Treating Chronic Low Back Pain Via the Brain

Seattle-based research indicates that both mindfulness-based stress reduction (MBSR) and cognitive behavioral therapy (CBT) appear to achieve greater improvements in back pain and functional limitations at 26 weeks, when compared with usual care, among adults with chronic low back pain. The study, published in the March 22/29 issue of JAMA, found no significant differences in outcomes between patients treated with MBSR or CBT, suggesting that MBSR may be an effective treatment option for patients with chronic low back pain.

The findings offer hope to those suffering from this leading cause of disability in the United States, for which treatments with demonstrated effectiveness, low risk, and potentially widespread availability are needed. According to the study authors, only one other randomized clinical trial has evaluated MBSR—which focuses on increasing awareness and acceptance of moment-to-moment experiences, including physical discomfort and difficult emotions—in the treatment of chronic low back pain, and that trial focused only on older adults.

For the randomized, interviewer-blind, clinical trial, Daniel C. Cherkin, PhD, from the Group Health Research Institute in Seattle, WA, and colleagues enrolled 342 adults with chronic low back pain (average duration of 7.3 years) and aged 20 to 70 years (average, 49 years) from an integrated healthcare system in Washington State between September 2012 and April 2014 and randomized them to receive MBSR (n = 116), CBT (n = 113), or usual care (n = 113). Usual care included whatever, if any, care participants received, whereas CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups.

Cherkin and colleagues were primarily interested in the percentages of participants with clinically meaningful (30% or greater) improvement from baseline in functional limitations, based on a modified Roland Disability Questionnaire (RDQ) with a 0-23 range, as well as improvement from baseline in self-reported back pain bothersomeness, based on a 0-10 scale, at 26 weeks. These outcomes were also assessed at 4, 8, and 52 weeks.

At 26 weeks, the percentage of participants with clinically meaningful improvement on the RDQ was higher for those who received MBSR (60.5%) and CBT (57.7%) than the rate observed for those who received usual care (44.1%). Clinically meaningful improvements in pain bothersomeness at 26 weeks were observed in 43.6% of those who received MBSR, 44.9% of those who received CBT, and only 26.6% of those who received usual care. For both of the primary outcomes, these favorable findings for MBSR persisted with little change at 52 weeks.

“The effects were moderate in size, which has been typical of evidence-based treatments recommended for chronic low back pain,” wrote the study investigators. “These benefits are remarkable given that only 51 percent of those randomized to receive MBSR and 57 percent of those randomized to receive CBT attended at least 6 of the 8 sessions.”

In an accompanying editorial posted in the same issue of JAMA, Madhav Goyal, MD, MPH, and Jennifer A. Haythornthwaite, PhD, both from Johns Hopkins University School of Medicine, wrote, “Although understanding the specificity of treatment effects, mechanisms of action, and role of mediators are important issues for researchers, they are merely academic for many clinicians and their patients. For patients with chronic painful conditions, options are needed to help them live with less pain and disability now.

“The challenge is how to ensure that these mind-body interventions are available, given the existing evidence demonstrating they may work for some patients with chronic low back pain. Most physicians encounter numerous obstacles finding appropriate referrals for mind-body therapies that their patients can access and afford. High-quality studies such as the clinical trial by Cherkin et al create a compelling argument for ensuring that an evidence-based health care system should provide access to affordable mind-body therapies.”