Low back pain is a major health problem in the United States. During any three-month period, almost a third of American adults experience at least one day of low back pain, and it is a leading reason people visit their doctor or call in sick to work.
Treatments for low back pain include medications, injections, physical therapy and surgery. Cognitive behavioral therapy (CBT) — receiving psychological therapy to change pain-related thoughts and behavior — has also been found to be effective, and is widely recommended for people with non-specific chronic low back pain (pain that lasts more than three months and for which there is no obvious cause).
Now a new study, published earlier this week in the Journal of the American Medical Association (JAMA), offers yet another option to patients with this often-debilitating condition: mindfulness-based stress reduction. The study found that this mind-body therapy, which “focuses on increasing awareness and acceptance of moment-to-moment experiences, including physical discomfort and difficult emotions,” is as effective as CBT in easing low back pain and improving physical function.
The finding is particularly important given rising concerns about the overuse and misuse of prescription opioid painkillers for the treatment of chronic pain, including chronic back pain.
As I reported here last October, research has shown that opioid painkillers are no more effective than over-the-counter pain medications at relieving even severe low back pain, yet the use of opioids for low back pain has risen dramatically in recent years.
That increased use has had catastrophic health consequences. More than 16,000 Americans — an average of 44 people each day — die from overdoses of prescription opioid painkillers each year, according to the CDC.
For the current study, researchers from the Group Health Research Institute and from the University of Washington, Seattle recruited 342 individuals, aged 20 to 70, who had been experiencing back pain for at least three months. (For most, the pain had been occurring at least once a week for a year.) At the start of the study, the average pain level for these volunteers was six on 10-point scale, and all reported that they felt debilitated by their pain.
The study’s participants were randomized into three treatment groups: 1) usual care (which, unfortunately, is not described in detail), 2) usual care plus CBT and 3) usual care plus mindfulness-based stress reduction (which included yoga as well as meditation).
Both CBT and mindfulness therapy involved a two-hour group session with trained instructors once a week for eight weeks. Participants were also given instructions and materials to help them practice the therapies at home.
The participants were assessed at various points for up to a year. All groups showed an easing of their symptoms, but at 26 and 51 weeks, the participants in the CBT and mindfulness groups showed significantly greater improvement in back pain and function than those who received only standard care.
Specifically, 61 percent of the people in the mindfulness group reported at least a 30 percent improvement in function compared to 58 percent of those in the CBT group and 44 percent of those in the usual-care group. As for how much the pain continued to be “bothersome,” 44 percent of people in the mindfulness group, 45 percent of those in the CBT group and 27 percent of those in usual-care group reported meaningful improvement.
CBT and mindfulness therapy were not, however, free of adverse events: 30 percent of the people attending the mindfulness sessions reported some increased pain associated with the therapy’s yoga exercises, and 10 percent of the people receiving CBT reported increased pain with that therapy’s progressive muscle relaxation. Such problems were, however, mostly temporary, say the researchers.
Limitations and implications
This study, like all studies, comes with caveats. Most notably, only 51 percent of participants in the mindfulness group and 57 percent of those in the CBT group attended at least six group sessions. Nor does the study make clear how many of the participants practiced the therapy at home. Both factors could have affected the study’s results.
Still, as a commentary that accompanies the study points out, the results show “that for patients with chronic low back pain, both [mindfulness therapy] and CBT were better than usual care. Both interventions were associated with meaningful reductions in disability and pain bothersomeness related to chronic low back pain, and these effects lasted at least 1 year.”
The challenge posed by these findings, the commentary’s authors add, “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.”
Indeed, an eight-week course in mindfulness-based stress reduction at the University of Minnesota’s Center for Spirituality and Healing costs $425.
FMI: You can read the study and the commentary in full at JAMA’s website.