Thursday, April 21, 2016
Lower back pain continues to be a leading cause of disability among American adults, but little research into the effectiveness of — and existence of — low-risk treatments beyond pain medication exists.
In a March 22/29 Journal of the American Medical Association study entitled, “Mindfulness-Based Stress Reduction versus Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults with Chronic Low Back Pain,” researchers from the University of Washington examined whether mindfulness-based stress reduction (MBSR) or cognitive behavioral therapy (CBT) were more effective at reducing the impact of chronic lower back pain in younger adults than typical care.
Results indicated the MBSR group experienced the greatest pain reduction, suggesting it could be an effective low back pain treatment.
MBSR included activities, such as mindfulness-meditation and yoga, and CBT offered training on changing pain through thoughts and behaviors. Instructions for both strategies were offered in eight weekly, two-hour sessions. Usual care (UC) referred to a participant’s ongoing care, including pain medication.
The MBSR program, designed to shift focus away from pain, included workbooks and audio CDS, as well as home practice instructions for meditation, yoga, and relaxation. A six-hour optional retreat was also available. Four Ph.D.- level psychologists offered instruction to the CBT group about chronic pain, the relationship between thoughts, emotions, and physical reactions, sleep hygiene, relapse prevention, relaxation skills, and pain-coping strategies.
Overall 342 adults, recruited from integrated healthcare system Group Health, between ages 20 and 70 participated in the 26-week, randomized, interviewer-blind trial. The average age was 49.3 years, 65.7 percent of participants were women, and the mean duration of chronic back pain was 7.3 years.
Of that group, 116 received MBSR, 113 received CBT, and 113 participated in UC. Pain reductions were clinically significant if participants experienced more than 30 percent reduction in pain from baseline based on the modified Roland Disability Questionnaire (RDQ), range 0-23, and self-reported pain on a 0-10 scale.
After 26 weeks, 60.5 percent of the MBSR group and 57.7 percent of the CBT group reported RDQ clinically-significant improvement. Of the UC group, 44.1 percent experienced the same effect. Additionally, 43.6 percent (MBSR), 44.9 percent (CBT), and 26.6 (UC) reported a drop in self-reported pain.
Relative risk for MBSR versus UC was 1.37, MBSR versus CBT was 0.95, and CBT versus UC was 1.31.
More work is needed, however, researchers said to understand how best to manage chronic pain.
“Further research is needed to identify moderators and mediators of the effects of MBSR on function and pain, evaluate the benefits of MBSR beyond one year, and determine its cost effectiveness,” they wrote.
In an April 12 commentary in the Journal of Family Practice, Neil Skolnik, M.D. wrote MBSR and CBT could offer effective treatments in a medication-wary environment.
“Both the CBT and MBSR groups did significantly better with regard to decreased disability and decreased pain with the assigned therapy,” he wrote. “The implications of this are obvious in an age where concerns about pain medication side effects with both opioid analgesics and with NSAIDs continue to make treatment of chronic low back pain a challenging clinical entity.”
Daniel C. Cherkin, PhD; Karen J. Sherman, PhD, 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," JAMA. March 22/29, 2016. JAMA. 2016;315(12):1240-1249. doi:10.1001/jama.2016.2323.
The Journal of Family Practice, Neil Skolnik, M.D.