Chronic low back pain ranks as a leading cause of functional disability among adults in the United States. Despite numerous treatment options and increased resources being devoted to the medical care of these individuals, this patient group often continues to struggle with functional limitations. “Many of the available treatment options for chronic low back pain are ineffective,” explains Daniel C. Cherkin, PhD. “There is a need for effective, low-risk treatment options to be more widely available to those with low back pain.”
In clinical investigations, researchers have found that psychosocial factors play an important role in pain and its associated physical disability. Clinical guidelines recommend many different treatments for persistent back pain, some of which are non-pharmacologic. Two of these examples include cognitive behavioral therapy (CBT), which has been shown to be effective for various chronic pain conditions, and mindfulness-based stress reduction (MBSR). These mind-body approaches focus on increasing awareness of moment-to-moment experiences of pain, including physical discomfort and difficult emotions.
MBSR is becoming increasingly popular and available in the U.S., making it important to determine if this treatment approach is beneficial for chronic low back pain. “MBSR could be another option for a large number of Americans who are suffering from this condition,” he says. “CBT, MBSR, and other mindfulness-based interventions have been found helpful for many health conditions, but few studies have looked specifically at MBSR for chronic low back pain.”
A Comparative Assessment
For a randomized clinical trial published in JAMA, Dr. Cherkin and colleagues compared the effect of different approaches to the self-management of chronic low back pain. The analysis involved 342 adults aged 20 to 70 who were randomly assigned to receive MBSR, CBT, or usual care. The MBSR group received training in mindfulness meditation and yoga while the CBT group was trained to change their pain-related thoughts and behaviors. Each of these groups received their intervention in eight weekly 2-hour groups. The usual care group was not provided any care as part of the study.
In intent-to-treat analyses at 26 weeks, the percentage of study patients with clinically meaningful improvement on the Roland Disability Questionnaire was higher for those receiving MBSR and CBT than for the usual care group (Table). The percentage of participants with clinically meaningful improvements in pain bothersomeness at 26 weeks was also higher for the MBSR and CBT groups. The study authors note that their findings for MBSR persisted with little change at 52 weeks for both of these outcomes.
“Among adults with chronic low back pain, both MBSR and CBT led to greater improvements in back pain and functional limitations when compared with usual care,” says Dr. Cherkin. “These benefits were seen up to 1 year after entry into the trial.” He notes that the findings persisted even though only 51% of patients receiving MBSR and 57% of those receiving CBT attended six or fewer sessions of the eight they could have attended.
Supporting Previous Research
Findings of the trial support findings of previous research that has shown CBT to be more effective than control and active interventions for pain conditions. Earlier studies have also suggested that that there are long-lasting effects associated with CBT for chronic low back pain. “Mind-body treatments like MBSR and CBT may offer patients valuable, long-lasting skills that are effective for managing pain,” Dr. Cherkin says.
More to Come
More research is needed to identify moderators and mediators of the effects of MBSR on function and pain. “Additional studies are needed to identify reasons why patients do not attend all of their MBSR sessions, strategies to increase attendance, and methods for determining the minimum number of sessions required for patients to benefit from them,” Dr. Cherkin says. Investigations are also needed to evaluate the benefits of MBSR beyond 1 year.
Many physicians are unaware of the availability of MBSR to help manage patients who live with chronic low back pain, according to Dr. Cherkin. “Our results suggest that it’s reasonable to recommend patients to receive treatment with MBSR and/or CBT because they are both safe and effective,” he says. “These strategies may be helpful treatment options that could ultimately reduce the burden of chronic low back pain.” A major challenge is to make these treatments more accessible to patients by familiarizing clinicians with their value, ensuring that health insurance covers these treatments, and improving access to these strategies.
Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315:1240-1249. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2504811.
Cherkin DC, Sherman KJ, Balderson BH, et al. Comparison of complementary and alternative medicine with conventional mind-body therapies for chronic back pain: protocol for the Mind-body Approaches to Pain (MAP) randomized controlled trial. Trials. 2014;15:211.
Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back pain. BMC Complement Altern Med. 2012;12:162.
Sherman KJ, Cherkin DC,Wellman RD, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171:2019-2026.