Trait mindfulness is associated with pain outcomes in patients with chronic back pain from a rural sample in the United States

INTRODUCTION

Chronic pain, or pain that lasts for more than three months or longer than a reasonable recovery period,^[1] is a growing national US health crisis. In 2023, 24.3% of US adults (~60 million individuals) reported experiencing chronic pain, which was a 3.9% increase from 2019.^[2] However, not all communities are affected equally. In particular, chronic pain prevalence rates are higher in rural communities than in more urban communities.^[2]

Pain management in rural areas is complex due to the limited availability of efficacious treatments for chronic pain, such as physical therapy, acupuncture, or advanced pain procedures.^[3] Treatment costs and the difficulty of traveling for care are also significant barriers to treatment in rural areas.^[4] Resulting care gaps in pain treatment have been associated with less efficacious or even detrimental pain management strategies in rural areas, such as opioid prescribing,^[5,6] as well as patient self-treatment of pain, either through licit or illicit substances, such as cannabis, in rural Appalachian areas.^[7] Given the risk of addiction and other negative consequences of long-term opioid or substance use,^[8] it is imperative to identify non-pharmacological treatments for chronic pain in rural communities.

A growing body of research indicates that mindfulness-based interventions improve chronic pain management and reduce subjective pain.^[9,10] Mindfulness entails attention to the present moment and non-judgmental awareness of what one is experiencing internally and externally.^[11] Mindfulness can be conceptualized at both a state and a trait level.^[12] State mindfulness is a transient experience, often intentionally induced through practices such as meditation and yoga.^[13] Trait mindfulness is a predisposition to be mindful, independent of intentional practice.^[14] Individuals inherently differ in trait mindfulness (i.e., the extent to which they are mindful in their daily lives), but trait mindfulness can be increased through repeated practice of state mindfulness.^[15] Indeed, the underlying goal of mindfulness-based interventions is to learn exercises that induce state mindfulness and through repeated practice of these exercises to increase trait mindfulness,^[16] which accounts for the health and well-being benefits of mindfulness-based interventions.^[17,18]

Several studies have demonstrated a link between trait mindfulness and better pain outcomes. For example, greater trait mindfulness has been associated with lower self-reported pain intensity and pain interference among adults with and without chronic pain.^[19,20] This association has also been found with behavioral pain measures.^[21] These findings suggest that dispositional mindfulness may buffer against the experience of pain.^[22,23] However, most of this work did not include or focus on rural communities and relied on a cross-sectional design.

Indeed, some researchers have noted the potential importance of mindfulness interventions in rural populations and called for the need for increased study.^[24] To initiate effective behavioral interventions, it is important to demonstrate basic associations between intervention targets and primary outcomes within the population of interest, both cross-sectionally and prospectively. As mindfulness-based interventions are generally time and resource-intensive^[25] and little is known about mindfulness in rural communities, it is important to demonstrate that mindfulness is associated with pain outcomes in rural communities. The present study aimed to recruit a sample of individuals with chronic back pain from rural communities to determine (1) the extent to which trait mindfulness was associated with pain outcomes cross-sectionally and (2) whether trait mindfulness prospectively predicted improved pain outcomes in a sample of US adults with chronic spinal pain in a rural community. Based on previous findings with different samples, we expected greater trait mindfulness to be associated with better pain outcomes both cross-sectionally and prospectively.

MATERIALS AND METHODS

RESULTS

DISCUSSION

Growing evidence suggests that mindfulness improves the experience of pain and benefits pain management. However, most of this work has been conducted with middle-class samples in urban or suburban areas. In the present study, we sought to extend existing literature and test whether trait mindfulness was associated with better pain outcomes in a rural sample. We found that greater trait mindfulness was generally associated with better self-reported pain outcomes in a sample with chronic back pain from a rural community. Furthermore, more mindful participants reported greater decreases in self-reported pain over a 3-month period. These findings suggest that mindfulness may be a viable intervention target for chronic pain in rural populations.

Cross-sectionally, greater mindfulness was correlated with a lower pain rating and pain intensity, as well as less pain interference and disability due to pain. All effects were medium-sized and consistent with the existing literature. Mindfulness was not significantly associated with fear of pain. Other studies^[19] have also found a nonsignificant association, but the lack of effect may also stem from the abbreviated version of the measure or a smaller sample size if the effect is small. Future work should further explore the association between mindfulness and fear of pain.

A novel aspect of the current study was the assessment of pain outcomes at 2 time points (initial visit and ~3-month follow-up) and the ability to assess the prospective relation between trait mindfulness and change in pain outcomes. Greater trait mindfulness at the initial visit prospectively predicted lower pain rating and pain intensity at the follow-up session. Trait mindfulness entails greater present moment focus and self-awareness, which may have facilitated better adherence to standard non-operative care (e.g., physical therapy and interventional procedures) provided by the spine clinic, resulting in improved pain experience. Interestingly, trait mindfulness did not prospectively predict pain hypervigilance, fear of pain, pain interference, or disability due to pain. The lack of effects may be due to the small sample size not being powered to detect smaller effects. Alternatively, trait mindfulness may not predict changes in concern about pain. Additional work is necessary to understand the nuances in the relationship between trait mindfulness and different pain outcomes.

These findings indicate that it is important to understand the baseline relationships of trait mindfulness and pain outcomes in rural communities. Trait mindfulness may be a relevant individual difference factor that may indicate who will or will not respond more beneficially to standard care. Similarly, trait mindfulness may be an important focus for future interventions in rural samples with chronic pain. At a fundamental level, mindfulness-based interventions are intended to increase trait mindfulness through repeated state mindfulness practice. A few studies have tested mindfulness interventions in rural populations^[31] but there are noted differences between urban and rural groups.^[32] Importantly, the success of such interventions depends on factors such as culturally sensitive delivery strategies^[33] for rural populations. Due to access, time, and travel constraints often experienced by rural populations, virtual or app-based intervention administration may be more effective.^[34]

As with all studies, there are limitations to this study. The sample size was relatively small, and roughly half of the sample did not complete the follow-up survey. As such, the present dataset may lack the power to detect existing effects within the sample. Furthermore, participants were recruited from a single spine clinic. Thus, the findings may not be broadly generalizable to rural communities. Additional research is needed to replicate findings with other samples across rural locations. All data stemmed from self-report measures, which are prone to social desirability and misinterpretation. Further, abbreviated versions of validated measures were used. Although the abbreviated versions were reliable and correlated with one another in expected directions, construct validity was not assessed. Findings should be replicated with full versions of the self-report measures and behavioral measures. Finally, the study was correlational. Although data were collected at two timepoints, which may suggest directionality, causal claims cannot be made without experimental manipulation of mindfulness.

CONCLUSION

Given the higher prevalence of chronic pain and opioid prescription in rural communities, there is a critical need to identify potential targets of non-pharmaceutical intervention. The present study demonstrated that trait mindfulness was cross-sectionally and prospectively associated with better pain outcomes in a rural sample with chronic back pain. Mindfulness-based interventions may be an effective means of reducing pain experience and improving pain management. However, common barriers and needs of rural communities must be considered to tailor mindfulness interventions appropriately.