activation of pain-processing brain regions during painful heat stimulation than controls did. This effect was observed even while individuals were not in a meditative state. Controls showed similar effects after 5 months of training in these techniques, suggesting that the potential pain-related benefits are not limited to long-term practitioners (9) even if the amount of time spent meditating has definitely enormous health benefits (24).
Therefore, both meditation and pain alter sensory, cognitive and affective dimensions of the individual subjective experience. A study using Arterial Spin Labelling functional magnetic resonance imaging assessed the neural mechanisms by which mindfulness meditation influences pain in healthy participants. The results showed that mindfulness meditation reduced pain-related activation of the contra lateral primary somatosensory cortex. Multiple regression analysis was then used to identify brain regions associated with individual differences in the magnitude of meditation-related pain reductions. It was noted how 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 pain perception processing. Reductions in pain unpleasantness ratings were associated with orbitofrontal cortex activation, an area implicated in reforming the contextual assessment of sensory events. Consequently, it can be concluded that meditation employs multiple brain mechanisms that alter the construction of the subjectively available pain experience from afferent information (18). In a study 15 adults were taught how to meditate for 20 minutes a day for four days and consequently exposed to painful stimuli. Brain scans before and after showed that during meditation, they had less activity in the primary somatosensory cortex, the part of the brain that registers where pain is coming from, and greater activity in the anterior cingulate cortex, which plays a role in handling unpleasant feelings. Subjects also reported feeling 40% less pain intensity and 57% less unpleasantness while meditating (25).
Other studies showed that chronic pain represents a malfunction in the brain processing systems and that how people think about pain has a major impact on how it actually feels. The pain signals take detours into areas of the brain involved with emotion, attention and perception of danger and can cause grey matter to atrophy. This dysfunction induces patients into a vicious cycle of increased pain, anxiety, fear, and depression. This cycle can be interrupted since mindfulness meditation redirects attention away from the pain to breath, sounds, and guided imagery.
In a study patients could watch their brain reactions to pain in real time and learn to control their response, which led them to ease their own pain significantly (25).
This is of great importance when considering that witnessing how the brain reacts to pain, medication, and pain reducing stimuli can help sufferers learn to control how they perceive pain by allowing them to gain control over their experience, through self-management and self-regulation (19, 21). In addition, learning how the brain processes information will help determine what tactics have the greatest effect on reducing pain and the adaptability of VR will provide patients with individualized treatments (18).
The acknowledgement of patients’ central role in promoting and managing their own health is essential and the encouragement of active self-care through complementary and integrative techniques is the gateway for a more diverse, patient-centred treatment of such complex symptoms (26). Thus, when patients have developed the ability to manage their attention and awareness, they will be able to exert agency over their experience of pain and become more independent in promoting their well-being.
This literature review discussed the role of simulated mindfulness meditation or VR technology assisted, in self-managing and self-regulating chronic pain. It provided evidence on how mindfulness mediation can influence and ultimately change the subjective experience of pain in order to provide a way for improving the quality of life of chronic pain sufferers. It argued that fostering focussed attention, which is the core of mindfulness meditation, is more effective, in the long term, than using distraction.
It therefore advocates a systematic use of this technique in the treatment of chronic pain due to its efficacy, long-term benefits, easiness to learn and teach and very low costs. For this reason, more effort, time and money should be invested in finding access to expert teachers and sound training programs, for adequately training healthcare providers, teaching and assisting patients in developing the necessary skills for self-managing their pain by giving them the invaluable tools to exert direct control over it and gain a greater sense of agency over their health.
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