Mindfulness-Based Therapy for Military Populations with Chronic Pain: A Systematic Review

Abstract

Background:

Due to the limited role of chronic pain medication in military personnel and the distress caused to the military population, mindfulness-based therapy has been considered for the follow-up treatment of military personnel with chronic pain. The purpose of this review is to explore the effect and the implementation of mindfulness-based therapy for the military population with chronic pain.

Methods:

The keywords for the search included “mindfulness” AND (“pain” OR “chronic pain”) AND (“military” OR “veteran”). The PubMed, Embase, and Cochrane Library databases were searched. The Cochrane Collaboration tool was used to independently assess the risk of bias of the included randomized controlled trials, and the Newcastle–Ottawa Scale was used to independently assess the risk of bias of the included case–control studies.

Results:

A total of 175 papers were identified; 65 duplicates were excluded, and 59 papers that did not meet the inclusion criteria were excluded after reading the titles and abstracts. The remaining 51 papers were read in full, 42 of which did not meet the inclusion criteria. Nine papers met the inclusion criteria and were included in the study. The nine studies included 507 veterans and 56 active-duty female military personnel. All pain interventions were mindfulness-based therapy, and all of them were integrated into or adapted from standard mindfulness courses. The results all showed that after mindfulness-based therapy, the relevant indicators improved.

Conclusions:

Mindfulness-based therapy is an effective treatment method for the military population with chronic pain. The review indicates that future research should focus on the best setting for mindfulness-based therapy, including the course content and time.

Introduction

Mindfulness-based therapy helps participants explore themselves, discover physical and mental resources, connect with their inner wisdom, enhance their ability to come out of the emotional entanglement of pain, and cultivate their concentration and awareness so that they can focus on their current life.¹ Mindfulness-based therapy has achieved good results in the treatment of chronic pain patients, effectively relieving the distress caused by the pain.² Armed Forces are a population of particular importance, as veterans report greater pain prevalence and greater pain severity than civilians.³ Military training injuries and war trauma are both accompanied by severe pain. Many such patients have chronic pain in their prognosis, and chronic pain is very widely considered as a significant adverse factor for the quality of life of veterans.⁴ According to the former study, it showed that the prevalence of chronic pain in military veteran occupations ranged from 25% to 72%.⁵ In the U.S. military, a study found that 63% of the nondeployed active-duty soldiers in the study had at least one pain diagnosis and 59% of them had a primary pain diagnosis.⁶ A Longitudinal Study of Prevalence Ratios for Musculoskeletal Back Injury Among U.S. Navy and Marine Corps Personnel, 2009–2015, demonstrated that the prevalence of back pain showed an upward trend, ranging from 9.99% in 2009 to 12.09% in 2015.⁷ Active-duty military service members and veterans are high-risk groups for pain^8,9 due to the limited therapeutic effect of drugs, which often have side effects and become addictive.¹⁰

It is meaningful that growing research on the application of mindfulness-based therapy to military personnel may provide an adjuvant treatment method for chronic pain. However, there is no unified standard for the design or application of mindfulness-based therapy for soldiers with chronic pain. The content of the interventions is diverse, and the work of active-duty soldiers is complex, making it difficult to effectively implement the courses. Previous studies showed that chronic pain soldiers often have complex symptoms, such as depression, posttraumatic stress disorder (PTSD), and insomnia, whereas mindfulness-based therapy helps to reduce chronic pain intensity and improve complex symptoms.⁶

The purpose of this systematic review is to explore the effectiveness of mindfulness for the treatment of chronic pain in military personnel, the settings and implementations of mindfulness courses, and the shortcomings of mindfulness-based intervention for chronic pain with other symptoms.

Methods

Search strategy

To identify relevant studies on mindfulness-based therapy for military personnel with chronic pain, we searched for “mindfulness” AND (“pain” OR “chronic pain”) AND (“military” OR “veteran”) in PubMed, Embase, and Cochrane Library (see search strategy in Supplementary Data S1).

The reference lists of the included publications were manually searched to identify relevant articles that were not found in the original search. The study was utilized the PRISMA 2020 checklist as a guideline in supplementary material (see Supplementary Data S2 in supplementary material).

Study eligibility criteria

The search cutoff was December 31, 2022. The inclusion criteria were as follows: (1) the language was English; (2) the population of the study was active-duty military personnel or veterans; (3) the article assessed pain; (4) the study implemented a mindfulness-based treatment for pain; (5) the study is a case–control study, cohort study, or randomized controlled trial (RCT); and (6) intervention addresses chronic pain, defined as pain occurring more than 3 months is considered as chronic pain. The exclusion criteria were as follows: (1) the research subject does not have any accompanying pain symptoms, and (2) mindfulness-based therapy did not directly address the symptoms of pain itself.

Data extraction

The following data were extracted from eligible studies by two independent authors using Excel 2010: study author, year of publication, population, sample size, intervention duration, intervention type, control group, detection scales for pain, concomitant symptoms, and outcomes. Data on concomitant symptoms were extracted to understand the complexity of the disease in the military population and to provide further information for mindfulness-based therapy to follow-up on complex symptoms. If there were disagreements, a third reviewer would have been consulted, but this did not occur.

Quality assessment and risk of bias assessment

The first and second authors used the Cochrane Collaboration tool to independently assess the risk of bias in the included RCTs. The Cochrane Collaboration tool for assessing risk of bias aims to make the process clearer and more accurate in RCTs.¹¹ For each trial, the risk of bias was rated as high, low, or unclear for the following domains: random sequence generation, allocation concealment, blinding (participants and personnel), blinding (assessment of outcomes), attrition, and selective reporting. Disagreements between the first and second implementation authors were resolved by discussion until a consensus was reached.

For the case–control studies, the first and second authors used the Newcastle–Ottawa Scale to independently assess the risk of bias in the included case–control studies. Nonrandomized studies included in this review were critically assessed, using an adapted version of the Newcastle–Ottawa quality assessment scale.¹² For each study, the risk of bias includes three aspects: selection, comparability, and exposure.

Results

Included studies

A total of 175 papers were retrieved from PubMed (n = 55), Cochrane (n = 43), and Embase (n = 77). Among them, 65 duplicate studies were identified and excluded, and 59 papers were excluded because their titles and abstracts did not meet the inclusion criteria. The remaining 51 papers were read in full, 42 of which did not meet the inclusion criteria, so nine papers were included in the study.^{13

–21} The nine studies included 563 active-duty military personnel or veterans. The literature inclusion process is shown in Figure 1. The relevant information from the nine studies is shown in Table 1. Table 2 shows the risk of bias ratings for the included RCTs (n = 2). There were only two RCTs out of nine studies, so there was a high risk of bias for inclusion. Table 3 shows the risk of bias ratings for the included case–control studies (n = 7). The Newcastle–Ottawa Scale rated three studies as moderate quality and four studies as high quality.

FIG. 1.

Flow chart of the inclusion and exclusion processes.

Table 1.

Search Results

Authors	Population	Sample	Mean age	Female	Time	Intervention type and comparison group (group based)	RR/OR (95% CI)	Pain detection scale	Accompanying symptoms	Findings
Williams et al.¹³	Veterans	n = 328	53.2	84 (25.6)	8 weeks	Mindfulness meditation (108) vs. hypnosis (110) vs. education control (110)	None (−3.83, −3.05)	API	Depression, PTSD, anxiety, sleep disturbance	Greater decreases in API and pain interference
Crisp et al.¹⁴	Military women	n = 15	21–46	15 (100.0)	8 weeks	MBSR (15) training program vs. baseline	None	BPI	Cytokine detection	Promoted mindfulness, reduced pain, and promoted modulation of select proinflammatory cytokines
Crisp et al.¹⁵	Military women	n = 41	21–55	41 (100.0)	6 weeks	MBSR (21) vs. self-paced healthy lifestyle (20)	None	BPI	Depression	Reduced pain perception
Kearney et al.¹⁶	Veterans	n = 55	51.3 ± 6.8	8 (14.5)	8 weeks	MBSR (26) vs. treat as usual (29)	None	SF-MPQ-2; a 22-item measure of pain	Depression, PTSD	Greater reductions in pain
Eaton et al.¹⁷	Veterans	n = 22	48.9 ± 15.2	4 (18.2)	8 weeks	Mindfulness-based care for chronic pain (22) vs. baseline	None	RMDQ, pain bothersomeness, pain intensity, CPAQ	Depression (the Patient Health Questionnaire-9, PHQ-9), functional impairment	Clinically meaningful decrease in pain intensity and in depressive symptoms; meaningful decrease in pain bothersomeness and functional impairment
Vowles et al.¹⁸	Veterans	n = 37	50.5 ± 10.5	5 (13.5)	12 weeks	Acceptance and commitment therapy and mindfulness-based relapse prevention (None) vs. usual care (None)	None	Opioid misuse, pain interference, and pain behavior	Opioid misuse	A significant effect in favor of the integrated intervention for opioid misuse, pain interference, and pain behavior
Thomas HN.¹⁹	Veterans	n = 9	47.7	0 (0)	8 weeks	Mindfulness meditation (4) vs. routine medical treatment (5)	None	The numeric rating scale and VAS, BPI, DVPRS	Depression, mood disorder, sleep disturbance	Clinically meaningful reduction in pain intensity, lowered pain interference
Rae et al.²⁰	Veterans	n = 20	51.0	3 (15.0)	8 weeks	Yoga class with mindfulness (10) vs. stretching without mindfulness (10)	None	PEG (an ultrabrief, three-item scale derived from the BPI)	None	Has the potential to alleviate low-back pain
Okvat et al.²¹	Female veterans	n = 36	51.8 ± 10.8	36 (100.0)	8 weeks	A mindfulness-based pilot program (36) vs. baseline	None	Pain catastrophizing, pain interference and functioning, pain self-efficacy, chronic pain diagnoses	Mood disorder, PTSD, depression	Moderate-to-large pre–post improvements in pain severity, pain catastrophizing, physical functioning, depression, self-compassion, and positive affect

API, average pain intensity; BPI, Brief Pain Inventory; CPAQ, Chronic Pain Acceptance Questionnaire; DVPRS, Defense and Veterans Pain Rating Scale; MBSR, mindfulness-based stress reduction; PHQ-9, Patient Health Questionnaire-9; PTSD, posttraumatic stress disorder; RMDQ, Roland Modified Disability; SF-MPQ-2, Short-form McGill Pain Questionnaire; VAS, Visual Analogue Scale.

Table 2.

Risk of Bias for the Included Randomized Controlled Trials

Citation	Random sequencegeneration	Allocationconcealment	Blinding (participantsand personnel)	Blinding (outcomeassessment)	Attrition	Selective reporting
Vowles et al.¹⁸	Unclear	Low risk	High risk	Low risk	Low risk	High risk
Rae et al.²⁰	Low risk	Low risk	High risk	Low risk	Low risk	High risk

(n = 2), evaluated using the Cochrane Collaboration tool.

Table 3.

Risk of Bias for the other Article (N = 7), Evaluated using the Newcastle–Ottawa Scale

Citation	Selection^a	Comparability^a	Exposure^a	Qualityscores^b
Williams et al.¹³	****	**	***	9
Crisp et al.¹⁴	***	*	**	6
Crisp et al.¹⁵	****	*	***	8
Kearney et al.¹⁶	***	*	***	7
Eaton et al.¹⁷	***	*	**	6
Thomas HN.¹⁹	****	**	***	9
Okvat et al.²¹	***	*	**	6

The number of the “*” stands for the quality scores.

1–3: low quality; 4–6: moderate quality; 7–9: high quality.

Characteristics of the research participants

The nine studies included 507 veterans, 196 of whom were female. Two studies included 56 active-duty female military personnel, and one study included 36 female veterans. Veterans were mainly managed by the Ministry of Veterans Affairs, so it was more practical to implement mindfulness-based therapy in veterans through this office.

Intervention implementation

All pain interventions were mindfulness-based therapy, and all of them were integrated into or adapted from standard mindfulness courses. The most commonly used method in the included studies was mindfulness-based stress reduction (MBSR), with three studies using MBSR as a pain intervention.^14
–16 Eaton et al.¹⁷ used a mindfulness-based care course specifically for veterans with back pain. Vowles et al.¹⁸ applied a mindfulness-based relapse prevention curriculum for military personnel with opioid abuse for chronic pain. The sessions usually ran once a week, ranging from 90 to 150 min each. Some courses included a 6-h mindfulness day course,¹⁴ seven studies were 8-week mindfulness courses, one study was a 6-week mindfulness course,¹⁵ and one study was a 12-week mindfulness course with acceptance-commitment therapy.¹⁸ The content of mindfulness courses included common mindfulness meditation, breath awareness, mindful eating, mindful listening, and other courses related to pain cognition, providing references for implementation.

Control conditions

Of the nine included studies, there were a total of 10 control criteria: three baseline controls, three treat as usual, and one each of hypnosis, educational control, self-paced healthy lifestyle, and stretching without mindfulness.

Pain outcome measures

Measures of pain relied primarily on pain intensity,^13,17
–19 and the most common measurement scale was the Brief Pain Inventory (BPI, 13 items).^14,15,19 Studies also applied several other assessment methods, including pain anxiety, pain perception, and measurement tables, such as the PEG scale (pain, enjoyment of life, and general activity)²⁰ and pain catastrophizing.²¹ The results all showed that after mindfulness-based therapy, the relevant indicators improved. The study by Kearney et al.¹⁶ showed that in intention-to-treat analyses, at 6-month follow-up, veterans, involving two or more regions of the body pain, randomized to mindfulness plus treatment as usual reported greater reductions in pain compared with treatment as usual only. Eaton et al.’s study¹⁷ showed that 5 of the 11 veterans had a clinically meaningful decrease in pain intensity and depressive symptoms, whereas 6 of 11 veterans had a meaningful decrease in pain bothersomeness and functional impairment. Outcome measures of pain included before-and-after mindfulness-based therapy measures; multiple measurements were also taken during treatment, which showed that the pain levels of the participants who received mindfulness gradually decreased over time. Therefore, the pain measurement method is important to the effective implementation of mindfulness-based therapy for soldiers and the effect validation.

Comorbidities

Six studies^{13,15
–17,19,21} reported that depression symptoms or scores were relieved after treatment. Depression was measured by the PHQ-9. Three studies with PTSD as a comorbidity showed alleviation of PTSD symptoms or reduction in scores.^13,16,21 One study¹⁸ examined chronic pain veterans with drug abuse problems, and results support the feasibility of providing integrated treatment for both opioid risk and pain interference. The physical condition of soldiers with pain is complex, and PTSD, depression, and drug abuse are typical comorbidities that are more likely to be found together in the military population. One study¹³ showed effective improvement of anxiety symptoms and reduction in Patient Reported Outcomes Measurement Information System (PROMIS) anxiety score. One study¹⁷ showed effective improvement of functional impairment. One study¹⁹ showed effective improvement of mood disorder and sleep disturbance.

Discussion

1. Mindfulness is an effective coping approach for military personnel with chronic pain. The nine studies included in this article all demonstrated the effectiveness of mindfulness-based therapy for military personnel with chronic pain, as their pain levels were reduced after the therapy. Mindfulness-based therapy has been proven to be effective for the general population and has been the target of corresponding guidelines or standard courses.²² For the military chronic pain population, the context in which the pain occurs is different. Although these nine studies have proven their effectiveness, as only two are RCT studies, further normative research is needed to confirm the effectiveness of mindfulness intervention in chronic pain treatment for military personnel. Due to the training and combat needs of service members, pain treatment is necessary to lessen the impact on daily work and life. Furthermore, as the special group of soldiers, their psychological states are unique. The effect of mindfulness-based therapy, as a type of cognitive-behavioral intervention therapy, on the military population needs to be further confirmed. The main purpose of the outcome measurement is to better measure the pain level of patients, to compare their ratings before and after the test, and to provide more accurate support for mindfulness-based therapy.

2. Mindfulness-based therapies for military personnel with chronic pain were adapted from standard mindfulness courses in this study findings. Mindfulness-based therapy courses mainly include MBSR therapy and mindfulness-based cognitive therapy. In this study, the content of therapy courses of included researches is diverse. Previous researches suggested more than 10 kinds of mindfulness courses suitable for different diseases have been developed, most of which are 8-week standard courses that are widely used in various general groups and have good effects. Brintz et al.²³ studied factors such as the timing of the assessment intervention, the development process, and the method of course implementation, and an online mindfulness course was developed for military service members. The course underwent military-focused adjustment by combining military culture, language, terminology, practical and logistical factors, etc. Crisp et al.¹⁴ highlighted that a standard MBSR program is difficult to implement in the active-duty military population, and other forms of programs may be considered. Therefore, it is still necessary to improve the curriculum design for the military population and come to a relatively unified and standard curriculum system.

Due to the daily work and training of active-duty military personnel, it is difficult for standard mindfulness-based therapy programs to be implemented in the active-duty population, and other forms of mindfulness-based therapy should be considered. Mindfulness-based therapy needs to be done at a specific time and in a relatively quiet and suitable place. Still, the working hours and the workplace of active-duty military personnel are not fixed, making it difficult to implement mindfulness-based therapy. Therefore, in our included studies, veterans accounted for the vast majority of the study population. According to Huberty et al.,²⁴ mindfulness meditation offered through a mobile phone app may be an attractive and effective way to reduce stress among college students. Brintz et al.²⁵ solved the problem of low attendance and acceptability of the study population caused by the length of the course by designing a 4-week mindfulness course for people with chronic pain, which effectively improved the attendance rate and acceptability of the study population and thus improved the pain indicators. In the future, we can consider adopting online courses, miniaturization, and flexible course implementation methods, which might be more convenient to carry out in the active-duty military population.

3. Chronic pain combined with other symptoms in military personnel should be comprehensively considered in mindfulness-based interventions. Due to the high occurrence of first-hand witnesses of traumatic events and deaths, most veterans, who are survivors of war, are vulnerable to PTSD.^26
–28 Therefore, when considering soldiers with chronic pain, the impact of PTSD on treatment should be considered, and even combined treatment should be used to relieve pain while treating PTSD. Some studies demonstrated that mindfulness-based therapy can alleviate PTSD,^29,30 but there were only three studies included in our review. It is necessary to adjust the mindfulness-based treatment method in the future studies. Evidence on the effects of mindfulness-based therapy on PTSD is scarce and requires further examination in future work.

Depression is a mental disorder with a high prevalence but high clinical cure rate.³¹ Depression is also prevalent in military settings, often accompanied by negativity, and even suicidal tendencies.³² In previous studies, mindfulness had a good therapeutic effect on depression. There are already specialized courses for depression, and they have shown good improvement effects.³³ This parallels our findings. Mindfulness-based therapies can improve the pain combined with depression.

In addition, due to the severity of early pain, long-term use of opioid analgesics, nonsteroidal anti-inflammatory drugs, etc. leads to drug use dependence, especially when opioids exert analgesic effects, and they also have side effects caused by long-term dependence on analgesic medications.³⁴ Garland et al.³⁵ showed that mindfulness enhanced patient self-regulation and reduced opioid doses in response to an exacerbated opioid dose crisis in chronic pain patients. The findings in this study are in accordance with the literature. For the complicated pain with opioid abuse, it needs future evaluation.

The included patients in this study had comorbidities such as PTSD, depression, and substance abuse. From the results of our findings, mindfulness-based therapy alleviated not only pain but also other comorbid symptoms. Other studies also have suggested that mindfulness-based therapy can improve the ability of military groups to adapt to their working environment, improve the dynamic regulation of stress, and improve memory.³⁶ In the future, mindfulness-based therapy should be considered for the health maintenance of the military population. Future research may consider adding more relevant evaluation indicators besides pain in their evaluations to reflect the effect of mindfulness-based therapy better.

Limitations

The main limitation of this review is that the sample size of the included studies was relatively small, and there was a lack of universal methods and controlled studies.

For Further Research

In the future, we recommend conducting a large-sample, multicenter, randomized, controlled study to further clarify the effect of mindfulness-based therapy and facilitate its promotion and application. A standardized setting for mindfulness courses, including reasonable settings for content and time, can better meet the needs of the military population, including balancing mindfulness-based therapy and daily work. Enhancing transparency in data analysis and thorough presentation of results play a crucial role in improvements to the reporting of studies.

Conclusion

This article demonstrates the benefit of mindfulness-based therapy in the military population with chronic pain. There are still numerous aspects that can be improved to achieve better results. While effectively measuring and assessing the current status of pain, the application of information technology should be considered to reduce the burden of filling out forms for the participants undergoing treatment. What is more, the inclusion criteria of research subjects with comorbidities should be reasonable. Besides, mindfulness-based therapy courses for comorbidities should be adjusted for the lives of military personnel, and their effectiveness should be tested. There is a strong rationale for additional studies to enrich current research results. One can consider integrating mindfulness-based therapy into the military population’s pain rehabilitation treatment plan to improve the pain treatment outcomes based on more studies done in the future.

Footnotes

Acknowledgments

The authors thank all the participants involved in the study for their cooperation and kind help to collect data.

Authors’ Contributions

L.Z. and H.C. were responsible for the design and implementation of the study. Z.J. and Y.D. collected and analyzed the data, whereas H.-L.C. and B.L. drafted the article.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the Military Medical Science and Technology Youth Cultivation Program, No. 21QNPY032.

Supplementary Material

Supplementary Data S1

Supplementary Data S2

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Supplementary Material

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