Multiple sclerosis (MS) is one of the most common chronic neurological diseases, affecting between 1 in 500 to 1 in 1500 people in Australia, Europe, and America [
Although meditation in all its forms has been around for centuries, interest in the practice as a medical treatment in the Western world has been more recent. The interest was particularly sparked by Kabat-Zinn’s research into mindfulness meditation suggesting that meditation could be a useful tool for treating chronic pain [
Meditation is a term that encompasses a wide range of techniques such as mindfulness-based meditation (including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT)), mantra meditation (including transcendental and clinically standardised meditation), and many more [
In its various forms, meditation has been shown to be associated with symptom reduction in medical and psychiatric conditions, electroencephalography (EEG) changes, and beneficial structural brain changes on neuroimaging with long term use [
Yet, few studies have examined the effect of meditation on mental health outcomes or QOL in MS, despite its great potential benefit.
This integrative review aims to examine the existing peer-reviewed literature on the use of meditation in MS to reduce depression, anxiety, stress, chronic pain, and fatigue and whether meditation can lead to improved QOL for those with MS.
It also aims to gather evidence on the effectiveness of meditation as secondary prevention for MS morbidity. Finally, it aims to identify gaps and limitations in the current literature.
This review of literature published prior to March 2014 was undertaken using PubMed, PsycINFO, the Cochrane library, and Google Scholar. Search terms used were multiple sclerosis, MS, meditation, and mindfulness (all were searched as MeSH terms). The Boolean operator term OR was used to search [mindfulness OR meditation]; these results were then combined with the Boolean operator term AND to search [(mindfulness OR meditation) AND (multiple sclerosis OR MS)].
Articles which cited a key randomised controlled trial by Grossman et al. [
Primary literature was selected only if the patient sample had MS and the assessment of mindfulness or another form of meditation (hypnoses and complementary and alternative therapies were excluded) was examined in the study, including both observation and intervention studies. Intervention studies were accepted regardless of whether or not there was a control group. In the context of an integrative review, all qualitative and quantitative research was selected (assuming it met the criteria above) regardless of whether validated tools were used to measure outcomes or not. In studies where MS and another medical condition were examined, measures specific to the MS group were reported, where possible.
The reference list of all studies that were accepted for the review was analysed to see if there were any additional relevant papers that had not been found using the search methods above.
All search results were reviewed by a single reviewer (AL) to determine relevance to the criteria; included papers were then reviewed by a second reviewer (EH) and any discrepancies were resolved by a third reviewer (TW). The assessment of intervention and observation studies was guided by the PRISMA guidelines [
Summary of primary literature: studies on meditation/mindfulness in MS.
Author, year, country | Aim | Study type, intervention (if appropriate) | Participant recruitment | Data collected/tools used | Findings | Limitations/comments |
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Grossman et al. [ |
To examine the effects of a mindfulness-based intervention (MBI) compared to usual care upon quality of life, depression, and fatigue among people with MS. | Randomised controlled trial. |
150 participants with relapsing-remitting or secondary progressive MS |
Outcomes measured before intervention, after intervention, and at six-month follow-up: |
Compared to baseline, at postintervention MBI participants showed significant improvements in PQOLC, HAQUAMS, CES-D, MFIS, and STAI greater than the UC group. The benefits remained at six-month follow-up although the effect was lessened for PQOLC and depressive symptoms. |
Control group not offered sham intervention. |
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Mills & Allen [ |
To examine whether mindfulness of movement affects balance and change in symptoms (pilot study). | Randomised controlled trial. |
12 intervention participants and 12 control participants |
Outcomes measured before intervention, after intervention, and at three-month follow-up: |
The intervention group showed greater likelihood of improvement and less deterioration in symptoms. |
All patients with secondary progressive MS and inclusion criteria were having at least one symptom which affected their life on an ongoing basis. |
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Hadgkiss et al. [ |
To measure change in health-related quality of life one and five years after attending a retreat for people with MS. | Pre- and postintervention (longitudinal follow-up); survey |
274 baseline participants; 196 one-year participants; 96 five-year participants. |
Outcome measured before intervention and at 1 year and 5 years after intervention: |
Significant improvements in physical and mental composite scores and overall quality of life one and five years after attending the retreat. | No control group. |
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Tavee et al. [ |
To determine whether meditation affects pain and quality of life in people with MS and peripheral neuropathy (PN). | Nonrandomised controlled trial. |
22 intervention participants (10 with MS) and 18 control participants (7 with MS). |
Outcomes measured before intervention and after intervention (or baseline and 2 months after UC for controls): |
After 8 weeks, meditation participants had significant improvements in pain scale, physical, and mental health composite scores and three domains-vitality, physical role, and bodily pain (MS only). |
Nonrandomised intervention groups assigned based on preference to participate in meditation. |
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Li et al. [ |
To measure change in health-related quality of life one and 2.5 years after attending a retreat for people with MS. | Pre- and postintervention (longitudinal follow-up); survey |
109 baseline participants; 65 one-year participants; 33 2.5-year participants. |
Outcome measured before intervention and at 1 year and 2.5 years postintervention: |
Significant improvements in physical and mental composite scores and overall quality of life one and 2.5 years after attending the retreat. | No control group. |
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Pritchard et al. [ |
To determine whether the practice of Yoga Nidra meditation impacts stress levels for people with MS or cancer. | Pre- and postintervention |
22 intervention participants (12 with MS). |
Outcome measured before intervention and after intervention: |
After the completion of the 6-week program, participants had significantly lower PSS scores. | No control group. |
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Senders et al. [ |
To evaluate the association between mindfulness, perceived stress, coping strategies, and resilience. | Cross-sectional survey. | 119 participants |
Demographics. |
After controlling for age, gender, education, disease modifying therapy, type of MS, stressful life events, and disability, trait mindfulness was significantly associated with decreased perceived stress (model accounted for 25% variance), increased resilience (44%), increased adaptive coping (11%), decreased maladaptive coping (29%), and higher mental health QOL (20%). | Mainly recruited from single center. |
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Skovgaard et al. [ |
To assess and compare characteristics of complementary and alternative medicine (CAM) users and CAM nonusers, and their respective use of CAM and conventional treatments. | Cross-sectional, online survey. | 1865 participants |
Demographics. |
Of the study sample, 91 (4.9%) reporting meditating in the last 12 months. | Self-selecting sample. |
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Esmonde and Long [ |
To collect data on the use and benefits of CAM for MS. | Mixed methods, survey and focus group discussions. | 138 participants in survey and up to 35 participated in the focus groups. |
Demographics. |
34/138 (24.6%) reported using relaxation and meditation. |
Relaxation and meditation not distinguished from each other. |
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Simmons et al. [ |
To explore patient views on factors that affect disease onset and progression. | Cross-sectional, online survey. | 2529 participants |
Demographics. |
218/2529 (9%) of participants reported that meditation “improved” their MS; 6/2529 (0.2%) reported that meditation “worsened” their MS. The remaining participants had no view on the effect of meditation on MS. | Unable to verify diagnosis of MS online. |
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Nayak et al. [ |
To explore the use of CAM among a national sample of people with MS. | Cross-sectional survey. | 3140 participants |
Demographics. |
12.6% of participants reported ever practicing meditation. On a scale from 0–5, the mean (standard deviation) efficacy was 2.06 (1.78) and length of use was 6.10 (7.67) years. The top three symptoms treated by meditation were reported as pain (40.9%), overall symptoms (14.0%), and fatigue (13.4%). | Very large national sample. |
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Berkman et al. [ |
To explore the prevalence of the use of CAM therapies, perceived benefits, harms, and reasons for use. | Cross-sectional survey. | 240 participants |
Demographics. |
22.9% of the sample had ever used meditation (that is, previous or current use). |
Analysis did not differentiate between meditation and other types of traditional and alternative therapies. |
Using the search criteria 19 results were found on PubMed, PsycINFO, and the Cochrane library and 9030 results were found on Google Scholar. The first seven pages of Google Scholar articles were scanned to find relevant articles. There were also 72 articles which cited Grossman et al. [
Using the selection criteria 12 pieces of primary literature were selected to be included in the literature review. Of these, two were randomised controlled trials [
Grossman et al. conducted a randomised controlled trial of 150 patients residing in Switzerland with relapsing-remitting or secondary progressive MS. Cases were assigned: one 2.5 hour session of mindfulness meditation a week for eight weeks, a one-day seven-hour session, and 40 minutes of meditation homework daily. Controls continued their usual care. High attendance rates and low dropout rates were reported for the intervention group. It was found that, using validated self-report measures, the meditation group had significant improvements in QOL and significantly lower rates of fatigue (MFIS), depression (CES-D), and anxiety (STAI) when compared to the control group [
Mills and Allen conducted a randomised controlled trial on patients with secondary progressive MS, with 12 participants randomised to the meditation group and 12 to the control group. The meditation group received an hour of one-on-one meditation sessions for six weeks as well as handouts, tapes, and written material. The control group continued on normal therapy. At the completion of the mindfulness course and at three months after intervention, self-reported MS symptoms were found to have significantly improved in the intervention group. Each participant also had a relative or a friend assess their symptoms before and after intervention and significant improvements were also noted with that measure. Given the small size of the study and a relatively large dropout rate, the results must be treated with caution. Additional limitations include not having any sham control and follow-up being limited to three months [
In a longitudinal study, Hadgkiss et al. and Li et al. found that a five-day live-in course which focussed on lifestyle modifications including diet, sunlight exposure, exercise, and meditation improved physical and mental HRQOL compared to baseline; effects were followed and found to be significant at one, two and a half, and five years after the course was completed [
Tavee et al. performed an intervention study of meditation in MS patients, with the intervention group undertaking weekly meditation classes for two months and control subjects receiving standard care. It was found that those who participated in meditation had significantly less pain, improvements in cognitive and psychosocial aspects of fatigue, and improved QOL after intervention but no statistically significant change in mobility. The study was limited by a small sample size (less than 20 patients with MS), lack of long term follow-up, and lack of a sham control group. Furthermore, it was not randomised meaning that those who chose to be in the meditation group may have had an increased perception of the beneficial effects of meditation [
Pritchard et al. conducted a study which demonstrated decreased stress compared to baseline after a six-week meditation course. Stress was assessed on a validated scale and shown to significantly decrease after the course, suggesting an association between meditation and decreased stress levels in MS [
In a survey of over 3000 MS patients conducted by Nayak et al., it was found that 12% of the survey responders had tried meditation, with modest efficacy (determined by a self-reported five-point scale of reduction in perceived disease severity) [
In an online survey of 2529 patients with MS, which looked at a range of issues relating to the disease, Simmons et al. found that 9% of respondents had ever practised meditation and reported that it improved their MS. Interestingly, a small number of respondents (0.2%) reported that meditation worsened their MS symptoms [
In another large online survey Skovgaard et al. also found that 5% of responders had used meditation in the previous 12 months to help treat their MS symptoms. The survey found that respondents who had tried any form of complementary or alternative medicine were most likely to be females aged between 18 and 40 years old, which was not surprising given this is a significant proportion of the MS demographic. It was also found that meditators were more likely to have been university-educated and have a higher income [
Senders et al. undertook a cross-sectional survey examining trait mindfulness and its effect on various outcomes, all assessed using validated tools. They found that having a mindful disposition (as assessed by the Five Facet Mindfulness Questionnaire (FFMQ)) was significantly associated with decreased perceived stress (model accounted for 25% variance), increased resilience (44%), increased adaptive coping (11%), decreased maladaptive coping (29%), and higher mental health QOL (20%). It should be noted that participants FFMQ scores were independent of whether they had participated in formal meditation practice or not, and as such the variation in the above mentioned scores cannot be solely attributed to participation in meditation [
In a mixed methodology study, incorporating a survey of attendees at an MS congress and focus group of attendees at a “complementary therapies and MS” workshop, conducted by Esmonde and Long, 25% were found to have participated in relaxation and meditation activities in the previous 12 months. Reported benefits included improved sleep, reduced spasticity, easing of muscle tension, and increased sense of well-being. Relaxation and meditation were reported to be at least somewhat helpful in relieving MS symptoms, with over a quarter rating it as extremely helpful. Participants in the workshop may have been more likely to ascribe benefits to the practice of relaxation and meditation as they may have been more open to trying nonpharmacological therapies. The study was also limited by the use of a nonvalidated survey and having participants discuss their experiences in small groups rather than individually, which may have led to unease discussing personal experiences, especially if they were negative. Nevertheless, the reports of benefits for some patients are an indication that meditation may be a useful augmentative treatment in MS [
All the above mentioned surveys had limitations. A common limitation was that of participant selection. Surveys were sent to large cohorts and were voluntarily-completed leading to a selection bias as patients who had tried meditation and found it effective may have been more likely to commence and complete the surveys. Furthermore, results were limited by the self-reporting nature of surveys, which could have been biased by poor recall or under- or overestimation of responses. Some useful analyses within these papers did not distinguish meditation from CAM therapies, thus limiting the interpretation of findings.
In some surveys it was difficult or even impossible (in the case of online surveys) to verify the MS diagnosis [
Some of the studies did not employ validated instruments, so the reliability and validity of results are not clear [
Finally, all of the surveys were cross-sectional from which causation or change over time cannot be deduced.
The literature shows that stress plays a significant role in MS pathogenesis and progression. Past studies have found that 85% of MS exacerbations were associated with stressful life events, strongly suggesting a link between stress and disease course [
Cortisol, which is released by the hypothalamic pituitary axis in response to stress, is often chronically elevated in MS patients. As a result of chronically increased levels of cortisol, it has been proposed that MS patients form resistance to the hormone and as such do not benefit from the normal anti-inflammatory effects of the hormone, which would otherwise help to allay their symptoms [
Meditation has been shown to decrease cortisol levels and improve sleep for both novice and experienced meditators. Given that cortisol plays a key role in stress modulation, the results suggest that the beneficial effects of meditation may operate partly through this mechanism [
Given that stress has been shown to be implicated in relapses in MS [
Because stress and depression affect QOL in people with MS and may lead to disease exacerbation [
Our review shows that a substantial proportion of people with MS either have tried meditation or meditate regularly. The available body of research has consistently found meditation to be of benefit to those with MS, with very few or no harmful side effects.
Despite weaknesses in the evidence base, meditation appears to have important benefits in improving QOL as well as potential benefits for the management of pain, stress, fatigue, and depression risk in people with MS. There is currently however limited evidence to suggest that meditation has an effect on relapse rates or other markers of disease course, although it is biologically plausible and this may be shown to be true in future better-designed studies.
Despite these limitations, overall the evidence supports a beneficial effect of meditation on symptom management and QOL among people with MS. It seems that meditation may have an important role to play in the integrated management of MS. Further studies on meditation in MS are required, preferably randomised controlled trials utilising some sham form of therapy.
MS is a disease which can have significant negative effects on QOL. MS is associated with a higher risk of depression, anxiety, stress, chronic pain, and fatigue, and stress has been shown to worsen MS course.
Meditation has been investigated as a possible beneficial intervention for stress and symptom relief for people with MS. The current literature suggests a beneficial effect of meditation in MS, particularly QOL; however, further research is needed to better understand the potential for meditation as an adjunct to the management of MS.
Professor Jelinek has been a group leader for the residential retreats reviewed in references [