{"paper_id":"0d93547a-29e5-4104-b9e0-c2dd383614c4","body_text":"General Rights \nCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners \nand it is a condition of accessing publications that users recognize and abide by the legal requirements associated with these rights. \n • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. \n • You may not further distribute the material or use it for any profit-making activity or commercial gain  \n• You may freely distribute the URL identifying the publication in the public portal \nIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and \ninvestigate your claim. \n \nIf the document is published under a Creative Commons license, this applies instead of the general rights. \nThis coversheet template is made available by AU Library \nVersion 2.0, December 2017 \n \nCoversheet \n \nThis is the accepted manuscript (post-print version) of the article. \nContentwise, the accepted manuscript version is identical to the final published version, but there may \nbe differences in typography and layout.  \n \nHow to cite this publication \nPlease cite the final published version: \n \nKarina Ejgaard Hansen, Ulrik Schiøler Kesmodel, Mette Kold & Axel Forman (2017) Long-term effects of \nmindfulness-based psychological intervention for coping with pain in endometriosis: A six-year follow-up \non a pilot study, Nordic Psychology, 69:2, 100-109, DOI: 10.1080/19012276.2016.1181562  \n \nPublication metadata \n \nTitle: Long-term effects of mindfulness-based psychological intervention for \ncoping with pain in endometriosis: A six-year follow-up on a pilot study \nAuthor(s): Karina Ejgaard Hansen, Ulrik Schiøler Kesmodel, Mette Kold & Axel Forman \nJournal: Nordic Psychology \nDOI/Link: https://doi.org/10.1080/19012276.2016.1181562 \n \nDocument version: \n \nAccepted manuscript (post-print) \n \n \n \n \n \n\nLong-term Effects of Mindfulness-Based Psychological Intervention for \nCoping with Pain in Endometriosis: A Six Year Follow-up on a Pilot \nStudy \nKarina Ejgaard Hansen*a, Ulrik Schiøler Kesmodelb, Mette Koldc , & Axel Formand \n* Corresponding author keh@psy.au.dk  \na  MSc in Psychology, Ph.D-fellow, Department of Psychology and Behavioral Sciences, Aarhus \nBSS, Aarhus University, Bartholins Allé 9,  8000 Aarhus C, Denmark and Department of \nObstetrics and Gynecology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus \n8200, Denmark, e-mail: keh@psy.au.dk, phone: + 45 87 16 58 17 \nb Associate Professor, PhD, Department of Obstetrics and Gynecology, Aarhus University \nHospital, Palle Juul Jensens Boulevard 99, Aarhus 8200, Denmark, e-mail: ukes@clin.au.dk, \nphone: + 45 78 45 33 53 \nc MSc in Psychology, PhD., Time2be, Vesterbro 18, 9000 Aalborg, Denmark, e-mail: \nmettekold.time2be@gmail.com, phone: + 45 22 81 81 32 \nd Professor MD, DMSc, Department of Obstetrics and Gynecology, Aarhus University Hospital, \nPalle Juul Jensens Boulevard 99, Aarhus 8200, Denmark, e-mail: af@clin.au.dk, phone: + 45 78 \n45 33 54 \n \nAcknowledgements \nThis research was supported by the Danish Endometriosis Association which is a non-\ngovernmental organization run by women with endometriosis and by a scholarship from the \nHealth Research Fund of Central Denmark Region. \n \n\nLong-term Effects of Mindfulness-Based Psychological Intervention for \nCoping with Pain in Endometriosis: A Six Year Follow-up on a Pilot Study \n \nAbstract (250 ord) \nObjective: Development of chronic pain problems in endometriosis is frequent. Until now there \nhas been no alternative treatment offer when medical and surgical treatment has been unhelpful \nin relieving the pain. The aim of this study was to evaluate the long-term effects of a mindfulness-\nbased psychological intervention on chronic pain and quality of life in endometriosis when \nconducting a six year follow-up on a pilotstudy.  \nMaterials and methods: In the original study, participants were recruited through Aarhus \nUniversity Hospital and included ten women with diagnosed endometriosis and chronic pelvic \npain. The women participated in 10 sessions of mindfulness-based psychological intervention. \nWhen contacted after 6 years all ten women agreed to participate in the follow-up study. Quality \nof life was measured by the endometriosis specific questionnaire EHP-30 and the generic form SF-\n36. Results: When comparing data from the 12 months follow-up with data from the six year \nfollow-up, results showed no significant differences in mean scores on all scales of the EHP-30 and \nalmost all scales of the SF-36 scale scores. The results indicate lasting improvement on almost all \nscales of the EHP-30 and the SF-36.  \nConclusion: Although conclusions remain preliminary until tested in a randomized controlled trial, \nresults presented in this article indicate that mindfulness-based psychological treatment of chronic \npain seems very relevant to women with endometriosis with the potential to improve quality of \nlife. \n \nKeywords (3-6 stk): endometriosis, mindfulness, chronic pain, psychological intervention, quality \nof life \n  \n\nIntroduction \nEndometriosis is a chronic and painful gynecological disease defined as the presence of \nendometrium-like tissue elements outside the uterus, usually in the abdominal cavity. These \nelements cause bleeding, adhesions and inflammatory reactions with development of symptoms \nlike cyclical and chronic pelvic pain, dyspareunia, pain at defecation and urination, constipation, \ndiarrhea, abnormal bleeding, fertility problems and fatigue. Estimated prevalence among women \nof reproductive age is 5-10 % (Hansen, Kesmodel, Baldursson, Kold, & Forman, 2014; Vigano, \nParazzini, Somigliana, & Vercellini, 2004). Despite a biological explanation of these symptoms \nendometriosis is often overlooked, and it is associated with a diagnostic delay of 7-9  years from \nsymptoms onset to diagnosis and treatment (Hudelist et al., 2012; Husby, Haugen, & Moen, 2003; \nNnoaham et al., 2011). Despite optimal treatment, development of chronic pain with the risk of \nreduced quality of life, work absence and job loss is frequent. Estimated socioeconomic costs in DK \namount to more than 500 million EUR per year, and new intervention strategies are therefore \nneeded (De Graaff et al., 2013; Hansen, Kesmodel, Baldursson, Schultz, & Forman, 2013; Lemaire, \n2004; Simoens et al., 2012).  \nMindfulness-based treatments seem to have a positive impact on quality of life in patients with \nother chronic pain syndromes (Garland et al., 2012; Garmon et al., 2014; la Cour & Petersen, \n2015), but previous studies are limited by short follow-up periods, and the long-term effects of \nmindfulness-based interventions are unknown. \nMindfulness originates from Eastern traditions of meditation and is used in the West as a \ntherapeutic and self-help tool to enhance physical and psychological well-being (Kabat-Zinn, \n2013). From a treatment perspective mindfulness is conceptualized as a set of skills. The skills \ntraining approach suggests that with a regular praxis of different mindfulness exercises, people \ncan learn to be more observant of inner experiences, describe them without reacting on or judging \nthem and act with awareness in daily life. This will help people to be more acceptant of unpleasant \ninner experiences (Baer et al., 2008; Kabat-Zinn, Lipworth, & Burney, 1985).  \nIn 2007 we performed an observational pilot study on mindfulness-based psychological \nintervention with a view to coping with endometriosis-related pain (Kold, Hansen, Vedsted-\nHansen, & Forman, 2012). Health related quality of life was measured by the endometriosis \nspecific questionnaire Endometriosis Health Profile 30 questionnaire (EHP-30) and the general \nquestionnaire Short Form 36 (SF-36) before intervention, after intervention and at six and twelve \nmonths´ follow-up. Repeated measures analysis showed significant improvements in four out of \nfive standard scales of EHP-30: “pain”, “control and powerlessness”, “emotional well-being” and \n“social support”. From the modular questionnaire two out of three scales showed significant \nimprovements: “work-life” and “relationship with children. In according SF-36 showed significant \nimprovements in all eight scales. The intervention thus seemed to improve short-term quality of \nlife but the long-term effects are not known. The purpose of this study was therefore to perform a \nsix-year follow-up of these patients before running a randomized controlled study. \n \n\nMaterials and methods \nParticipants and recruitment \nIn 2007, in the original study, ten participants were recruited at Aarhus University Hospital, which \nrepresents one of two national centers for treatment of severe endometriosis (Kold et al., 2012). \nOnly patients with endometriosis and chronic pain despite treatment according to the European \nSociety of Human Reproduction and Embryology (ESHRE) guidelines for endometriosis were \nincluded. Patients had to commit themselves to practice mental techniques at home and women \nunwilling to make this commitment were excluded. The ten participants were contacted by e-mail \nin 2013, six years after the intervention, for the purpose of participating in the follow-up study. \nAfter written consent self-administered questionnaires were sent out by postal mail, filled out at \nhome and returned to the department. \nPsychological intervention \nThe original study consisted of 10 sessions of mindfulness-based psychological intervention (five \nindividual and five group sessions) over a period of 10 weeks. The intervention included \nmindfulness training, visualization techniques, counselling, group support and patient-education \nfocusing on fatigue, quality of sleep, job, relationship- and family-issues etc. (Kold et al., 2012). The \nintervention has been fully described elsewhere. \n \nMeasurement \nIn both the original and the follow-up study health related quality of life was measured by EHP-30 \nand SF-36. The EHP-30 questionnaire has been shown to be more sensitive to change among \nwomen with endometriosis than SF-36 (Jones, Jenkinson, & Kennedy, 2004).  \nThe patient generated questionnaire EHP-30 relates specifically to quality of life among women \nwith endometriosis (Jones et al., 2004; Jones, Jenkinson, Taylor, Mills, & Kennedy, 2006; Jones, \nKennedy, Barnard, Wong, & Jenkinson, 2001). It consists of a core questionnaire containing 30 \nitems applicable to every woman with endometriosis. Supplementary questions only relevant to \nsome women with endometriosis can be added by means of a modular questionnaire. The core \nquestionnaire concerns the influence of endometriosis on daily life as categorized in five standard \nscales:  “pain”, “control and powerlessness”, “emotional wellbeing”, “social support” and “self-\nimage”. The modular questionnaire concerns the influence of endometriosis on “work life”, \n“relationship with children”, “sexual intercourse”, “medical profession”, “treatment” and \n“infertility”.  \nSF-36 is widely used and measures health related quality of life in general (Bjorner, Damsgaard, \nWatt, & Groenvold, 1998; Bjorner, Thunedborg, Kristensen, Modvig, & Bech, 1998). It consists of \neight subscales that represent important aspects of general health, including: “physical \nfunctioning”, “role – physical”, “bodily pain”, “general health”, “vitality”, “social functioning”, “role \n– emotional” and “mental health”. \nTogether with EHP-30 and SF-36 participants answered some general questions and a \nretrospective transition question about their subjective judgment of changes in health status and \n\npain level from pre-intervention till today. Respondents could choose between five response \ncategories: “much worse”, “worse”, “the same”, “better” or “much better”. The study also \nincludes qualitative data on which techniques are used and how they are implemented in daily \nlife. \nThe study was approved by the Danish Data Protection Agency (J.no. 2013-41-2607). \n \nStatistical methods \nEHP-30 and SF-36 scale scores are standardized on a range from 0-100. Better quality of life is \nindicated by lower scores for EHP-30 and higher scores for SF-36. Differences in scale scores were \ncalculated by paired t-test. The level of statistical significance was set at p < 0.05 in all analyses. \nStatistical analysis was performed using SPSS version 21. \nResults \nAll ten participants in the original study agreed to answer the follow-up questionnaires. At the six \nyear follow up the women were between 33 and 68 years (mean = 48.00, standard deviation = \n10.00). During the follow-up period one woman had entered natural menopause, three had had \nendometriosis lesions removed surgically, and two of these had had a hysterectomy. \nDifferences in EHP-30 scale scores \nEHP-30 scores are presented in table 2. The modular scales “medical profession”, “treatment” and \n“infertility” were excluded from the analyses since only 1-3 of the participants found these aspects \nrelevant.  \nResults showed that all significant improvements from the original study 12 months after the \nintervention (four out of five scales on the core questionnaire) remained during the following five \nyears: “pain”, “control and powerlessness”, “emotional wellbeing” and “social support”. Also the \nmodular scales “work life“ and “relationship with children” indicated lasting improvement from \ntwelve months´ follow-up till six years´ follow-up. All scales improved further during the twelve \nmonths´ to six years´ follow-up, but the improvement did not reach statistical significance. \nDifferences in SF-36 scale scores  \nSF-36 scores are presented in table 3. Results showed that significant improvements from the \noriginal study remained during the five year period from 12 months after the intervention. \nImprovements remained on all eight scales: “physical functioning”, “role – physical”, “bodily pain”, \n“general health”, “vitality”, “social functioning”, “role – emotional” and “mental health”. In \naddition the scale “social functioning” improved significantly during the five year period from 12 \nmonths follow-up.  \nUse of mindfulness techniques and quality of life today \nSix years after completed intervention, nine out of ten still used the mindfulness-techniques and \nother mental techniques learned during the intervention. Seven of these nine women experienced \nbenefits from these techniques to a great or very great extent.  \n\nThe body scan and breathing meditation were the most used mindfulness techniques among the \nwomen at follow-up (table 4). Body scan was often used for dealing with pain and problems falling \nasleep. Some women used the technique almost every night. The breathing meditation was \nprimarily used for pain relief during the day both at home and at work.  \nOne participant wrote “I use the body scan when I am in pain and when I go to sleep. The course \nhas helped me to a great extent also the day today.” Another participant wrote “When I am \nsleepless I lie on the back and I do a body scan. I use this technique almost every day. The \nbreathing techniques have been the most helpful techniques. They are a major help in my \neveryday life. In the beginning it was difficult, but now I just do it. All in all the course has been \nvery useful to me”. A third participant wrote ”Breathing meditation helps me relax my abdomen”, \nand a fourth wrote “I use the body scan and breathing meditation when in pain during \nmenstruation or at bed time together with meditation music. This helps me endure the pain and \nmakes it go away faster – and I sleep better.”   \nThe patient´s subjective judgment of quality of life six years after completed intervention \ncompared to pre-intervention levels was a better or much better quality of life in all cases, and \neight of ten participants also experienced a better or much improved pain level (table 4).  \n \nDiscussion \nThis pilot series represents the first data on the potential long term effects of mindfulness-based \npsychological intervention for chronic pain in endometriosis.  With reservation for the \nweaknesses, our results may suggest a lasting positive effect on health related quality of life of \nwomen with endometriosis six years after the end of treatment.  \nThe patient generated questionnaire EHP-30 represents different life-areas affected by \nendometriosis and endometriosis-related pain. Together these life-areas comprise a measure of \nthe quality of life in women with endometriosis. These life-areas include daily activities, work-life, \nrelationship with children, sexual activity, social relationships, emotional wellbeing, self-image and \nthe feeling of control or powerlessness in one´s life. Detailed results of the EHP-30 questionnaire \nsuggested that mindfulness-based psychological treatment could have lasting positive effects on \nthese life areas except for “sexual activity” and “self-image” in women with endometriosis-related \nchronic pelvic pain. The “self-image” scale improved during the study- and follow-up period, but \nthe difference was not significant. \nAlso results of SF-36 suggested that mindfulness-based psychological intervention could have \nlasting positive effects on general health-related quality of life. A lasting effect was found on all \nscales of SF-36 and in addition we found another significant improvement in “social functioning” \nduring the time from 12 month follow-up till six years follow-up. There is a possibility that this \ncontinued improvement in social functioning could be the result of continued mindfulness-\ntraining, where the patient learns to accept the pain and live with it. She could have learned to be \npresent without letting the pain get in her way, and if accepting the pain she would possibly find it \n\neasier to talk about. Hence, endometriosis will not have that much of an influence of her social \nrelations anymore. It could also be due to the fact that people learn to live with chronic conditions \nalong the way. \nWe actually observed a small continued improvement of the quality of life in all endometriosis-\nspecific scales and almost all general scales in the period from 12 months follow-up till six years \nfollow-up, but the differences were not significant.  \nUnfortunately our study did not include a control group and the sample is very small. However \npatients included had chronic pain despite previous medical and surgical treatment, probably due \nto persistent changes in the peripheral and central nervous system (Stratton & Berkley, 2011). \nThree cases had repeat surgery during the follow-up period, but available data indicate that pain \nrecurrence is frequent in such cases (Vercellini et al., 2009). Only one had entered the menopause \nduring the follow-up period, and decreased ovarian function did not seem to play a major role for \nthe persistent improvement in quality of life seen in our study.  \nContinuing improvements in quality of life during the period after the end of mindfulness-based \npsychological treatment could to some extent be facilitated by the mindfulness treatment in which \nthe goal is to learn to observe and describe the pain without evaluation or judgement of the pain \nand without reacting on the inner experience. The purpose is to learn to accept the pain and live \nlife in a valuable way despite the pain. Learning mindfulness techniques could make the woman \nindependent of her practitioner, because she can continue the praxis on her own and in time get \nmore and more experienced. This is supported by the qualitative data in which the women \ndescribe what techniques they use and how they implement them in their daily lives. Also the \nquantitative data suggest that nine out of the ten women still uses the mindfulness techniques \nlearned during the treatment period at six years follow-up. Seven of them experienced a great or \nvery great extent of benefits from the techniques, which could suggest that independent, \ncontinuous use of mindfulness is realistic and feasible. \nWhen comparing the women´s own subjective evaluation of their quality of life and the more \nobjective measurements by EHP-30 and SF-36 from pre-intervention till six years follow-up, there \nseems to be consistence between the results. On the contrary some women have evaluated the \ndifference in quality of life higher than the difference in pain level from pre-intervention till six \nyears follow-up. The reason that some women experience higher quality of life despite some \npersistent pain could come from a mindfulness facilitated change in acceptance of the pain or a \nchange in the pain experience. Pain is defined as “An unpleasant sensory and emotional \nexperience associated with actual or potential tissue damage, or described in terms of such \ndamage” (International Association for the Study of Pain) (Merskey & Bogduk, 1994, pp. 209-214). \nOne could envisage that the difference is due to a change in the quality of the pain in which the \nemotional aspect or the unpleasantness of the pain more than the sensory aspect or the intensity \nof the pain has changed. Since the study is limited by the absence of a control condition, we do \nnot know if a change would have happened spontaneously anyway.  \nMany former articles have described the situation of women with endometriosis and the negative \nconsequences of the disease.  These include a diagnostic delay of 5-7 years, a feeling of being \n\nignored and stigmatized, reduced quality of life and work ability and billions in socio-economic \ncosts every year due to loss of work ability and health care costs. So far research in the treatment \nof endometriosis has focused on medical and surgical treatment, but new strategies for \nrehabilitation of these patients such as mindfulness-based psychological pain treatment might \nimply both significant benefits to the patients as well as savings in the healthcare system. \nThis study was limited by a small study-group, the lack of a placebo control group and a lack of a \nstandardized pain measure. Future studies should focus on including more participants in a \nrandomized placebo-controlled study including data on endometriosis-specific pain symptoms \nmeasured by standardized pain scores.  \nDespite the limitations the study suggests that this treatment could have potential benefits for \nwomen suffering from endometriosis related chronic pelvic pain. \nConclusion  \nAlthough conclusions remain preliminary until tested in a randomized controlled trial, the results \npresented in this article suggests that mindfulness-based psychological treatment of chronic pain \nseems relevant to women with endometriosis with the potential to  improve quality of life.  \n \nReferences \n \nBaer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., . . . Williams, J. M. (2008). Construct \nvalidity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. \nAssessment, 15(3), 329-342. doi:10.1177/1073191107313003 \nBjorner, J. B., Damsgaard, M. 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Chronic pelvic pain and endometriosis: translational evidence of the \nrelationship and implications. Hum Reprod Update, 17(3), 327-346. doi:10.1093/humupd/dmq050 \nVercellini, P., Crosignani, P. G., Abbiati, A., Somigliana, E., Vigano, P., & Fedele, L. (2009). The effect of \nsurgery for symptomatic endometriosis: the other side of the story. Hum Reprod Update, 15(2), \n177-188. doi:10.1093/humupd/dmn062 \nVigano, P., Parazzini, F., Somigliana, E., & Vercellini, P. (2004). Endometriosis: epidemiology and aetiological \nfactors. Best Pract Res Clin Obstet Gynaecol, 18(2), 177-200. doi:10.1016/j.bpobgyn.2004.01.007 \n \n\nTable 1 Symptoms and endometriosis treatment of participants in the period from pre-intervention \ntill six years follow-up.   \n Pre-\nintervention \n \nN = 10 \nThe time period between \npost-intervention till six \nyears follow-up \nN = 10 \nSix years´ \nfollow-up \n \nN = 10 \nSymptoms because of endometriosis in the past 4 weeks \nAbdominal pain \nNausea or vomiting \nTiredness \nPain at urination \nPain at defecation \nConstipation or diarrhea \nIrregular bleeding \nMenstruation pain \n \n8 \n3 \n10 \n3 \n7 \n8 \n1 \n3 \n \n- \n- \n- \n- \n- \n- \n- \n- \n \n5 \n4 \n7 \n2 \n5 \n7 \n0 \n1 \nHave entered natural menopause \nYes  \nNo \n \n2 \n8 \n \n- \n- \n \n3 \n7 \nTreatment for endometriosis \nOperation removing endometriosis lesions \nOperation removing uterus \nOperation removing ovaries \nHormonal treatment \nMedical pain treatment \nPhysical treatment \nPsychotherapeutic treatment \nAlternative treatments \nPain Clinic \nNo treatment \n \n- \n- \n- \n- \n- \n- \n- \n- \n- \n- \n \n3 \n2 \n0 \n5 \n6 \n4 \n1 \n2 \n1 \n1 \n \n- \n- \n- \n3 \n5 \n1 \n0 \n1 \n0 \n3 \n    \n \n \n \n \n\nTable 2. The difference in EHP-30 scale scores from 12 months´ follow-up (T4) till six years´ follow-\nup (T5). \n \n T1 T4 T5 T4 – T5 \nEHP-30 scales N Mean (SD) N Mean (SD) N Mean (SD) 95 % CI P-value \nPain 9 52,53 (12,52) 10 28,18 (15,9) 10 24,55 (11,97) -10,83 – 18,1 0,583 \nControl and \npowerlessness \n9 65,28 (18,98) 10 35,42 (22,5) 10 31,67 (14,46) -12,24 – 19,74 0,609 \nEmotional Wellbeing 10 52,08 (16,23) 10 34,17 (19,02) 10 29,17 (16,2) -8,09 – 18,09 0,41 \nSocial support 10 52,50 (25,89) 10 31,88 (20,72) 10 25,63 (14,86) -10,87 – 23,37 0,430 \nSelf-image 10 41,67 (21,52) 10 30,00 (22,64) 10 25,00 (15,21) -11,91 – 21,91 0,52 \nWork-lifea 7 47,86 (29,94) 4 13,75 (13,15) 4 3,75 (4,79) -15,16 – 35,16 0,295 \nRelationship with \nchildrena \n7 46,43 (22,49) 7 12,50 (19,09) 7 5,36 (9,83) -14,84 – 29,14 0,457 \nSexual intercoursea 9 66,67 (12,82) 8 59,79 (29,12) 8 58,13 (32,40) -22,85 – 26,19 0,877 \na = only patients who found answering the modular scale relevant at both measuring times were included in the analysis \nT1 = pre-intervention  \nSD = standard deviation  \nLower means indicate better quality of life \n \n\nTable 3. The difference in SF-36 scale scores from 12 months´ follow-up (T4) till six years´ follow-up \n(T5). \n T1 T4 T5 T4 – T5 \nSF-36 scales N Mean (SD) N Mean (SD) N Mean (SD) 95 % CI P-value \nPhysical functioning 10 69.50 (14.80) 10 82.50 (12.96) 10 78.50 (16.68) -12.07 – 20.01 0.587 \nRole – physical 10 15.00 (21.08) 10 50.00 (39.09) 10 60.00 (35.75) -45.97 – 25.97 0.545 \nBodily pain 10 31.30 (14.39) 10 57.80 (12.52) 10 59.10 (24.96) -22.82 – 20.22 0.894 \nGeneral health 10 36.10 (14.08) 10 55.40 (22.25) 10 56.40 (20.35) -12.45 – 10.45 0.848 \nVitality 10 27.50 (17.83) 10 49.00 (20.11) 10 55.50 (24.55) -23.28 – 10.28 0.404 \nSocial functioning 10 47.50 (24.86) 10 70.00 (26.48) 10 83.75 (18.68) -26.00 – (-1.50) 0.032 \nRole – emotional 10 23.33 (35.31) 10 50.00 (42.31) 10 76.67 (35.31) -65.28 – 11.95 0.153 \nMental health 10 59.20 (22.69) 10 69.60 (20.76) 10 75.60 (9.13) -18.08 – 6.08 0.290 \nT1 = pre-intervention  \nSD = standard deviation  \nHigher means indicate better quality of life \n \n \n \n\nTable 4 Use of mindfulness techniques, benefits, quality of life and pain level of participants at six \nyears´ follow-up. \n Participants  \nN = 10 \nAre you still using the mindfulness techniques learned at the intervention today?  \nYes \nNo \n \n9 \n1 \nWhat mindfulness techniques are you using today?a \nBodyscan \nBreathing meditation \nYoga \nMindful walking \nMindful music \nOwn meditation \n \n5 \n6 \n1 \n1 \n3 \n1 \nTo what extent do you benefit from these techniques today?a \nNo benefits \nTo a lesser extent \nTo some extent \nTo a greater extent \nTo a very great extent \n \n0 \n1 \n1 \n4 \n3 \nHow do you experience your general quality of life today compared with the time  before the \nintervention? \nMuch worse \nWorse \nThe same \nBetter \nMuch better \n \n \n0 \n0 \n0 \n5 \n5 \nHow do you experience your general pain level today compared with the time before the \nintervention? \nMuch worse \nWorse \nThe same \nBetter \nMuch better \n \n \n0 \n0 \n2 \n3 \n5 \na N = 9","source_license":"CC0","license_restricted":false}