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OPEN Mindfulness‑based randomized

controlled trials led to brain
structural changes: an anatomical
likelihood meta‑analysis
Savannah Siew *
& Junhong Yu
Mindfulness has become increasingly popular and the practice presents in many different forms.
Research has been growing extensively with benefits shown across various outcomes. However,
there is a lack of consensus over the efficacy of randomized controlled mindfulness interventions,
both traditional and mind–body formats. This study aimed to investigate the structural brain
changes in mindfulness-based interventions through a meta-analysis. Scopus, PubMed, Web of
Science, and PsycINFO were searched up to April 2023. 11 studies (n = 581) assessing whole-brain
voxel-based grey matter or cortical thickness changes after a mindfulness RCT were included.
Anatomical likelihood estimation was used to carry out voxel-based meta-analysis with leave-one-
out sensitivity analysis and behavioural analysis as follow-ups. One significant cluster (p < 0.001,
Z = 4.76, cluster size = 632 ­mm3) emerged in the right insula and precentral gyrus region (MNI = 48, 10,
4) for structural volume increases in intervention group compared to controls. Behavioural analysis
revealed that the cluster was associated with mental processes of attention and somesthesis (pain).
Mindfulness interventions have the ability to affect neural plasticity in areas associated with better
pain modulation and increased sustained attention. This further cements the long-term benefits and
neuropsychological basis of mindfulness-based interventions.

Mindfulness has become increasingly popular in today’s wellness culture with it gaining popularity in the West
with roots in Buddhism and Hinduism. Kabat-Zinn1 coined the modern definition of mindfulness which means
“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (p. 4). There
have been several conceptualizations of mindfulness and one widely-cited operational definition is a two-com-
ponent model involving the self-regulation of attention to the present moment and orientation of acceptance
towards that ­moment2. This definition strongly parallels one conceptualized within the Relational Frame Theory,
in terms of four psychological processes of acceptance, defusion, present-moment awareness, and the observer
­self3. It seems that mindfulness can be characterized broadly by attention to the present moment and non-
judgemental acceptance and this definition will be relied upon in this study.
The practice of mindfulness can look very ­different4, ranging from meditative religious practices of Vipassana
and Zen to structured programs like mindfulness-based stress reduction (MBSR), and therapeutic modalities
such as dialectical behaviour therapy and mindfulness-based cognitive therapy. Vipassana—A meditative prac-
tice from Buddhism, involves a constant body scan from head to toe while maintaining a stance of non-reactive
­observation5. This is sometimes referred to as open monitoring meditation which also includes Zen meditation,
which focuses on regulating attention. MBSR is a structured programme developed by Kabat-Zinn 6 where
participants undergo an eight-week intensive mindfulness practice. Mind–body practices, such as yoga and the
Chinese ancient art of Tai Chi Chuan (TCC) and Baduanjin, incorporate mindfulness into movement. Yoga
focuses on the regulation of the breath and being aware of one’s thoughts while engaging in physical movement
and stretches and the practice has now been widely accepted as secular and is popular around the world. TCC
and Baduanjin are less well-known globally but these are widely practised in China as well as countries that
inherited Confucius cultural heritage such as Singapore. TCC involves meditative and cognitive components
in addition to physical movements and is often practised with a group. Baduanjin uses the breath to guide slow
coordinated physical movements to cultivate one’s internal energy, called “Qi”. This shares similarities with
Ashtanga yoga, where poses are executed in synchrony with each breath, and Hatha yoga which involves both

Psychology, School of Social Sciences, Nanyang Technological University, Singapore, Singapore. *

email:
[email protected]

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yoga postures and breathing techniques and is traditionally used to preserve the vital “force” within one’s body.
Thus, these mind–body practices can be viewed to involve similar components with each other as well as the
traditional mindfulness practices without the physical component. Often, present-moment awareness is the key
concept during these practices.
Research in the field has been growing extensively over the years due to its wide-ranging effects. It is effi-
cacious in reducing primary symptoms of various medical ­conditions7–13 and their associated psychological
­factors7,8,10,13–16. Apart from clinical populations, mindfulness extends benefits to the general ­population17–22.
Other outcome variables such as biomarkers of immune f­unctioning23 and stress r­ egulation18, cognitive
­functions24, and neuroimaging m ­ easures25–29 have also been associated with mindfulness practice.
Researchers have turned to neuroimaging to explore the neurobiological basis of the mechanisms involved
in the process. Mindfulness affects both functional connectivity and structural anatomy in the ­brain25,30. Eight
brain regions, for example, the sensory cortices and insular, hippocampus and anterior cingulate cortex (ACC),
are often correlated with mindfulness meditation across studies, with a moderate effect ­size26. These include
grey matter (GM) and white matter (WM) volume differences between long-term meditators and meditation-
naïve controls, and pre- and post-mindfulness interventions among meditation-naïve participants. Moreover,
these regions are congruent with the purpose of mindfulness practice. The insular cortex, linked to the effects
of mindfulness such as body awareness and emotional self-awareness, has shown structural and functional
­differences26. GM volume in the hippocampus is significantly larger in long-term meditators compared to those
without ­experience31 and this is seen among yoga practitioners as w ­ ell32. The hippocampus has a key role in the
memory organization of new memories, converting them from short-term to long-term memory stores. It is
proposed that the structural differences observed here could explain one’s ability to deal with the spontaneous
thoughts that occur during the practice and the memory organization ability that is r­ equired26. Cortical thickness
in pain-related brain regions, the secondary somatosensory cortex and dorsal ACC​33, and attention-related brain
regions such as the left superior frontal gyrus and bilateral superior parietal ­lobule34 were significantly larger
in long term Zen meditators. The structural changes occur in areas associated with the benefits of mindfulness
practice and range from increased GM v­ olume25,29 to increased connectivity in the WM ­microstructure28.
There is much more literature available on functional neuroimaging. During meditation, the brain areas of
neural networks associated with present-moment awareness were highly activated during meditation tasks in
both novice and experienced p ­ articipants25,35. Activations in the brain regions such as the ACC and insula were
often observed during mindfulness ­practice27. Moreover, functional connectivity within and between specific
brain networks, such as the default mode network and the sensorimotor network was altered by mindfulness
practice during resting-state or meditation-state functional ­scans36. Further establishing that the associated brain
activations were indeed due to the mindfulness practice, dissociable patterns of activation were reliably observed
in the different types of meditations, in line with the characteristics embodied by each ­type27.
As evidenced by research, the benefits of mindfulness have been relatively well-established across a variety of
outcomes. However, with regard to neuroimaging outcomes, many studies focus on the GM differences between
long-term practitioners compared to c­ ontrols25,26,35. Within these meta-analyses, the lack of consolidation of
studies that include an experimental method makes it difficult to isolate the impact of mindfulness since there
is a chance that certain individual traits could predispose someone to be more likely to engage in mindfulness
practice. In addition, mind–body interventions such as yoga and qigong practice are often excluded from the
meta-analyses of the subject ­matter26,29, which often leaves out the popular MBSR programme because one of
the sessions involves yoga practice. This means that we are overlooking a good opportunity to investigate the
physical-mental interactions and benefits of these practices, of which mindfulness is a huge aspect. On the other
hand, other reviews only focused on mind–body p ­ ractices37 which does not allow us to sufficiently understand
the full picture regarding all mindfulness-based interventions. Thus, there is a lack of consensus over the efficacy
of rigorous mindfulness interventions, both traditional and mind–body formats, in the form of randomized
controlled trials (RCT). This study aims to understand the current state of structural neuroimaging findings
regarding mindfulness-based interventions. It is hypothesized that brain regions associated with the mechanisms
and benefits of mindfulness will show significant changes after mindfulness practice in the intervention compared
to the control groups across the studies included in this meta-analysis.

Methodology
Study selection
Search strategy
A systematic literature search was carried out in four databases, Scopus, PubMed, Web of Science, and APA
PsycINFO from the earliest studies up till April 2023. This is to ensure that both the psychological and neuro-
science aspects of the research topic are covered as well as any inter-disciplinary research. The keywords used
for the search in both the title and abstract were: “voxel-based” or “morphometr*” or “voxelwise” or “VBM” or
"brain structur*" or "structur* change*" or "structural MRI" or "structural scan*” or “gray matter” or “grey mat-
ter”, together with “Meditat*” or “Mindful*” or “mind–body” or “mind body” or “yoga”, and lastly with “RCT”
or “intervention” or “trial”.
All records that surfaced were imported into ­Covidence38 which helped to flag studies that were duplicated.
All the duplicated articles were checked manually before being removed from the review. Following this, the
author did an abstract screen to remove articles that were clearly irrelevant to the research question. If the study
was relevant or the relevance was uncertain, and it appears to have met the following eligibility criteria, the full-
text article was retrieved. Additionally, the studies included in systematic reviews and meta-analysis that were
relevant to our topic was checked to ensure that we did not miss out any studies. Then, a full-text screen was

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conducted to ensure that all eligibility criteria were met. In addition, all the references of the papers selected in
the first round of full-text review were included in the meta-analysis.

Eligibility criteria
Included studies must be RCTs with either a random or quasi-random allocation, with a treatment and a con-
trol group. Control groups could be active or passive, with some studies including both types of control groups
within the study design. Only RCTs were included to conduct a more rigorous meta-analysis of mindfulness-
related structural changes and control for individual differences that could surface when comparing expert
practitioners to those without mindfulness experience in cross-sectional studies. The outcome measure must be
a voxel-based or vertex-based comparison of whole-brain GM. Thus, only studies of the GM volume and cortical
thickness conducted with structural MRI were included. Regions-of-interest analysis could introduce biases in
terms of different methods of choosing and including the brain regions to focus on. Study populations were not
restricted to healthy subjects and clinical populations were included as well, regardless of gender and race. In
addition, all interventions that meet the definition of mindfulness as a form of present-moment awareness were
included since the aim of the study is to surface brain structures related to mindfulness practice. Thus, both the
traditional forms of interventions that examined solely the effect of mindfulness and holistic mind–body forms
of mindfulness were included.
Studies with less than 10 subjects were excluded due to the low validity of the study. In addition, studies will
be excluded when the required information cannot be extracted or obtained from the corresponding authors.
Studies that re-analysed previously published data, protocol papers, and abstract-only papers were not included.
Studies with null findings were excluded as they do not provide spatial coordinates that were necessary for the
analysis method used in this study. To provide more stringent findings, studies that do not employ correction
for multiple comparisons or cluster-level family-wise error correction in determining statistically significant
clusters were excluded.

Meta‑analysis
The preferred reporting items for systematic reviews and meta-analysis (PRISMA)39 and the following neuro-
imaging meta-analysis g­ uidelines40,41 were followed in this study.

Data extraction
Study characteristics including the author, year of publication and country of study, subject characteristics of
age, gender, education, and health or clinical status, and intervention details such as the type of mindfulness
practice, length of intervention, type of randomization and control group, and sample size were extracted from
the study articles. Statistical data of the analysis design, the cluster-based statistical thresholds used to determine
which voxels were statistically significant, and the software, which can be Statistical Parametric Mapping, FMRIB
Software Library or other packages, and stereotactic space, which can be Montreal Neurological Institute (MNI),
raw Talairach, or MNI converted to Talairach using Brett transform, were also noted. Lastly, the significant brain
regions with their peak coordinates, and the direction of change, which can increase or decrease for the interven-
tion group in comparison to the control group were extracted.

Statistical analysis
Voxel-based meta-analysis were carried out with Anatomical Likelihood Estimation (ALE). ALE is derived from
activation likelihood estimation principles and detects convergence among the significant coordinates reported
across studies that are above chance-levels. ALE was carried out using BrainMap’s GingerALE v3.0.2. Studies that
reported coordinates in Talairach space were transformed to MNI space using the Lancaster transform icbm2tal
provided in GingerALE. First, ALE uses a Gaussian function to model the coordinates of the studies that were
included by accommodating the spatial uncertainty of significant coordinates that could be caused by differences
in the neuroanatomy or by using different normalization techniques and brain templates, and by taking into
account the sample size of each study. Second, each study has a whole-brain map constructed, where each voxel
is assigned a number that corresponds to the probability that a difference in volume between the treatment and
control groups occurs within the voxel. These maps from all the studies were then combined and yielded the ALE
image where the likelihood of a particular voxel having difference in volumes found minimally for one study was
represented in ALE values. Then, the statistical significance of these ALE values were analyzed with a cluster-
level family-wise error (FWE) correction threshold of p < 0.05 with 1000 permutations. The cluster-level FWE
correction is known to be the most appropriate method for inferring the statistical significance of ALE ­analyses42.
Following which, the Behavioural Analysis Plugin 3.1 for Mango 4.1 was used to access the behavioural pro-
files and mental processes that are associated with the identified significant ALE clusters. Based on the functional
metadata from the BrainMap Database, the significant ALE clusters were compared against this map to generate
the behavioural domains that could fall under Interoception, Cognition, Action, Emotion, and Perception, and
is further divided into 60 sub-domains. The significant ALE clusters was transformed to the Talairach space
using the transform tool MNI-to-Tal provided in Mango. The region of interest of the significant ALE cluster
was selected and the proportion of behavioural domains found within this cluster was compared to the propor-
tions of the behavioural domains across the whole functional database. A behavioural domain profile of the
significant cluster was thus generated where Z-scores above 3.0 were considered significant. Sensitivity analysis
will be conducted using a leave-one-out method to test the replicability of the results.

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Figure 1.  PRISMA flow chart of selection process. Selection process of included studies for this meta-analysis
according to PRISMA guidelines.

Results
Study search and characteristics
In the first round of search, a total of 254 articles were retrieved from the selected databases (PsycINFO = 44,
Scopus = 88, Web of Science = 64, PubMed = 58). Duplicates were surfaced by Covidence and manually checked
before deleting, which resulted in 109 studies to be screened. Following the eligibility criteria, 48 studies were
found to be irrelevant during the title and abstract screening stage. Thus, 61 full-text articles were closely assessed
for eligibility, leading to 10 included studies which met all the inclusion criteria. After which, all the references of
the 10 included studies were entered into the selection process but only one article met all the inclusion criteria.
Thus, the final number of included studies was 11. The full selection process and reasons for exclusion can be
found in the PRISMA flow chart in Fig. 1 while the characteristics of the 11 included studies can be found in
Table 1. Studies that were excluded for null findings were by Wolf, et al.43, Kral, et al.44, Seminowicz, et al.45 and
Mooneyham, et al.46 while Pickut, et al.47 was excluded for using an uncorrected threshold.
In summary, this meta-analysis had 581 participants (N = 11 studies) from various regions such as Asia
(n = 5), Europe (n = 3) and North America (n = 3). All studies reported significant intervention > control contrasts
while three studies reported significant control > intervention contrasts. Roughly half of the studies (n = 5) had
physical components together with the mindfulness aspect such as Yoga, TCC and Baduanjin. Majority of the
studies used a passive control group (n = 6), compared to an active control group (n = 3), while two studies had
both an active and passive control groups. The active control groups ranged from memory enhancement train-
ing and aerobic exercise to health education programmes. Lastly, about half the studies (n = 6) were on healthy
participants while the rest were on patient populations such as those with Mild Cognitive Impairment (MCI)
or chronic neuropathic pain.

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Study Subject Intervention details

Education, in
Author, years: mean Type of mindfulness Length of Type of Type of Sample size
year Country Age: mean (SD) (SD) Clinical status practice intervention randomization control group (female)
Grey matter volume
IG: 21.83 (2.48) IG: 16.33 (2.23) PCG: TAU​ IG: 12 (10)
PCG: 21.75 PCG: 16.33
48 8 weeks, 3 1 h PCG: 12 (10)
China (2.45) (1.50) Healthy TCC​ Random ACG: Aerobic
sessions per week
ACG: 21.92 ACG: 16.41 exercise
ACG: 12 (10)
(2.28) (2.27)
IG: 21.63 (2.02) Not available, IG: 12 (2)
49 Sahaja yoga medita- 4 weeks, 1 1 h
Italy PCG: 22.16 university stu- Healthy Random PCG: waitlist
tion session per week PCG: 30 (12)
(1.33) dents
1 1
IG: 67.00 (1.00) IG: 15.00 (0.75) Full body relaxa- IG: 11 (4)
2 weeks, 4 ses-
Clinical criteria tion, meditation on
50 7 sions guided and
India PCG: 71.00 PCG: 14.00 for aMCI or peace, witnessing the Quasi-random PCG: TAU​ 2
6 months, daily PCG: 11 (5)
(3.25)1 (0.88)1 probable AD breath, witnessing of
30 min at home
thoughts
IG: 48.36 Breast cancer
8 weeks, 1 2.5 h IG: 13 (13)
(12.82) survivors
51 session per week
Canada Not available suffering from MBSR Random PCG: waitlist
PCG: 56.50 and 1 full day
chronic neuro- PCG: 10 (10)
(8.11) session
pathic pain
IG: 38.00 (4.10) IG: 17.70 (1.90) 8 weeks, 1 2.5 h IG: 16 (10)
52 session per week
US PCG: 39.00 PCG: 17.30 Healthy MBSR Quasi-random3 PCG: waitlist
and 1 full day PCG: 17 (6)
(9.20) (1.80) session
IG: 60.90 (6.66)4 IG: 15.70 (2.06)4 12 weeks, 1 1 h IG: 11 (11)
session per week ACG: Memory
53
US ACG: 64.00 ACG: 16.1 At-risk for AD Yoga guided and daily Random enhancement
12 min recording training ACG: 11 (11)
(6.48)4 (1.66)4
at home
IG[1]: 62.181 IG[1]: 9.061 IG[1]: Baduanjin ACG: Basic IG[1]: 16 (10)
health educa-
54 IG[2]: 60.31 1
IG[2]: 9.611 12 weeks, 5 1 h IG[2]: 21 (13)
China Healthy Random tion and usual
IG[2]: TCC​ session per week
physical
ACG: 60.161 ACG: 8.371 activity ACG: 24 (18)

PCG: physical
IG: 65.79 (4.35)4 activity as IG: ­205
usual
55 24 weeks, 3 1 h
China PCG: 65.86 Not available MCI Baduanjin Random
session per week PCG: ­205
(5.28)4 ACG: brisk
ACG: 64.88 walking
ACG: ­205
(3.30)4
Cortical thickness
IG: 31.00 (4.00) 8 weeks, 1 2.5 h IG: 23 (12)
56 session per week
Italy PCG: 30.00 Not available Healthy MBSR Random PCG: waitlist
and 1 full day PCG: 22 (11)
(4.00) session
4
IG: 41.25 Breathing medita- IG: 127 (95)4
tion and body scan,
loving-kindness
57 39 weeks, 1 2 h PCG: matched
Germany Not available Healthy meditation and affect Random
PCG: 40.004 session per ­week6 retest control PCG: 72 (53)4
dyad, observing-
thoughts meditation
and perspective dyad
IG: 71.30 (5.60)4 IG: 5.20 (4.90)4 Mindfulness aware- IG: 20 (19)4
ness programme
(mindfulness of the
3 months, 1 ACG: health
58 senses, body scan,
Singapore ACG: 71.40 ACG: 3.40 MCI 45 min session Random education
walking meditation, ACG: 18 (21)4
(6.00)4 (4.30)4 per week programme
moving with aware-
ness, mind–body
coordination)

Table 1.  Characteristics of included studies. SD standard deviation, IG intervention group, PCG passive
control group, ACG​active control group, TCC​Tai Chi Chuan, TAU​treatment as usual, aMCI amnestic mild
cognitive impairment, AD Alzheimer’s disease, MBSR mindfulness-based stress reduction, US United States.
1
SD was not provided and if range was provided, the range rule, whereby the SD of the sample is approximately
1/4th the range of the data, is used to estimate it. 2 Authors combined the ACG that did a colouring task with
the PCG because of high dropout rates. 3 This was assumed from the study’s methods as it was not explicitly
stated. 4 These demographic variables were not based on the final sample but the sample at baseline. 5 Number
of females in the final sample with usable MRI scans were not known. 6 Intervention protocol involves multiple
training modules and has been simplified here for clarity’s sake. Please refer to the paper for more details. 7 This
study had both grey matter volume and cortical thickness data.

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Figure 2.  Risk of bias assessment. Results of the risk of bias assessment for all included studies.

Risk of bias of included studies

The revised tool to assess the risk of bias in randomized trials were used in this a­ ssessment59. Availability of
outcome data for nearly all participants randomized were considered when drop-out rates after the intervention
were less than 10%. All included studies were assessed to be of low risk, as seen in Fig. 2.

Significant ALE clusters

One significant cluster, as seen in Fig. 3, emerged from the intervention > control ALE contrast and covered the
right insula and precentral gyrus in the Brodmann area 13 (BA13) and 44 (BA44) respectively. The cluster size was
632 ­mm3 with one peak voxel MNI coordinates at 48, 10, 4. The ALE value for this cluster was 0.017 (p < 0.001,
Z = 4.76) with two contributing experiments by Santarnecchi, et al.56 and Krause-Sorio, et al.53. There were no
significant clusters from the intervention < control ALE contrast. Moreover, since both GM and cortical thick-
ness measures were included, we re-conducted the ALE meta-analysis without the cortical thickness measures
to see if that affected the results and no clusters remained significant.

Sensitivity and behavioural analysis

Using the leave-one-out method, the stability of the findings were tested. The region of interest that emerged
above remains significant in all except two of the repetitions, when the studies that contributed to the clusters
were excluded. These occurred when we left out the two studies that contributed to the significant cluster above.
Behavioural analysis of the significant ALE cluster above indicated that the cognitive subdomain of attention
(Z = 3.77) and the perception subdomains of somesthesis, in particular pain (Z = 3.01) were the mental processes
associated in the region.

Discussion
Across the intervention groups, there was a significant structural increase in the right insula and precentral
gyrus region. Using behavioural analysis, this cluster was found to be associated with the cognitive process of
attention and the perception process of pain-sensing. This region of interest remained significant in all but two
of the repetitions, occurring when the studies contributing to the significant clusters were r­ emoved53,56. This
signifies that the ALE cluster was due to a small set of studies. However, this brain region was consistently acti-
vated even though the type of mindfulness practice was varied, with one using yoga as the intervention while
the other used MBSR. Interestingly, one sample was healthy while the other used participants who were at risk
for Alzheimer’s disease.
The insula is often implicated in both sensorimotor and emotional processing, especially during interoceptive
­experiences60. The insula is also involved in top-down control of pain expression and t­ ransmission61 which could
explain findings of improved pain symptoms amongst those suffering from chronic pain following mindfulness
­interventions62,63. The posterior insula, where Brodmann area 13 is located, is crucial in processes like emotion
regulation and attentional ­control64. The neural plasticity in this brain region with engagements in mindfulness
practice could be the mediating factor for the well-being outcomes often observed. The right insula in particu-
lar has shown more involvement in self-related processing than the left due to specific neural ­features65. With
mindfulness practice largely focused on an awareness of the self, it could explain this observation of a unilateral
structural change in the insula.
The precentral gyrus, similar to the insula is often activated during interoceptive ­attention66. The right precen-
tral gyrus especially is activated during awareness of the ­self67 and the right side of prefrontal activation is often
observed during sustained attention ­tasks68. Overall, it seems that the mechanisms underlying mindfulness-based
interventions stem from improvements in attention, especially attention inward to the self, and pain processing.

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Figure 3.  Results of the ALE meta-analysis. The highlighted cluster represent significant convergence of
structural increase in mindfulness intervention participants compared to controls. The cluster is depicted
on an MNI standard brain template and the colour indicates the ALE values. L = left; R = right, A = anterior,
P = posterior.

Given the research surrounding the overlap of brain regions activated during both emotional and physical ­pain69,
an increase in the structural volume of the right insula and precentral gyrus could contribute to the benefits of
mindfulness practice as a therapeutic tool.
In the most recent meta-analysis on GM changes relating to mindfulness meditation, only structural change
in the right anterior ventral insula was found to be consistent across s­ tudies29. The study excluded any mindful-
ness interventions with physical components, such as yoga and the popular MBSR programmes and the brain
region found to be significant was similar but more in the anterior region, compared to the findings of this
study which saw more structural changes in the posterior insula. The selection of included studies was also
mentioned as a weakness since most were cross-sectional. The studies compared structural volume differences
in the brains of meditators and non-meditators at a single timepoint or looked at the association of meditation
experience with structural brain volume in meditators only. Thus, the stringent inclusion criteria set in this
meta-analysis helped to address issues relating to experimental biases in previous meta-analyses. The insula was
also consistently activated across fMRI studies during meditation tasks among participants with no experience
in ­mindfulness35. It seems that the benefits of the intervention could be enduring given the structural change
observed in this same region.
Another comprehensive and widely cited meta-analysis on morphometric changes associated with mindful-
ness practice mainly looked at significant differences between long-term practitioners and participants with no
prior ­experience26. Only five studies used a mindfulness intervention on participants with no prior experience.
Thus, there were more significant structural differences in brain regions observed in the anterior- and mid-
cingulate cortex, middle frontal gyrus, anterior precuneus, fusiform gyrus, orbitofrontal cortex, inferior temporal
gyrus, somatomotor cortices, and anterior insula. These additional brain regions could be attributed to either
longer-term effects of consistent mindfulness practice, or biases arising from the cross-sectional design of the
study. In contrast, the findings from our meta-analysis shows that even short-term mindfulness practice can effect
structural changes in the brain. The two studies that contributed to the significant cluster found had mindfulness
intervention durations between 8 to 12 weeks with 1 session per week. 8 weeks of mindfulness intervention was
also the most common intervention duration used and could be the minimum period for mindfulness interven-
tions to reflect effectiveness in terms of structural brain changes. This provides more convincing support for the
benefits of mindfulness practice and allows us to allude the improvements in awareness and pain processing to the
practice itself. Moreover, it seems that the benefits do not require years of mindfulness practice before appearing
but we should take caution in interpreting the longevity of these changes since post-intervention follow-ups are
usually not carried out in the studies.
The number of studies included in this meta-analysis did not meet the recommended good practice amount
of 17 b­ y40. However, we believe that it is crucial to explore what the current landscape of high-quality RCTs
provides in terms of the evidence of the benefits of mindfulness intervention as interest in the area grows. This
also surfaces multiple future research directions. With an increased sample size of included studies, future sub-
group analysis could compare the effects of an active versus passive control group, or the effects of including a
physical component to the mindfulness intervention, potentially isolating the unique mechanisms of the various
components of mindfulness practices. Additionally, differential effects on a healthy versus patient population
could also be explored. It is interesting that the patient populations in this meta-analysis have impairments in

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areas such as pain-processing and cognitive deficits which overlaps with the mental processes associated with
the significant brain regions found. There is a possibility that the effectiveness of mindfulness interventions only
pertains to clinical populations where deficits are seen in attention and pain-processing. However, future studies
are needed to confirm that.
Unfortunately, it was also not possible to verify the effect of potential confounding variables such as age,
gender, and length of intervention using meta-regressions with the ALE method, and the exclusion of studies
without significant results also causes a selection bias. An important study that was excluded because of non-
significant results was a large-scale and rigorously controlled study by Kral et al.44. It is possible that they did not
detect significant GM changes due to their stringent exclusion criteria which included anyone with expertise in
nutrition, music or physical activity. Additionally, participants had to undergo various other assessments as part
of a larger multi-project study with each visit taking 2–4 h which could introduce other variabilities. These are
all potential areas that future studies should take into account.
In conclusion, this meta-analysis has found evidence for structural brain changes following mindfulness
interventions. These interventions, both traditional and mind–body formats, have the ability to affect neural
plasticity in the brain regions associated with pain modulation and sustained attention. During the mindfulness
intervention, the repeated practice of engaging one’s attention and awareness to the self repeatedly activates
these regions of the brain. Over time, neural plasticity could lead to an increase in the volume of these regions.
This further cements the long-term benefits and neuropsychological basis of mindfulness-based interventions.

Data availability
The data that support the findings of this study are available from the corresponding author upon request.

Received: 9 May 2023; Accepted: 23 October 2023

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Acknowledgements
We would like to acknowledge the Nanyang Assistant Professorship (Award no. 021080-00001) grant.

Author contributions
S.S. prepared the first draft of the manuscript and both authors edited and approved the final draft. Both authors
were involved in the planning and data analysis of the study.

Competing interests
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to S.S.
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