Psychological therapies ease lower back pain

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Among adults with chronic low back pain, both mindfulness-based stress reduction and cognitive behavioural therapy resulted in greater improvement in back pain and functional limitations when compared with usual care, according new to a study.

Low back pain is a leading cause of disability in the US and there is need for treatments with demonstrated effectiveness that are low risk and have potential for widespread availability. Mindfulness-based stress reduction (MBSR) focuses on increasing awareness and acceptance of moment-to-moment experiences including physical discomfort and difficult emotions. Only 1 large randomised clinical trial has evaluated MBSR for chronic low back pain, and that trial was limited to older adults.

Dr Daniel C Cherkin, of Group Health Research Institute, Seattle, and colleagues randomly assigned 342 adults age 20 to 70 years with chronic low back pain to receive MBSR (n = 116), cognitive behavioural therapy (CBT; n = 113), or usual care (n = 113). CBT (training to change pain-related thoughts and behaviours) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever other treatment, if any, the participants received. The average age of the participants was 49 years; the average duration of back pain was 7.3 years.

The researchers found that at 26 weeks, the percentage of participants with clinically meaningful improvement on a measure of functional limitations was higher for those who received MBSR (61%) and CBT (58%) than for usual care (44%). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 44% in the MBSR group and 45% in the CBT group, vs 27% in the usual care group. Findings for MBSR persisted with little change at 52 weeks for both primary outcomes.

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

“These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain.”

Abstract
Importance: Mindfulness-based stress reduction (MBSR) has not been rigorously evaluated for young and middle-aged adults with chronic low back pain.
Objective: To evaluate the effectiveness for chronic low back pain of MBSR vs cognitive behavioral therapy (CBT) or usual care.
Design, Setting, and Participants: Randomized, interviewer-blind, clinical trial in an integrated health care system in Washington State of 342 adults aged 20 to 70 years with chronic low back pain enrolled between September 2012 and April 2014 and randomly assigned to receive MBSR (n = 116), CBT (n = 113), or usual care (n = 113).
Interventions: 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. Usual care included whatever care participants received.
Main Outcomes and Measures: Coprimary outcomes were the percentages of participants with clinically meaningful (≥30%) improvement from baseline in functional limitations (modified Roland Disability Questionnaire [RDQ]; range, 0-23) and in self-reported back pain bothersomeness (scale, 0-10) at 26 weeks. Outcomes were also assessed at 4, 8, and 52 weeks.
Results: There were 342 randomized participants, the mean (SD) [range] age was 49.3 (12.3) [20-70] years, 224 (65.7%) were women, mean duration of back pain was 7.3 years (range, 3 months-50 years), 123 (53.7%) attended 6 or more of the 8 sessions, 294 (86.0%) completed the study at 26 weeks, and 290 (84.8%) completed the study at 52 weeks. In intent-to-treat analyses 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 for usual care (44.1%) (overall P = .04; relative risk [RR] for MBSR vs usual care, 1.37 [95% CI, 1.06-1.77]; RR for MBSR vs CBT, 0.95 [95% CI, 0.77-1.18]; and RR for CBT vs usual care, 1.31 [95% CI, 1.01-1.69]). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 43.6% in the MBSR group and 44.9% in the CBT group, vs 26.6% in the usual care group (overall P = .01; RR for MBSR vs usual care, 1.64 [95% CI, 1.15-2.34]; RR for MBSR vs CBT, 1.03 [95% CI, 0.78-1.36]; and RR for CBT vs usual care, 1.69 [95% CI, 1.18-2.41]). Findings for MBSR persisted with little change at 52 weeks for both primary outcomes.
Conclusions and Relevance: Among adults with chronic low back pain, treatment with MBSR or CBT, compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain.

JAMA material
JAMA abstract
JAMA editorial


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