Mindfulness-Based Stress Reduction

Mindfulness-Based Stress Reduction

PEP Topic 
Cognitive Impairment
Description 

Mindfulness-based stress reduction (MBSR) is a consciousness discipline that is grounded in eastern philosophy and traditions such as yoga and Buddhism, focusing on awareness of the present moment. It aims to teach people to deal more effectively with experience through awareness of feelings, thoughts, and bodily sensations. Participants learn to engage in mindfulness practices such as body scan, simple yoga exercises, and meditation. MBSR has been studied in patients with cancer for its effect on anxiety, cognitive impairment, fatigue, sleep-wake disturbance, and depression. It has also been studied in caregivers of patients with cancer for its effect on caregiver strain and burden (Piet, Würtzen, & Zachariea, 2012).

Effectiveness Not Established

Research Evidence Summaries

Hoffman, C. J., Ersser, S. J., Hopkinson, J. B., Nicholls, P. G., Harrington, J. E., & Thomas, P. W. (2012). Effectiveness of mindfulness-based stress reduction in mood, breast- and endocrine-related quality of life, and well-being in stage 0 to III breast cancer: a randomized, controlled trial. Journal of Clinical Oncology, 30, 1335–1342.

doi: 10.1200/JCO.2010.34.0331
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Study Purpose:

  • To assess the effectiveness of a mindfulness-based stress reduction (MBSR) intervention for mood, breast- and endocrine-specific quality of life, and well-being after hospital treatment in women with stage 0 to III breast cancer.
  • To compare MBSR to usual care and its effect on mood and disease-related quality of life.
  • To measure if a dose-related effect was evident with formal, eight-week MBSR practice.

Intervention Characteristics/Basic Study Process:

The intervention consisted of an eight-week MBSR program closely following the Kabat-Zinn method. The intervention involved 2- to 2.25-hour classes and a 6-hour retreat. Home practice was recommended for 45 minutes, six to seven days per week. Outcomes were measured at baseline, weeks 8 to 12, and weeks 12 to 14. A wait-list control group received usual care.

Sample Characteristics:

  • A total of 229 patients (100% female) participated.
  • Mean age was 49 years (SD = 9.26 years) in the treatment group and 50.1 years (SD = 9.14 years) in the control group.
  • Patients had been diagnosed with stage 0 to III breast cancer; 47% had stage II cancer.
  • Participants were recruited from The Haven, a charitable day center that provides free psychosocial services for patients with breast cancer. All patients had received an average of 30 hours of support prior to entering the study.

Setting:

  • Single site
  • Outpatient
  • The Haven, London, England

Phase of Care and Clinical Applications:

  • Patients were undergoing long-term follow-up.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a randomized, controlled trial design.

Measurement Instruments/Methods:

  • Profile of Mood States (POMS) questionnaire
  • Functional Assessment of Cancer Therapy (FACT)–Breast and Endocrine Symptoms 
  • World Health Organization (WHO) (Five) Well-being Index

Results:

  • The study revealed significant differences between the groups in regard to POMS subscale scores (p < 0.001): depression (p = 0.017), anxiety (p < 0.001), anger (p = 0.005), vigor (p < 0.001), fatigue (p = 0.002), and confusion (p = 0.002).
  • Participants completed a mean of 19.58 hours (standard deviation = 11.49 hours) of home MBSR practice over eight weeks, or 21 minutes per day. Increased hours of MBSR practice improved POMS scores at T3 for overall mood (p = 0.004), vigor (p = 0.02), fatigue (p = 0.03), and anxiety (p = 0.01). POMS scores improved at T2 and T3 for anger (p = 0.005 and 0.02, respectively), confusion (p = 0.04 and 0.001, respectively), and well-being.

Conclusions:

MBSR significantly improved mood and reduced confusion.

Limitations:

  • The study lacked an appropriate control group.
  • The control group was not attention controlled, which limited the interpretation of between-group differences.
  • The setting was unique, and the intervention used many resources, which made implementing and generalizing findings difficult.
  • The study had a risk of bias due to lack of blinding.

Nursing Implications:

Although further study is needed to measure MBSR and its impact on depression and anxiety, in this sample, home-based practice was feasible and improved mood. In practice and education, nurses can promote components of MBSR, such as breathing, yoga, relaxation, meditation, seeking support resources, and gentle stretching.

Johns, S.A., Von Ah, D., Brown, L.F., Beck-Coon, K., Talib, T.L., Alyea, J.M., . . . Giesler, R.B. (2016). Randomized controlled pilot trial of mindfulness-based stress reduction for breast and colorectal cancer survivors: Effects on cancer-related cognitive impairment. Journal of Cancer Survivorship, 10, 437–448. 

doi: 10.1007/s11764-015-0494-3
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Study Purpose:

To examine the effect of an eight-week Mindfulness-Based Stress Reduction (MBSR) program compared to an eight-week education and support (ES) program on subjectively and objectively assessed cognitive function among breast and colorectal survivors experiencing fatigue

Intervention Characteristics/Basic Study Process:

Seventy-one breast and colorectal survivors experiencing moderate-to-severe fatigue were randomized into the MBSR group (n = 35) and ES group (n = 36). The MBSR group received a modified eight-week mindfulness meditation and movement training course facilitated by experienced MBSR teachers certified by the Center for Mindfulness at the University of Massachusetts. The training included the use of body scans, hatha yoga, sitting meditation, and loving-kindness meditation. The ES group received an eight-week education and support course taught by social workers that included both didactic content and group discussion regarding cancer-related symptoms and late effects of cancer treatment. Classes for the MBSR and ES groups were held on the same night, and the class size was limited to 10 participants in each group. All class and meditation sessions were two hours long and delivered over eight weeks. The final all-day meditation retreat typical of the MBSR training program was eliminated for this cohort because of fatigue.

Sample Characteristics:

  • N = 69  
  • AGE = 56.9 years
  • MALES: 9.9%, FEMALES: 90.1%
  • KEY DISEASE CHARACTERISTICS: Causasian (70.4%), not college educated (56.3%), employed (52.1%), married or partnered (54.9%), self-reported “comfortable income level” (52.1%)
  • OTHER KEY SAMPLE CHARACTERISTICS: Cancer type: Breast (MBSR 51.7%), (ES 48.3%), CRC MBSR (36.4%), (ES 63.6%). Average years since treatment completed was 2.4 years. Any individual reporting experience with meditation was excluded from the sample. Over 50% did not have more than a high school education.

Setting:

  • SITE: Single site  
  • SETTING TYPE: Multiple settings  
  • LOCATION: Midwestern National Cancer Institute–designated cancer center and affiliate clinics

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship

Study Design:

Two-arm, randomized, clinical trial, pilot study

Measurement Instruments/Methods:

Attentional Functional Index (AFI), the subjective measure, is a 13-item self-report measure of assessing levels of attention required for common activities requiring attention and working memory. Three subscales are identified in this instrument: effective action, attentional lapses, and interpersonal effectiveness. This instrument provides respondents with a 100 mm–long horizontal line starting at “not at all” to “extremely well or a great deal.” The total length of each reply is added together to score a person's AFI. A higher score indicates greater capacity to direct attention.  
 
Stroop Color and Word Test, the objective measure, is a test of executive function that specifically evaluates selective attention, cognitive flexibility, and control. Participants are asked to look at a color word and then quickly select the actual color of the word presented. Accuracy rates and reaction times are recorded as testing outcomes.
 
Five Facets Mindfulness Questionnaire (FFMQ) is a 39-item measure of tendencies toward mindful behaviors in everyday life presented on a five-point Likert-type scale ranging from 1 (never or very rarely true) to 5 (very often or always true). The instrument identifies five facets/elements of mindfulness: observing, describing, acting with awareness, nonjudgment of inner experience, and nonreactivity to inner experience. A higher mean score across all scales is associated with a greater tendency toward mindful behavior.
 
MBSR, AFI, and Stroop were measured at baseline. AFI and Stroop were repeated at the completion of the eight-week intervention (T2) and six months after the intervention (T3).

Results:

MBSR participants reported significantly greater improvements in overall AFI scores at T2 and T3. The Effective Action and Attentional Lapses subscales were significantly and substantially higher in the MBSR group at T2 and remained stable six months later. The Interpersonal Effectiveness subscales scores were higher but not significantly so in the MBSR group.
 
MBSR participants performed significantly better on the Stroop accuracy at T2 and T3 (p ≤ 0.03). No difference between ES and MBSR was noted at T1, suggesting that improvement may be related to MBSR training. No significant between-group difference in reaction time existed. When within group accuracy and reaction times were examined, the MBSR group had a lower error rate at T3 relative to T1, which the ES group did not realize.                                                                           
 
AFI and lapses data were higher in the MBSR group at eight weeks (p ≤ 0.004) and at six months (p < 0.027), with reported effect sizes (standard response mean) ranging from 0.55–0.9. Both groups showed improvement in cognitive function over time.

Conclusions:

This pilot study demonstrated that MBSR offers significant and sustained improvements in both subjectively and objectively measured chemotherapy-related cognitive impairment. The findings indicated that the MBSR intervention addressed issues of executive function and attentional control in breast and colorectal survivors reporting cancer-related fatigue and cognitive impairment.

Limitations:

  • Small sample (< 100)
  • Baseline sample/group differences of import
  • Risk of bias (sample characteristics)
  • Key sample group differences that could influence results
  • Findings not generalizable
  • Fatigue levels were used as a proxy for the presence of chemotherapy-related cognitive impairment in the selection of sample. The presence of chemotherapy-related cognitive impairment was assessed at baseline after selection of the study sample, and, at that time, a "large majority of participants reported cognitive impairment as measured by the baseline AFI."

Nursing Implications:

The findings of this study suggest that MBSR may improve late effect cognitive/emotional fatigue and cognitive impairment in patients with cancer. As no identified adverse effects of MBSR training or mindfulness meditation exist, this low-risk intervention may be beneficial for patients.

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