Abstract
Identifying barriers to compliance with mindfulness-based interventions (MBIs) during the perioperative period is paramount to the design and implementation of non-pharmacologic, opiate-sparing pain regimens. We prospectively investigated the acceptability and adherence patterns of an app-based MBI amongst surgical patients with chronic pain. Patients were provided a subscription code to a meditation app and encouraged to use the app an average of 10 minutes/day over a 6-week study period. Patients reported a high level of interest in using the app prior to enrollment. 71% used the app at least once, 30% for half the recommended time, and 8% for the recommended amount of time. 88% of respondents enjoyed using the app and agreed it improved mental health and stress levels. Surgical patients with pre-existing pain report a high level of interest in utilizing MBIs perioperatively. Identifying barriers to compliance represents an important area of future investigation.
Emerging evidence suggests a role for mindfulness-based interventions (MBIs) in the management of both acute and chronic pain and preoperative mindfulness training may improve surgical outcomes.1,2 To date, most studies involving mindfulness interventions utilize programs dependent on lengthy and in-person instruction which may prevent widespread implementation amongst in-patient and surgical populations. 3 Given the ubiquity of cellular devices, use of smartphone apps for intervention delivery may improve accessibility and adoption of mindfulness techniques amongst diverse patient populations and can be easily incorporated into existing perioperative pain management strategies. To this end, we preliminarily investigated the acceptability and adherence patterns of a smartphone app-delivered MBI during the perioperative period amongst surgical patients with chronic pain.
Participants (n = 17) were patients within the Emory University system who self-reported chronic, distressing pain and were scheduled to undergo surgery within 6 weeks of study enrollment. Once enrolled, all participants completed a Time 1 assessment delivered electronically via Qualtrics. Interest in meditation was rated by participants on a scale of 1 to 7 (1 = “do not agree at all”; 4 = “somewhat agree”; and 7 = “completely agree”) in learning meditation techniques to improve management of their pain, stress, personal relationships, and physical and mental health. After the Time 1 assessment, each participant received a mindfulness meditation mobile app. Patients were provided a subscription code to the meditation app (Headspace) and asked to complete the Introduction and Pain modules. Participants were encouraged to use the app an average of 10 minutes/day during the 6-week study period (420 minutes). At the completion of the study, participants completed a Time 2 post-intervention assessment and participants rated their enjoyment using the app and the degree to which it improved physical and mental health on a scale of 1 to 7 as described above. App usage was quantified as total number of meditation sessions completed, type of session completed, and the amount of time the app was used.
Patient Characteristics
A total of 17 patients were enrolled. There were no significant differences in baseline demographics between the groups. There were no serious adverse events reported. The majority of operations were performed for benign conditions (95%) with the top three surgical diagnoses amongst participants being inguinal hernia (25%), ventral hernia (20%), and chronic pancreatitis (10%).
Adherence
Of the 17 patients enrolled, 12 patients (71%) successfully downloaded the app, completed the introduction module, and at least one pain module (10 minutes). The average total app time reported amongst users was 120 minutes (Figure 1). Four (30%) patients used the app for at least half the recommended time (210 minutes), and one patient (8%) used the app for the recommended amount of time (420 minutes) or more. Distribution of total app use in minutes across participants who utilized the app at least once. Average total app usage across participants = 120 minutes. Level of interest in app-based mindfulness meditation. Participants reporting a score of 5 or higher on a 7-point Likert scale were categorized as reporting a “high” level of interest.
Acceptability
Prior to randomization, 96% of participants reported a high level of interest in using the app (Figure 2). Top reasons for wanting to practice mindfulness were to manage stress and improve mental health. Eight patients (47%) completed post-study acceptability surveys. The majority of respondents randomized to mindfulness (88%) enjoyed using the app and agreed that it improved mental health and stress levels.
Our findings describe adherence patterns and acceptability of an app-based mindfulness program in a patient population at high risk for poorly controlled postoperative pain and opioid-related adverse events. To our knowledge, this is the first report investigating a digital mindfulness intervention in a surgical cohort with self-reported chronic pain. While we were unable to draw conclusions regarding impact on pain-related or surgical outcomes following surgery, these findings demonstrate a potential role for mindfulness interventions as part of a comprehensive, multimodal pain management strategy in the perioperative period.
This study identifies potential barriers to patient adherence and provides important insight for mindfulness researchers and clinicians aiming to design and implement feasible and effective mindfulness-based programs in surgical populations. In particular, 30% of participants failed to complete all of the required introductory modules precluding access to the pain modules, and total app time reported suggests an average daily practice of only 12 days over the 6-week study period. Providing direct access to pain-specific mindfulness interventions as well as utilization of automated text messaging or cellular alerts to remind patients to complete their daily meditation may improve compliance. Additionally, emerging evidence suggests that mindfulness-based interventions may be used acutely, with some studies reporting as little as two, 10-15-minute guided mindfulness meditations significantly decrease pain scores and improve postoperative outcomes. 2 As such, abbreviating the duration and frequency of MBIs may further enhance feasibility and acceptability amongst surgical patients while maintaining their efficacy. It is also important to note that patients who practiced less than half the recommended time were more likely to report feeling pressured to use the app. This finding is supported elsewhere in the literature and the success of MBIs may therefore be influenced by a patient’s ability to self-motivate and approaches to enhance this attribute may directly influence outcomes. 4
Our results highlight a need for future mindfulness research aimed toward the design of mindfulness-based pain management programs that address the myriad of psychosocial and physical factors contributing to both acute and chronic post-surgical pain while promoting compliance during the perioperative period. Given the paucity of data surrounding the safety profile of mindfulness interventions in surgical patients, as well as limited information regarding effective dosage and frequency, phase I and II clinical trials represent immediate and important opportunities for future study in varied surgical populations.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.