Mindfulness and CBT Effectively Treat Chronic Back Pain

Tara Haelle

March 22, 2016

Both mindfulness-based stress reduction (MBSR) training and cognitive behavioral therapy (CBT) showed similar improvements over usual care in pain and disability among adults with chronic low back pain, according to a randomized clinical trial published in the March 22/29 issue of JAMA.

"The effects were moderate in size, which has been typical of evidence-based treatments recommended for chronic low back pain," write Daniel C. Cherkin, PhD, from the Group Health Research Institute in Seattle, Washington, and colleagues.

The researchers randomly assigned 342 adults, aged 20 to 70 years, with chronic low back pain to either usual care (n = 113) or one of two interventions, delivered in weekly 2-hour group sessions for 8 weeks. CBT was provided to 113 adults, and the remaining 116 participants received MBSR training, including both meditation and yoga.

Then the researchers assessed participants' improvement in terms of a 10-point self-reported back pain scale and achievement of at least 30% improvement in functional limitations based on a disability questionnaire. Interviewers, blinded to each participants' group, administered the questionnaires at 4, 8, 26, and 52 weeks.

The participants had experienced back pain for an average of 7.3 years. The researchers excluded patients with minimal pain or pain lasting less than 3 months and those whose pain did not interfere with their daily activities. Eleven percent of the patients reported using opioids in the past week for pain relief, 17% had at least moderate levels of depression, and 18% had at least moderate levels of anxiety.

More than half of those assigned the interventions (53.7%) attended at least six training sessions. Among the 86.0% of participants who remained in the study through 26 weeks, 60.5% of those receiving mindfulness training and 57.7% receiving CBT passed the 30% improvement threshold for clinically meaningful reduction in disability compared with 44.1% of those receiving usual care (P = .04).

Compared with usual care, those receiving mindfulness training were 1.37 times more likely to significantly improve (95% confidence interval [CI], 1.06 - 1.77), and those receiving CBT were 1.31 times more likely to improve (95% CI, 1.01 - 1.69).

Participants receiving either intervention similarly experienced greater pain improvement than those receiving usual care: 43.6% of the mindfulness group, 44.9% of the CBT group, and 26.6% of the usual care group reported clinically meaningful improvement on the pain scale (P = .01). Likelihood of improvement among mindfulness participants exceeded that of usual care participants by 1.64 times (95% CI, 1.15 - 2.34), and patients receiving CBT had 1.69 times greater likelihood of pain improvement compared with those receiving usual care (95% CI, 1.18 - 2.41).

No significant differences in pain or disability improvement occurred between those receiving either of the two interventions, and neither group showed improvement within the 8 weeks before treatment had ended. One year after the interventions, with 84.8% of the original participants still in the study, the improvements in pain and disability among the mindfulness participants remained. Although the improvement differences between the CBT and mindfulness groups still were not significant at 52 weeks, CBT was no longer superior to usual care.

Some significant shifts in anxiety and depression incidence occurred among the different groups through 26 weeks, but no differences across the three groups remained at 52 weeks.

Nearly a third (29%) of the participants in the mindfulness group reported an adverse event, usually temporary pain related to yoga, and 10% of those in the CBT group reported adverse events, primarily temporarily increased pain resulting from muscle relaxation.

"Although our trial lacked a condition controlling for nonspecific effects of instructor attention and group participation, CBT and MBSR have been shown to be more effective than control and active interventions for pain conditions," the authors write. "Further research is needed to identify moderators and mediators of the effects of MBSR on function and pain, evaluate benefits of MBSR beyond 1 year, and determine its cost effectiveness."

The authors acknowledge potentially limited generalizability from the findings, as the participants generally had high levels of education and were enrolled in a single healthcare system in Washington. In addition, "[b]ecause our sample was not very distressed at baseline, further research is needed to compare MBSR to CBT in a more distressed patient population," the authors write.

In an accompanying editorial, Madhav Goyal, MD, MPH, and Jennifer A. Haythornthwaite, PhD, both from the Johns Hopkins University School of Medicine in Baltimore, Maryland, point out that meditation techniques have never been intended to cure specific health complaints but, rather, to manage stress and difficult life experiences by observing, rather than reacting to, physical and mental responses to such stress and adversity.

"The potential relevance of mind-body interventions for chronic low back pain derives from the tremendous individual and societal burden caused by this disabling, costly, and increasingly prevalent condition," write Dr Goyal and Dr Haythornthwaite. "Despite the dissemination of published guidelines, care for chronic low back pain often relies on physician-driven ordering of imaging studies and prescription of opioids that perpetuate the costly biomedical model."

They also point out the noteworthiness of the success of CBT and mindfulness-based training in treating lower back pain, given that only about half the participants in both groups attended most of the group sessions.

"This level of participation is not unusual in mind-body interventions, yet an unanswered question is whether the results would have been different had attendance been higher," Dr Goyal and Dr Haythornthwaite write. "[F]uture studies should examine the relationship of home practice and skill development with clinical outcomes to enhance understanding of how these interventions work and help identify the most appropriate candidates for these treatments."

They also point out that some of the success of the behavioral interventions may arise from factors such as therapists' attention, but "for patients it really may not matter if the intervention helps their condition."

The research was funded by the National Center for Complementary and Integrative Health. The authors and editorialists have disclosed no relevant financial relationships.

JAMA. 2016;315:1236-1237, 1240-1249. Article full text, Editorial extract


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