Table 1: Summary of primary literature: studies on meditation/mindfulness in MS.

Author, year, countryAimStudy type, intervention (if appropriate)Participant recruitmentData collected/tools usedFindingsLimitations/comments

Grossman et al. [29] 2010,
Switzerland
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.
Intake interview, 8 weekly 2.5- hour classes, one 7- hour retreat, 40 minutes of homework daily versus usual care (UC) (including medical examination before intervention and six months after intervention).
150 participants with relapsing-remitting or secondary progressive MS
recruited from outpatient neurology clinic, other physicians, or advertisements in the Swiss Multiple Sclerosis Society Bulletin.
Blinded, randomised group allocation.
Outcomes measured before intervention, after intervention, and at six-month follow-up:
Profile of Health-Related Quality of Life in Chronic Disorders (PQOLC),
Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS),
Center for Epidemiologic Studies Depression Scale (CES-D),
Modified Fatigue Impact Scale (MFIS),
Spielberger Trait Anxiety Inventory (STAI),
Neurologist-administered Neuropsychological assessment,
Researcher-devised assessment of personal goal attainment after MBI, and self-reported homework adherence.
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.
The outcomes were not related to gender, EDSS, or taking disease modifying drugs.
Control group not offered sham intervention.
Exclusion criteria: other types of MS, Expanded Disability Status Scale score >6 or >1 step increase in previous 12 months, current MS exacerbation, symptomatic medication alteration in previous 3 months, serious psychological disorder or dementia, life threatening or severely disabling physical condition, and others.
5% attrition in intervention group and high attendance rate.

Mills & Allen [32], 2000,
United Kingdom
To examine whether mindfulness of movement affects balance and change in symptoms (pilot study).Randomised controlled trial.
Six individual sessions of one-to-one instruction and resources for guidance at home vs. usual care.
12 intervention participants and 12 control participants
recruited through local physiotherapists and general practitioners.
Outcomes measured before intervention, after intervention, and at three-month follow-up:
Activities of Daily Living questionnaire,
test of balance-timed single leg standing,
symptom rating questionnaire (21 listed symptoms), and
a close relative or friend was also asked to independently assess the degree of change.
The intervention group showed greater likelihood of improvement and less deterioration in symptoms.
Measures of overall symptom change showed significant differences between intervention and control groups after intervention and at 3 months.
The intervention group also showed improvements in balance which were maintained at 3 months.
All patients with secondary progressive MS and inclusion criteria were having at least one symptom which affected their life on an ongoing basis.
Very small sample size
3 dropped out of intervention group and 2 did not return all surveys; 4 did not return all surveys in control group.

Hadgkiss et al. [33] 2013,
Australia
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
five-day live-in educational retreat promoting lifestyle modification: meditation, healthy diet, vitamin D, and exercise.
274 baseline participants; 196 one-year participants; 96 five-year participants.
All enrolled program participants invited to the study.
Outcome measured before intervention and at 1 year and 5 years after intervention:
Multiple Sclerosis Quality of Life questionnaire (MSQOL-54)
Significant improvements in physical and mental composite scores and overall quality of life one and five years after attending the retreat. No control group.
Meditation one of several program recommendations.
Participants overlap with study by Li et al. [34]

Tavee et al. [45] 2011,
United States of America
To determine whether meditation affects pain and quality of life in people with MS and peripheral neuropathy (PN).Nonrandomised controlled trial.
4-hour introductory session, 8 weekly 90-minute classes on Samatha (breathing), moving and walking meditation and daily practice encouraged versus usual care (UC).
22 intervention participants (10 with MS) and 18 control participants (7 with MS).
Recruited patients of a neurological clinic.
Outcomes measured before intervention and after intervention (or baseline and 2 months after UC for controls):
36 item Short Form Health Status Survey (SF-36),
Visual Analogue Scale for pain,
Patient Determine Disease Steps (measure of disability),
5-item Modified Fatigue Impact Scale (MFIS-5).
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).
Significant improvements in cognitive and psychosocial components of the MFIS for MS meditation group.
No change in disability scores for MS meditation group.
Nonrandomised intervention groups assigned based on preference to participate in meditation.
Small sample size.
High attrition rate.
Analysis does not differentiate between MS and PN patients for SF-36.
No long term follow-up.
Control group not offered sham intervention.

Li et al. [34] 2010,
Australia
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
five-day live-in educational retreat promoting lifestyle modification: meditation, healthy diet, vitamin D, and exercise
109 baseline participants; 65 one-year participants; 33 2.5-year participants.
All enrolled program participants invited to the study.
Outcome measured before intervention and at 1 year and 2.5 years postintervention:
Multiple sclerosis quality of life questionnaire (MSQOL-54).
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.
Meditation one of several program recommendations.
Participants overlap with study by Hadgkiss et al. [33].

Pritchard et al. [36] 2010,
United States of America
To determine whether the practice of Yoga Nidra meditation impacts stress levels for people with MS or cancer.Pre- and postintervention
6 weekly 90-minute classes and daily practice encouraged.
22 intervention participants (12 with MS).
Recruited members of an MS Society.
Outcome measured before intervention and after intervention:
Perceived Stress Scale (PSS).
After the completion of the 6-week program, participants had significantly lower PSS scores. No control group.
Small sample size, attrition rate not stated.
No demographic or clinical characteristics recorded.
Results were shown separately for MS and cancer patients.
No long term follow-up.

Senders et al. [42] 2014,
United States of America
To evaluate the association between mindfulness, perceived stress, coping strategies, and resilience.Cross-sectional survey.119 participants
recruited from an outpatient clinic.
Demographics.
Clinical characteristics.
Perceived Stress Scale.
Five Facet Mindfulness Questionnaire
Connor-Davidson Resilience Scale.
Brief Coping Orientation for Problem Experiences.
Social Readjustment Rating Scale.
Medical Outcome Study Short Form-36.
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.
Actual participation in formal mindfulness practice not measured.

Skovgaard et al. [39] 2013,
Denmark
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
recruited from Danish MS society register.
Demographics.
Clinical characteristics.
Researcher devised and piloted items on CAM use (list of modalities and free text option).
Of the study sample, 91 (4.9%) reporting meditating in the last 12 months.Self-selecting sample.
Recall bias.

Esmonde and Long [41] 2008,
United Kingdom
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.
Survey participants recruited from attendees of a national congress of the MS Trust and focus group participants recruited from a workshop at the congress.
Demographics.
Clinical characteristics.
Researcher devised and piloted questions on use of (last 12 months) and perceived helpfulness of a list of CAM therapies.
34/138 (24.6%) reported using relaxation and meditation.
Nearly 40% of those who use relaxation and meditation rate it as “extremely useful,” the remainder rate it as “helpful” or “somewhat helpful.”
Benefits of relaxation and meditation described as helping sleep, helping control of spasticity, easing muscle tension, relaxing the mind, clearing the mind, helping control frustration, and sense of well-being (open-ended responses).
Relaxation and meditation not distinguished from each other.

Simmons et al. [40] 2004,
Australia
To explore patient views on factors that affect disease onset and progression. Cross-sectional, online survey.2529 participants
recruited online from a national MS society and the MS International Federation websites.
Demographics.
Clinical characteristics.
Researcher-devised items on medication and alternative therapy use, diet, and environmental influences.
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.
Self-selecting sample.

Nayak et al. [37] 2003,
United States of America
To explore the use of CAM among a national sample of people with MS.Cross-sectional survey.3140 participants
recruited from a national mailing list of the MS Foundation.
Demographics.
Researcher-devised items on the use of conventional medicines and therapies, and a range of questions about lifetime CAM use including type/frequency/duration/reason/
perceived effectiveness. A checklist of popular CAM therapies was provided.
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.

Berkman et al. [38] 1999,
United States of America
To explore the prevalence of the use of CAM therapies, perceived benefits, harms, and reasons for use.Cross-sectional survey.240 participants
recruited from a randomly generated list of 500 members of two chapters of the National MS Society (1000 people contacted).
Demographics.
Clinical characteristics.
Researcher-devised survey on previous and current use of a list of traditional and alternative therapies, rating of how helpful/harmful the therapy is perceived to be, and reason for using therapy (slow progression/symptom relief/emotional relief).
22.9% of the sample had ever used meditation (that is, previous or current use).
Benefits of meditation were described as stress relief, relaxation, improved focus, more centered, emotional relief, less fatigue, more positive attitude, strengthened immune system, and slow progression (open-ended responses).
Analysis did not differentiate between meditation and other types of traditional and alternative therapies.