Volume 4, Issue 12 (Winter 2018)                   Caspian.J.Neurol.Sci 2018, 4(12): 18-23 | Back to browse issues page


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Abdolghaderi M, Kafi S, Saberi A, Ariaporan S. Effectiveness of Mindfulness-Based Cognitive Therapy on Hope and Pain Beliefs of Patients With Chronic Low Back Pain. Caspian.J.Neurol.Sci. 2018; 4 (12) :18-23
URL: http://cjns.gums.ac.ir/article-1-215-en.html
1- Department of Psychology, Faculty of Educational Sciences and Psychology, Mohaghegh Ardabili University, Ardabil, Iran
2- Department of Psychology, Faculty of Literature and Humanities, University of Guilan, Rasht, Iran
3- MD Neuroscience Research Center, Department of Neurology, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
4- Department of Psychology, Faculty of Literature and Humanities, Malayer University, Malayer, Iran
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Introduction 
Chronic pain is defined as any pain lasting longer than 3 or 6 months [1] (depending on the type of pain), which can result in significant medical, social, and economic consequences; relationship issues; low productivity; and more substantial health care costs. Researchers and therapists have long been studying the development of chronic pain, and modelled the chronic pain through what is called the biopsychosocial model of pain. The biopsychosocial model explains how biology and genetic (bio), psychological functioning (psycho) and social environment (social) can contibute in pain perception and its management [2]. The famous gate control theory of pain proposes that the brain plays a dynamic and active role in pain perception as opposed to being a passive recipient of pain signals [3]. Hope refers to a positive expectancy of goal attainment [4]. Hope has been formerly a construct more of interest to philosophy and religion than in psychology. Recent research has demonstrated that hope is closely related to optimism feelings of control and motivation toward achieving one’s goals. Snyeder and colleagus have introduced a new cognitive-motivational model called hope theory [5-7]
Hope theory can be divided into four categories: 1. Goals which are valuable and uncertain are the anchors of hope theory as they provide direction and a target for hopeful thinking; 2. Pathway thoughts refers to the routes we take to achieve our desired goals and the individual’s perceived ability to produce these routes; 3. Agency thoughts refers to motivation we have to undertake the routes towards our goals; and 4. Barriers block the attainment of our goals, and in the event of a barrier we can either give up, or we can use our pathway thoughts to create new routes. 
Specific pain beliefs have been identified that contribute to poor compliance, motivation, and misunderstanding about pain. These include catastrophic, limited perception of control over the pain experience and emotional distress. Based on study reports, negative pain beliefs have a detrimental impact on patients’ overall health, self-efficacy, and function [8].
Chronic Low Back Pain (LBP) is a source of physical disability and diminished psychological functions [3, 9]. It can affect people of all ages from children to elderly and is a common reason for medical consultations. The lifetime prevalence of LBP ranges from 6% to 70% in industrialized countries [10]. Several studies have been performed in Iran to evaluate the prevalence of LBP [11-13]. The results showed that about 50% of Iranian population suffer from LBP. Despite numerous treatments for LBP, there is still a need for treatments with proven effectiveness, low risk, and widespread availability.
Various studies have demonstrated that mindfulness can alleviate chronic pain [14-17]. Based on ancient eastern meditation practices, mindfulness is characterized by paying attention to the present moment with openness, curiosity, and acceptance. Jon Kabat-Zinn began teaching mindfulness course at the University of Massachusetts Medical School in the late 1970s, which was later adapted for clinical settings [18]. Over the past 35 years, mindfulness-based interventions have provided a wealth of evidence over its use fullness in psychological stress, general well-being, and disorders ranging from anxiety and depression to substance use disorders [19, 20]. Mindfulness is becoming increasingly popular in Iran and is using by Iranian researchers for the treatment of psychiatric disorders [21] and physical problems such as LBP [3, 22]. The purpose and the question of this study were to examine the effectiveness of mindfulness on hope and pain beliefs of patients with chronic LBP.
Materials and Methods
This research was a quasi-experimental study with pre-test and post-test and a control group. The participants included 30 patients with LBP aged between 30 to 50 years (mean age=38.41 y) who were selected through convenient sampling method from Neurology and Neurosurgery Clinica affiliated to Guialn University of Medical Sciences. Patients with LBP who were diagnosed by a neurologist were placed randomly in two groups of experiment and control (n=15 each). Both group were matched on severity and duration of pain by the diagnosis of a neurologist. Inclusion criteria were having chronic LBP which lasted longer than six months. Patients who abused substance or had mental disorders were excluded from the study. MBCT programme was administered by an experienced psychologist for the experimental group (for each patient individually) one session per week for eight weeks. Each session lasted for 90 minutes. In the first session, the patients received relevant information about the fundamentals of mindfulness, its description and mindful living techniques. The contents of subsequent sessions are body scan, awareness of breath, sitting meditation, acceptance of thoughts and emotions and awareness of pleasant and unpleasant events (Table 1) [23]. Kabat-zinn [19, 20] introduced the protocol of MBCT that used in this study. The intervention was carried out for each person individually.
The instruments of this study were Adult Dispositional Hope Scale (Snyder hope scale), pain beliefs, and perceptions Inventory. Snyder hope scale is a 12-item measure of a respondents level of hope. In particular, the scale is divided into two subscales that comprise Snyders cognitive model of hope: 1. Agency (i.e., goal-directed energy); and 2. Pathways (i.e., planing to accomplish goals). Each item is rated using a 8-point Likert-type scale ranging form definitely false to definitely true [4-6]. The Cronbach α and test-retest reliability were determined as 0.86 and 0.81, respectively in Kermani study [24, 25].
Pain beliefs and perceptions inventory has 16 items that was constructed by Williams and Thorn [26, 27]. The inventory assesses three dimensions of pain beliefs; 1. Self-blame; 2. Perception of pain as mysterious; and 3. Beliefs about the duration of pain. Test-retest reliability of this inventory was reported as 0.80 [26] and the Cronbach α value of subscales of this test was reported from 0.70 to 0.77 [25]. The multivariate analysis of covariance was used for analysis of data in SPSS (version 20). 
Results
In this study, all of the subject were women with high school education and mean age of 38.41 years. Table 2 displays means and standard deviations of hope and pain beliefs scores in two groups at pre-test and post-test.
Before performing the MANCOVA, the BOX test was carried out to assess the homogeneity of the variance-covariance matrices and the results demonstrated homogeneous matrices (f Box=0.434; P<0.856). The equality of error variances was also assessed using the Levene’s test for pain beliefs (f=0.597; P<0.58), and Hope (f=0.282; P<0.756). Also, the homogeneity of regression slope was performed by contraction of pretest of pain beliefs and group (f=0.640; P<0.538) pretest of hope and group (f=1.083; P<0.379). The p value demonstrated the homogeneity of regression slope. The relationship between pretest and post-test of pain beliefs (r=0.518; P<0.003) and between pretest and post-test of hope (r=0.486; P<0.006) were lower than 0.80.
Table 3 shows the results of MANCOVA for hope and pain beliefs and also hope dimensions in two study groups. Based on the Bonferroni alpha-correction of 0.05 divided by the number of the dependent variables, the level of statistical significance for each variable was calculated as less than 0.025. Because the levels of statistical significance for hope, agency, and pathways were less than this value, MBCT significantly increased hope (P<0.025) and its dimensions (agency and pathway) (P<0.025) but has no effect on pain beliefs.
Discussion
This study demonstrated the effectiveness of MBCT on the hope of patients with chronic LBP. Acceptance-based interventions such as mindfulness have beneficial effects on the physical and mental health of patients with chronic pain [3, 9, 15-17, 19, 22, 28, 29]. During body scan practice, subjects learn to see what their real body condition truly is, without trying to change the reality. Accepting their chronic illness helps them see the other possible abilities in their social and emotional roles. Through direct experience in body scan, patients realize the interconnection between mind and body which increases patient’s self-control over his or her life. Mindful living techniques help experience of the subtle positive emotions, like peace and joy, self-esteem, and confidence [18, 30]. As a result, with mindfulness techniques, people learn how to manage their health and begin to engage in their duties mindfully.
Hope is defined as the perceived capability to derive pathways to desired goals and motivate oneself via agency thinking to use these pathways [4]. Higher hope is always related to better outcomes in physical and mental health. High hope individuals do not react to barriers in the same way as low hope individuals. Instead they view obstacles as challenges to overcome and use their thoughts to plan an alternative route to their goals [5, 6]. The result of this study about the effectiveness of mindfulness on hope is consistent with the previous studies in this field [7, 31-33].
The present study demonstrated that MBCT could not be useful in pain beliefs, which is not consistent with the previous studies [26, 27, 33, 34]. A possible explanation is that the pain beliefs and perceptions inventory only assesses one aspect of pain namely cognitive or psychological aspect. According to the biopsychosocial model, physiological and social factors also play an essential role in pain which was not assessed by the inventory.
One limitation of this study was low sample size and using convenient sampling method which may restrict the generalization of the results. Use of unprescribed drugs in our patients can decrease their pain, which we did not have control over that. Also, we could not follow up the results.
Conclusion
MBCT is a useful intervention for increasing hope in patients with chronic LBP but is not effective in pain beliefs. MBCT may be developed for alliveating LBP.
Acknowledgments
We thank our patients for their kindly collaboration. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of Interest 
The authors declared no conflicts of interest.

Reffrences
  1. Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2016; 51(2):199–213. doi: 10.1007/s12160-016-9844-2
  2. Palermo TM, Law EF. Managing your child's chronic pain. Oxford: Oxford University Press; 2015.
  3. Banth S, Ardebil M. Effectiveness of mindfulness meditation on pain and quality of life of patients with chronic low back pain. Int J Yoga. 2015; 8(2):128-33. doi: 10.4103/0973-6131.158476
  4. Snyder CR, editor. Handbook of hope: Theory, measures, and applications. Cambridge: Academic press; 2000.
  5. Snyder CR. Target article: Hope theory: Rainbows in the Mind. Psychol Inq. 2002; 13(4):249–75. doi: 10.1207/s15327965pli1304_01
  6. Snyder CR, Harris C, Anderson JR, Holleran SA, Irving LM, Sigmon ST, et al. The will and the ways: Development and validation of an individual-differences measure of hope. J Pers Soc Psychol. 1991; 60(4):570–85. doi: 10.1037/0022-3514.60.4.570
  7. Thornton LM, Cheavens JS, Heitzmann CA, Dorfman CS, Wu SM, Andersen BL. Test of mindfulness and hope components in a psychological intervention for women with cancer recurrence. J Consult Clin Psychol. 2014; 82(6):1087–100. doi: 10.1037/a0036959
  8. Courvoisier DS, Agoritsas T, Glauser J, Michaud K, Wolfe F, Cantoni E, et al. Pain as an important predictor of psychosocial health in patients with rheumatoid arthritis. Arthritis Care Res. 2012; 64(2):190–6. doi: 10.1002/acr.20652
  9. Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain. JAMA. 2016; 315(12):1240-9. doi: 10.1001/jama.2016.2323
  10. Balague F, Troussier B, Salminen JJ. Non-specific low back pain in children and adolescents: risk factors. Eur Spine J. 1999; 8(6):429–38. doi: 10.1007/s005860050201
  11. Aghayari A, Ghasemi GhA, Eshaghian M, Ghojoghi M, Haghaverdian S. [Prevalence of low back pain and its association with anxiety and depression in male and female nurses (Persian)]. Sci J Manage Syst. 2014; 4(8):39-47.
  12. Ahmadi H, Farshad A, Motamedzadeh M, Mahjob H. [Epidemiology of low-back pain and its association with occupational and personal factors among employees of hamadan province industries (Persian)]. J Health. 2014; 5(1):59-66.
  13. Abdolahzadeh SM, Jafary M. [Prevalence of low back pain in bus drivers (Persian)]. Tehran Univ Med J. 2005; 63(2):160-5.
  14. Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness meditation-based pain relief employs different neural mechanisms than placebo and sham mindfulness meditation-induced analgesia. J Neurosci. 2015; 35(46):15307–25. doi: 10.1523/jneurosci.2542-15.2015
  15. Gard T, Holzel BK, Sack AT, Hempel H, Lazar SW, Vaitl D, et al. Pain attenuation through mindfulness is associated with decreased cognitive control and increased sensory processing in the brain. Cereb Cortex. 2011; 22(11):2692–702. doi: 10.1093/cercor/bhr352
  16. Brown CA, Jones AKP. Meditation experience predicts less negative appraisal of pain: Electrophysiological evidence for the involvement of anticipatory neural responses. Pain. 2010; 150(3):428–38. doi: 10.1016/j.pain.2010.04.017
  17. Kabat Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985; 8(2):163–90. doi: 10.1007/bf00845519
  18. Kabat Zinn J. Coming to our senses: Healing ourselves and the world through mindfulness. London: Hachette; 2005.
  19. Goyal M, Singh S, Sibinga EMS, Gould NF, Rowland-Seymour A, Sharma R, et al. Meditation programs for psychological stress and well-being. JAMA Intern Med. 2014; 174(3):357-68. doi: 10.1001/jamainternmed.2013.13018
  20. Brewer JA, Mallik S, Babuscio TA, Nich C, Johnson HE, Deleone CM, et al. Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug Alcohol Depend. 2011; 119(1-2):72–80. doi: 10.1016/j.drugalcdep.2011.05.027
  21. Shakernejad S, Alilou MM. Effectiveness of mindfulness in decreasing the anxiety and depression of patients suffering from irritable bowel syndrome. Caspian J Neurol Sci. 2016; 2(7):32–40. doi: 10.18869/acadpub.cjns.2.7.32
  22. Abdolghaderi M, Kafie M, Saberi A, Ariapooran S. [The effectiveness of Mindfulness-Based Cognitive Therapy (MBCT) and Cognitive Behavior Therapy (CBT) on decreasing pain, depression and anxiety of patients with chronic low back pain (Persian)]. J Shahid Sadoughi Univ of Med Sci. 2014; 21(6):795-807.
  23. Segal ZV, Williams JM, Teasdale JD. Mindfulness-based cognitive therapy for depression. New York: Guilford Press; 2012 Oct 18.
  24. Kermani Z, Khodapanahi M, Heidari M. Psychometrics features of the Snyder hope scale. J Appl Psychol. 2011; 5(3):7-23.
  25. Asghari MA, Karimzadeh N, Emarlow P. [The role of pain-related beliefs in adjustment to cancer pain (Persian)]. Daneshvar Raftar. 2005; 12(13):1-22. 
  26. Williams DA, Thorn BE. An empirical assessment of pain beliefs. Pain. 1989; 36(3):351–8. doi: 10.1016/0304-3959(89)90095-x
  27. Condello C, Piano V, Dadam D, Pinessi L, Lantéri-Minet M. Pain beliefs and perceptions inventory: A cross-sectional study in chronic and episodic migraine. Headache: J Head Face Pain. 2014; 55(1):136–48. doi: 10.1111/head.12503
  28. Anheyer D, Haller H, Barth J, Lauche R, Dobos G, Cramer H. Mindfulness-based stress reduction for treating low back pain. Ann Intern Med. 2017; 166(11):799-807. doi: 10.7326/m16-1997
  29. Grant JA, Rainville P. Pain sensitivity and analgesic effects of mindful states in Zen meditators: A cross-sectional study. Psychosom Med. 2009; 71(1):106–14. doi: 10.1097/psy.0b013e31818f52ee
  30. Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review. Clin Psychol: Sci and Pract. 2003; 10(2):125–43. doi: 10.1093/clipsy/bpg015
  31. Karoly P, Ruehlman LS. Psychological “resilience” and its correlates in chronic pain: Findings from a national community sample. Pain. 2006; 123(1):90–7. doi: 10.1016/j.pain.2006.02.014
  32. Thomas EA, Garland EL. Mindfulness is associated with increased hedonic capacity among chronic pain patients receiving extended opioid pharmacotherapy. Clin J Pain. 2017; 33(2):166–73. doi: 10.1097/ajp.0000000000000379
  33. Williams DA, Robinson ME, Geisser ME. Pain beliefs: assessment and utility. Pain. 1994; 59(1):71–8. doi: 10.1016/0304-3959(94)90049-3
  34. Elvery N, Jensen MP, Ehde DM, Day MA. Pain catastrophizing, mindfulness, and pain acceptance. Clin J Pain. 2017; 33(6):485–95. doi: 10.1097/ajp.0000000000000430
Type of Study: Research | Subject: Special
Received: 2017/10/15 | Accepted: 2017/12/11 | Published: 2018/01/1

References
1. Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2016; 51(2):199–213. doi: 10.1007/s12160-016-9844-2 [DOI:10.1007/s12160-016-9844-2]
2. Palermo TM, Law EF. Managing your child's chronic pain. Oxford: Oxford University Press; 2015.
3. Banth S, Ardebil M. Effectiveness of mindfulness meditation on pain and quality of life of patients with chronic low back pain. Int J Yoga. 2015; 8(2):128-33. doi: 10.4103/0973-6131.158476 [DOI:10.4103/0973-6131.158476]
4. Snyder CR, editor. Handbook of hope: Theory, measures, and applications. Cambridge: Academic press; 2000.
5. Snyder CR. Target article: Hope theory: Rainbows in the Mind. Psychol Inq. 2002; 13(4):249–75. doi: 10.1207/s15327965pli1304_01 [DOI:10.1207/S15327965PLI1304_01]
6. Snyder CR, Harris C, Anderson JR, Holleran SA, Irving LM, Sigmon ST, et al. The will and the ways: Development and validation of an individual-differences measure of hope. J Pers Soc Psychol. 1991; 60(4):570–85. doi: 10.1037/0022-3514.60.4.570 [DOI:10.1037/0022-3514.60.4.570]
7. Thornton LM, Cheavens JS, Heitzmann CA, Dorfman CS, Wu SM, Andersen BL. Test of mindfulness and hope components in a psychological intervention for women with cancer recurrence. J Consult Clin Psychol. 2014; 82(6):1087–100. doi: 10.1037/a0036959 [DOI:10.1037/a0036959]
8. Courvoisier DS, Agoritsas T, Glauser J, Michaud K, Wolfe F, Cantoni E, et al. Pain as an important predictor of psychosocial health in patients with rheumatoid arthritis. Arthritis Care Res. 2012; 64(2):190–6. doi: 10.1002/acr.20652 [DOI:10.1002/acr.20652]
9. Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain. JAMA. 2016; 315(12):1240-9. doi: 10.1001/jama.2016.2323 [DOI:10.1001/jama.2016.2323]
10. Balague F, Troussier B, Salminen JJ. Non-specific low back pain in children and adolescents: risk factors. Eur Spine J. 1999; 8(6):429–38. doi: 10.1007/s005860050201 [DOI:10.1007/s005860050201]
11. Aghayari A, Ghasemi GhA, Eshaghian M, Ghojoghi M, Haghaverdian S. [Prevalence of low back pain and its association with anxiety and depression in male and female nurses (Persian)]. Sci J Manage Syst. 2014; 4(8):39-47.
12. Ahmadi H, Farshad A, Motamedzadeh M, Mahjob H. [Epidemiology of low-back pain and its association with occupational and personal factors among employees of hamadan province industries (Persian)]. J Health. 2014; 5(1):59-66.
13. Abdolahzadeh SM, Jafary M. [Prevalence of low back pain in bus drivers (Persian)]. Tehran Univ Med J. 2005; 63(2):160-5.
14. Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness meditation-based pain relief employs different neural mechanisms than placebo and sham mindfulness meditation-induced analgesia. J Neurosci. 2015; 35(46):15307–25. doi: 10.1523/jneurosci.2542-15.2015 [DOI:10.1523/JNEUROSCI.2542-15.2015]
15. Gard T, Holzel BK, Sack AT, Hempel H, Lazar SW, Vaitl D, et al. Pain attenuation through mindfulness is associated with decreased cognitive control and increased sensory processing in the brain. Cereb Cortex. 2011; 22(11):2692–702. doi: 10.1093/cercor/bhr352 [DOI:10.1093/cercor/bhr352]
16. Brown CA, Jones AKP. Meditation experience predicts less negative appraisal of pain: Electrophysiological evidence for the involvement of anticipatory neural responses. Pain. 2010; 150(3):428–38. doi: 10.1016/j.pain.2010.04.017 [DOI:10.1016/j.pain.2010.04.017]
17. Kabat Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985; 8(2):163–90. doi: 10.1007/bf00845519 [DOI:10.1007/BF00845519]
18. Kabat Zinn J. Coming to our senses: Healing ourselves and the world through mindfulness. London: Hachette; 2005.
19. Goyal M, Singh S, Sibinga EMS, Gould NF, Rowland-Seymour A, Sharma R, et al. Meditation programs for psychological stress and well-being. JAMA Intern Med. 2014; 174(3):357-68. doi: 10.1001/jamainternmed.2013.13018 [DOI:10.1001/jamainternmed.2013.13018]
20. Brewer JA, Mallik S, Babuscio TA, Nich C, Johnson HE, Deleone CM, et al. Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug Alcohol Depend. 2011; 119(1-2):72–80. doi: 10.1016/j.drugalcdep.2011.05.027 [DOI:10.1016/j.drugalcdep.2011.05.027]
21. Shakernejad S, Alilou MM. Effectiveness of mindfulness in decreasing the anxiety and depression of patients suffering from irritable bowel syndrome. Caspian J Neurol Sci. 2016; 2(7):32–40. doi: 10.18869/acadpub.cjns.2.7.32 [DOI:10.18869/acadpub.cjns.2.7.32]
22. Abdolghaderi M, Kafie M, Saberi A, Ariapooran S. [The effectiveness of Mindfulness-Based Cognitive Therapy (MBCT) and Cognitive Behavior Therapy (CBT) on decreasing pain, depression and anxiety of patients with chronic low back pain (Persian)]. J Shahid Sadoughi Univ of Med Sci. 2014; 21(6):795-807.
23. Segal ZV, Williams JM, Teasdale JD. Mindfulness-based cognitive therapy for depression. New York: Guilford Press; 2012 Oct 18.
24. Kermani Z, Khodapanahi M, Heidari M. Psychometrics features of the Snyder hope scale. J Appl Psychol. 2011; 5(3):7-23.
25. Asghari MA, Karimzadeh N, Emarlow P. [The role of pain-related beliefs in adjustment to cancer pain (Persian)]. Daneshvar Raftar. 2005; 12(13):1-22.
26. Williams DA, Thorn BE. An empirical assessment of pain beliefs. Pain. 1989; 36(3):351–8. doi: 10.1016/0304-3959(89)90095-x [DOI:10.1016/0304-3959(89)90095-X]
27. Condello C, Piano V, Dadam D, Pinessi L, Lantéri-Minet M. Pain beliefs and perceptions inventory: A cross-sectional study in chronic and episodic migraine. Headache: J Head Face Pain. 2014; 55(1):136–48. doi: 10.1111/head.12503 [DOI:10.1111/head.12503]
28. Anheyer D, Haller H, Barth J, Lauche R, Dobos G, Cramer H. Mindfulness-based stress reduction for treating low back pain. Ann Intern Med. 2017; 166(11):799-807. doi: 10.7326/m16-1997 [DOI:10.7326/M16-1997]
29. Grant JA, Rainville P. Pain sensitivity and analgesic effects of mindful states in Zen meditators: A cross-sectional study. Psychosom Med. 2009; 71(1):106–14. doi: 10.1097/psy.0b013e31818f52ee [DOI:10.1097/PSY.0b013e31818f52ee]
30. Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review. Clin Psychol: Sci and Pract. 2003; 10(2):125–43. doi: 10.1093/clipsy/bpg015 [DOI:10.1093/clipsy/bpg015]
31. Karoly P, Ruehlman LS. Psychological "resilience" and its correlates in chronic pain: Findings from a national community sample. Pain. 2006; 123(1):90–7. doi: 10.1016/j.pain.2006.02.014 [DOI:10.1016/j.pain.2006.02.014]
32. Thomas EA, Garland EL. Mindfulness is associated with increased hedonic capacity among chronic pain patients receiving extended opioid pharmacotherapy. Clin J Pain. 2017; 33(2):166–73. doi: 10.1097/ajp.0000000000000379 [DOI:10.1097/AJP.0000000000000379]
33. Williams DA, Robinson ME, Geisser ME. Pain beliefs: assessment and utility. Pain. 1994; 59(1):71–8. doi: 10.1016/0304-3959(94)90049-3 [DOI:10.1016/0304-3959(94)90049-3]
34. Elvery N, Jensen MP, Ehde DM, Day MA. Pain catastrophizing, mindfulness, and pain acceptance. Clin J Pain. 2017; 33(6):485–95. doi: 10.1097/ajp.0000000000000430 [DOI:10.1097/AJP.0000000000000430]

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