Original research| Volume 98, ISSUE 11, P2265-2273.e1, November 2017

Mindfulness Is Associated With Treatment Response From Nonpharmacologic Exercise Interventions in Knee Osteoarthritis


      • Higher baseline mindfulness was associated with treatment response in knee osteoarthritis.
      • This finding was primarily driven by the acting-with-awareness mindfulness facet.
      • Mindfulness may be a prognostic indicator of treatment response among these patients.
      • Mindfulness-cultivating interventions might be helpful as a preparatory adjunct to exercise.



      To examine the association between baseline mindfulness and response from exercise interventions in knee osteoarthritis (OA).


      Cohort study; responder analysis of a clinical trial subset.


      Urban tertiary care academic hospital.


      Participants with symptomatic, radiographic knee OA (N=86; mean age, 60y; 74% female; 48% white).


      Twelve weeks (twice per week) of Tai Chi or physical therapy exercise.

      Main Outcome Measures

      Treatment response was defined using Osteoarthritis Research Society International criteria indicating meaningful improvements in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, WOMAC function, or Patient Global Assessment scores. At baseline, participants completed the Five Facet Mindfulness Questionnaire (mean total score, 142±17) and were grouped into 3 categories of total mindfulness: higher, medium, or lower. Relative risk (RR) ratios were used to compare treatment response across groups.


      Participants with higher total mindfulness were 38% (95% confidence interval [CI], 1.05–1.83) more likely to meet responder criteria than those with lower mindfulness. We found no significant difference between medium and lower mindfulness groups (RR=1.0; 95% CI, 0.69–1.44). Among the 5 mindfulness facets, medium acting-with-awareness was 46% (95% CI, 1.09–1.96) more likely to respond than lower acting-with-awareness, and higher acting-with-awareness was 34% more likely to respond, but this did not reach significance (95% CI, 0.97–1.86).


      In this study, higher mindfulness, primarily driven by its acting-with-awareness facet, was significantly associated with a greater likelihood of response to nonpharmacologic exercise interventions in knee OA. This suggests that mindfulness-cultivating interventions may increase the likelihood of response from exercise.


      List of abbreviations:

      BMI (body mass index), CI (confidence interval), FFMQ (Five Facet Mindfulness Questionnaire), OA (osteoarthritis), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ma V.Y.
        • Chan L.
        • Carruthers K.J.
        Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the united states: Stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain.
        Arch Phys Med Rehabil. 2014; 95: 986-995.e1
        • Zhang Y.
        • Jordan J.M.
        Epidemiology of osteoarthritis.
        Clin Geriatr Med. 2010; 26: 355-369
        • Nelson A.E.
        • Allen K.D.
        • Golightly Y.M.
        • Goode A.P.
        • Jordan J.M.
        A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative.
        Semin Arthritis Rheum. 2016; 43: 701-712
        • Arden N.
        • Richette P.
        • Cooper C.
        • et al.
        Can we identify patients with high risk of osteoarthritis progression who will respond to treatment? A focus on biomarkers and frailty.
        Drugs Aging. 2015; 32: 525-535
        • Bruyère O.
        • Cooper C.
        • Arden N.
        • et al.
        Can we identify patients with high risk of osteoarthritis progression who will respond to treatment? A focus on epidemiology and phenotype of osteoarthritis.
        Drugs Aging. 2015; 32: 179-187
        • Bennell K.L.
        • Hall M.
        • Hinman R.S.
        Osteoarthritis year in review 2015: rehabilitation and outcomes.
        Osteoarthritis Cartilage. 2016; 24: 58-70
        • Weigl M.
        • Angst F.
        • Aeschlimann A.
        • Lehmann S.
        • Stucki G.
        Predictors for response to rehabilitation in patients with hip or knee osteoarthritis: a comparison of logistic regression models with three different definitions of responder.
        Osteoarthritis Cartilage. 2006; 14: 641-651
        • Gierisch J.M.
        • Myers E.R.
        • Schmit K.M.
        • et al.
        Prioritization of patient-centered comparative effectiveness research for osteoarthritis.
        Ann Intern Med. 2014; 160: 836
        • Eyles J.
        • Lucas B.R.
        Targeting care: tailoring nonsurgical management according to clinical presentation.
        Rheum Dis Clin North Am. 2013; 39: 213-233
        • Hooten W.M.
        Chronic pain and mental health disorders: shared neural mechanisms, epidemiology, and treatment.
        Mayo Clin Proc. 2016; 91: 955-970
        • Bennell K.L.
        • Dobson F.
        • Hinman R.S.
        Exercise in osteoarthritis: moving from prescription to adherence.
        Best Pract Res Clin Rheumatol. 2014; 28: 93-117
        • Dobson F.
        • Bennell K.L.
        • French S.D.
        • et al.
        Barriers and facilitators to exercise participation in people with hip and/or knee osteoarthritis: synthesis of the literature using behavior change theory.
        Am J Phys Med Rehabil. 2016; 95: 372-389
        • Stahl B.
        • Goldstein E.
        A mindfulness-based stress reduction workbook.
        New Harbinger Publications, Oakland2010
        • Walach H.
        • Buchheld N.
        • Buttenmüller V.
        • Kleinknecht N.
        • Schmidt S.
        Measuring mindfulness—the Freiburg Mindfulness Inventory (FMI).
        Pers Individ Dif. 2006; 40: 1543-1555
        • Bawa F.L.
        • Mercer S.W.
        • Atherton R.J.
        • et al.
        Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis.
        Br J Gen Pract. 2015; 65: e387-e400
        • Chiesa A.
        • Serretti A.
        Mindfulness-based interventions for chronic pain: a systematic review of the evidence.
        J Altern Complement Med. 2011; 17: 83-93
        • Veehof M.M.
        • Oskam M.J.
        • Schreurs K.M.
        • Bohlmeijer E.T.
        Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis.
        Pain. 2011; 152: 533-542
        • Schütze R.
        • Rees C.
        • Preece M.
        • Schütze M.
        Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain.
        Pain. 2010; 148: 120-127
        • Mun C.J.
        • Okun M.A.
        • Karoly P.
        Trait mindfulness and catastrophizing as mediators of the association between pain severity and pain-related impairment.
        Pers Individ Dif. 2014; 66: 68-73
        • Mantzios M.
        Exploring the relationship between worry and impulsivity in military recruits: the role of mindfulness and self-compassion as potential mediators.
        Stress Health. 2014; 30: 397-404
        • Mantzios M.
        • Wilson J.C.
        Making concrete construals mindful: a novel approach for developing mindfulness and self-compassion to assist weight loss.
        Psychol Health. 2014; 29: 422-441
        • Mantzios M.
        • Wilson J.C.
        • Linnell M.
        • Morris P.
        The role of negative cognition, intolerance of uncertainty, mindfulness, and self-compassion in weight regulation among male army recruits.
        Mindfulness (N Y). 2015; 6: 545-552
        • Reel J.J.
        • Lee J.J.
        • Bellows A.
        Integrating exercise and mindfulness for an emerging conceptual framework: the intuitive approach to prevention and health promotion (IAPHP).
        Eat Disord. 2016; 24: 90-97
        • Gilbert D.
        • Waltz J.
        Mindfulness and health behaviors.
        Mindfulness (N Y). 2010; 1: 227-234
        • Wang C.
        • Iversen M.D.
        • McAlindon T.
        • et al.
        Assessing the comparative effectiveness of Tai Chi versus physical therapy for knee osteoarthritis: design and rationale for a randomized trial.
        BMC Complement Altern Med. 2014; 14: 333
        • Wang C.
        • Schmid C.H.
        • Iversen M.D.
        • et al.
        Comparative effectiveness of Tai Chi versus physical therapy for knee osteoarthritis: a randomized trial.
        Ann Intern Med. 2016; 165: 77-86
        • Chen Y.W.
        • Hunt M.A.
        • Campbell K.L.
        • Peill K.
        • Reid W.D.
        The effect of Tai Chi on four chronic conditions—cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: a systematic review and meta-analyses.
        Br J Sports Med. 2016; 50: 397-407
        • Wang C.
        • Collet J.P.
        • Lau J.
        The effect of Tai Chi on health outcomes in patients with chronic conditions.
        Arch Intern Med. 2004; 164: 493
        • Deyle G.D.
        • Allison S.C.
        • Matekel R.L.
        • et al.
        Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program.
        Phys Ther. 2005; 85: 1301-1317
        • Baer R.A.
        • Smith G.T.
        • Lykins E.
        • et al.
        Construct validity of the Five Facet Mindfulness Questionnaire in meditating and nonmeditating samples.
        Assessment. 2008; 15: 329-342
        • Park T.
        • Reilly-Spong M.
        • Gross C.R.
        Mindfulness: a systematic review of instruments to measure an emergent patient-reported outcome (PRO).
        Qual Life Res. 2013; 22: 2639-2659
        • Bellamy N.
        • Buchanan W.W.
        • Goldsmith C.H.
        • Campbell J.
        • Stitt L.W.
        Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
        J Rheumatol. 1988; 15: 1833-1840
        • Khan N.A.
        • Spencer H.J.
        • Abda E.A.
        • et al.
        Patient's global assessment of disease activity and patient's assessment of general health for rheumatoid arthritis activity assessment: are they equivalent?.
        Ann Rheum Dis. 2012; 71: 1942-1949
        • Ware Jr., J.E.
        • Sherbourne C.D.
        The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection.
        Med Care. 1992; 30: 473-483
        • Olsson L.
        • Swedberg K.
        Six minute walk test.
        Eur Heart J. 2005; 26: 2209
        • Beck A.T.
        • Steer R.A.
        • Brown G.K.
        Manual for the Beck Depression Inventory-II.
        Psychological Corp, San Antonio1996
        • Eskildsen A.
        • Dalgaard V.L.
        • Nielsen K.J.
        • et al.
        Cross-cultural adaptation and validation of the Danish consensus version of the 10-item Perceived Stress Scale.
        Scand J Work Environ Health. 2015; 41: 486-490
        • Brady T.J.
        Measures of self-efficacy: Arthritis Self-Efficacy Scale (ASES), Arthritis Self-Efficacy Scale-8 Item (ASES-8), Children's Arthritis Self-Efficacy Scale (CASE), Chronic Disease Self-Efficacy Scale (CDSES), Parent's Arthritis Self-Efficacy Scale (PASE), and Rheumatoid Arthritis Self-Efficacy Scale (RASE).
        Arthritis Care Res. 2011; 63: S473-S485
        • Pham T.
        • Van Der Heijde D.
        • Lassere M.
        • et al.
        Outcome variables for osteoarthritis clinical trials: The OMERACT-OARSI set of responder criteria.
        J Rheumatol. 2003; 30: 1648-1654
        • Yu M.
        • Clark M.
        Investigating mindfulness, borderline personality traits, and well-being in a nonclinical population.
        Psychology. 2015; 6: 1232-1248
        • Lee A.C.
        • Harvey W.F.
        • Price L.L.
        • Morgan L.P.
        • Morgan N.L.
        • Wang C.
        Mindfulness is associated with psychological health and moderates pain in knee osteoarthritis.
        Osteoarthritis Cartilage. 2017; 25: 824-831
        • Mason A.E.
        • Epel E.S.
        • Aschbacher K.
        • et al.
        Reduced reward-driven eating accounts for the impact of a mindfulness-based diet and exercise intervention on weight loss: data from the SHINE randomized controlled trial.
        Appetite. 2016; 100: 86-93
        • Nyklíček I.
        • Hoogwegt F.
        • Westgeest T.
        Psychological distress across twelve months in patients with rheumatoid arthritis: the role of disease activity, disability, and mindfulness.
        J Psychosom Res. 2015; 78: 162-167
        • Uusberg H.
        • Uusberg A.
        • Talpsep T.
        • Paaver M.
        Mechanisms of mindfulness: the dynamics of affective adaptation during open monitoring.
        Biol Psychol. 2016; 118: 94-106
        • Snijders G.F.
        • van den Ende C.H.
        • van den Bemt B.J.
        • et al.
        Treatment outcomes of a Numeric Rating Scale (NRS)-guided pharmacological pain management strategy in symptomatic knee and hip osteoarthritis in daily clinical practice.
        Clin Exp Rheumatol. 2012; 30: 164-170
        • Wolf S.
        • Foley S.
        • Budiman-Mak E.
        • et al.
        Predictors of weight loss in overweight veterans with knee osteoarthritis who participated in a clinical trial.
        J Rehabil Res Dev. 2010; 47: 171-181
        • Fuller N.R.
        • Sainsbury A.
        • Caterson I.D.
        • et al.
        Examining mindfulness as a predictor of weight loss - findings from the DIABEGG study.
        Obes Res Clin Pract. 2016; 11: 88-96
        • Bergomi C.
        • Tschacher W.
        • Kupper Z.
        The assessment of mindfulness with self-report measures: existing scales and open issues.
        Mindfulness (N Y). 2013; 4: 191-202
        • Karsdal M.A.
        • Christiansen C.
        • Ladel C.
        • Henriksen K.
        • Kraus V.B.
        • Bay-Jensen A.C.
        Osteoarthritis - a case for personalized health care?.
        Osteoarthritis Cartilage. 2014; 22: 7-16
        • Bamman M.M.
        • Cooper D.M.
        • Booth F.W.
        • et al.
        Exercise biology and medicine: innovative research to improve global health.
        Mayo Clin Proc. 2014; 89: 148-153
        • Lohmander L.S.
        • Roos E.M.
        Clinical update: treating osteoarthritis.
        Lancet. 2007; 370: 2082-2084
        • Messier S.P.
        • Callahan L.F.
        • Golightly Y.M.
        • Keefe F.J.
        OARSI Clinical Trials recommendations: design and conduct of clinical trials of lifestyle diet and exercise interventions for osteoarthritis.
        Osteoarthritis Cartilage. 2015; 23: 787-797
        • Marks R.
        Knee osteoarthritis and exercise adherence: a review.
        Curr Aging Sci. 2012; 5: 72-83
        • Bamman M.M.
        • Wick T.M.
        • Carmona-Moran C.A.
        • Bridges S.L.
        Exercise medicine for osteoarthritis: research strategies to maximize effectiveness.
        Arthritis Care Res (Hoboken). 2016; 68: 288-291
        • Fransen M.
        • Mcconnell S.
        • Harmer A.R.
        • Van der Esch M.
        • Simic M.
        • Bennell K.L.
        Exercise for osteoarthritis of the knee.
        Cochrane Database Syst Rev. 2015; 1: CD004376
        • Wayne P.M.
        • Kaptchuk T.J.
        Challenges inherent to T'ai Chi research: part I—T'ai Chi as a complex multicomponent intervention.
        J Altern Complement Med. 2008; 14: 95-102