Mindfulness physical therapy, pain management, rehabilitation

MBSR for Patients with Painful Diabetic Peripheral Neuropathy

Chronic distal symmetrical polyneuropathy is a common long-term complication of both type 1 and type 2 diabetes.1 In addition, it is estimated that 15–20% of patients with this type of polyneuropathy experience pain.1 Although the exact pathophysiology of diabetic neuropathic pain remains ambiguous, both peripheral and central mechanisms have been implicated and include enhanced spinal processing and changes in higher central nervous system centers.1 Evidence suggests that pharmacological treatments for painful diabetic peripheral neuropathy (PDPN) provide only modest improvements and can be associated with adverse effects on patient safety and quality of life.1,2 Diabetes self-management education programs that incorporate behavioral and psychosocial strategies have been recognized to improve outcomes and are recommended.3

In a study examining the effects of mindfulness training for patients whose PDPN pharmacotherapy had been optimized, Nathan and colleagues randomized 66 patients to a waiting list control or community-based Mindfulness-Based Stress Reduction (MBSR) course.4 Typically, 2–3 study patients joined a community-based MBSR course with participants with a variety of complaints such as pain, anxiety or depression. The MBSR course was not modified for study purposes. Patients in both the control and MBSR groups were discouraged from making changes in medication from the time of randomization until after the final assessment.

At the 3-month post-intervention assessment, patients assigned to MBSR experienced improved function, better health-related quality of life, and reduced pain severity, pain catastrophizing, and depression compared to those receiving usual care. Researchers reported that some of the improvements within the MBSR group at 12 weeks were unexpectedly large, including a 46.5% decrease in pain catastrophizing, a 42.0% decrease in the PHQ-9 (depression assessment), a 30.1% decrease in pain severity, and a 52.3% increase (improvement) in the SF-12 bodily pain subscale. Fourteen of 30 in the MBSR group (46.7%) compared to 2 of 32 in the control group (6.2%) reported that they were much or very much improved. No differences between the groups were identified in blood glucose reactions or A1C.

Nathan and colleagues conclude that clinicians can expect patients with PDPN to benefit from referral to community MBSR courses led by qualified teachers. They recommend future research include active control conditions designed to improve efficiency and efficacy and reveal essential elements of the therapeutic effect.

1Tesfaye MD, Boulton AJM, Dickerson AH. Mechanisms and Management of Diabetic Painful Distal Symmetrical Polyneuropathy. Diabetes Care. 2013;36(9): 2456–2465.
2Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015;14:162–173
3Funnell MM, Brown TL, Childs BP, et al. National Standards for Diabetes Self-Management Education. 2010 Jan; 33(Suppl 1): S89–S96.
4Nathan HJ, Poulin P, Wozny D, et al. Randomized Trial of the Effect of Mindfulness-Based Stress Reduction on Pain-Related Disability, Pain Intensity, Health-Related Quality of Life, and A1C in Patients With Painful Diabetic Peripheral Neuropathy. Clinician Diabetes. 2017;35(5):294-304.