Cognitive Behavioral Therapy for Chronic Low Back Pain
By Ashley Maltz, MD
Integrative Medicine Physician, Austin, TX
Dr. Maltz reports no financial relationships relevant to this field of study.
- Researchers randomized 342 patients with chronic low back pain to receive mindfulness-based stress reduction training and yoga, cognitive behavioral therapy, or usual care.
- Participants in both intervention groups showed significantly greater improvement in symptomatology and mental health measures at numerous time points, but did not vary significantly between themselves.
- Both interventions can be helpful for treating symptoms of chronic low back pain, but one intervention may not be significantly better than the other.
SYNOPSIS: Low back pain and functional limitation scores in adults with chronic low back pain improved among those randomly assigned to receive either cognitive behavioral therapy or mindfulness-based stress reduction interventions when compared to usual care.
SOURCE: Cherkin DC, Sherman KJ, Balderson BH, 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: A randomized clinical trial. JAMA 2016;315:1240-1249.
Mindfulness-based stress reduction (MBSR) is an awareness meditation technique that has been studied for its effects on various health conditions.1,2 Its practice consists of paying attention to the present moment without judgment.3 This practice helps cultivate self-acceptance and acknowledgment of thoughts and emotions within the body and mind. Because of the overwhelming data showing its benefit, MBSR has been embraced by hospitals4 and integrative health practices as an adjunctive treatment of chronic illnesses. However, prior to publication of the study by Cherkin et al, MBSR had not been studied clinically in the treatment of chronic low back pain, one of the most common ailments for which patients seek medical care.
In this study, 342 patients in Washington state with chronic low back pain were randomized to receive MBSR training and yoga (n = 116), cognitive behavioral therapy (CBT; n = 113), or usual care (n = 113). The participants were recruited from six cities in Washington through a large integrated healthcare system (Group Health). They ranged in age from 20 to 70 years and were enrolled in the study between September 2012 and April 2014. Participants had to have had back pain that persisted for at least three months to be included in the study.
Participants then were stratified equally between the three groups based on their baseline score on the modified Roland Disability Questionnaire (RDQ), one of the primary outcome measures of the study. The RDQ is a validated and widely used health measure for low back pain. It takes into account any functional limitations patients have because of their back pain. All participants received any medical care they needed, and those randomized to the usual care group received $50. The interventions were comparable in format, length (two hours/week), duration (eight weeks), frequency (once weekly), and number of participants. Participants in both intervention groups were given audio CDs, workbooks, and instructions for home practice.
Interviewers collected outcome survey answers (the RDQ and other measures explained below) by phone at baseline, four weeks, eight weeks, 26 weeks, and 52 weeks. Participants were given $20 per interview.
Primary outcome measures included the RDQ scale and ratings of bothersome pain as measured on a scale of 0 to 10, with 10 representing excruciating and debilitating pain. Secondary outcome measures were Graded Chronic Pain Scale, the Patient Global Impression of Change scale, PHQ-8 for depression, GAD-2 for anxiety, the SF-12 Mental Component Score, medication and opioid use for low back pain, and exercises practiced for three or more days per week.
Results showed significant improvements on primary outcome measures (the RDQ and scale of bothersome pain with P = 0.04; relative risk [RR], 1.37; 95% confidence interval [CI], 1.06-1.77; and P = 0.01; RR, 1.64; 95% CI, 1.15-2.34, respectively) in the MBSR group compared to usual care. The two intervention groups (MBSR and CBT) were not significantly different in terms of these improvements. Clinically meaningful improvement was defined as a 30% or more improvement from baseline on each primary outcome measure. Significant differences in these measures between MBSR and usual care continued at 52 weeks, with similar RRs to that at 26 weeks.
Analysis of secondary outcome measures (which were measured at all time points except at four weeks) showed that participants randomized to MBSR improved more than those randomized to usual care on the depression and SF-12 Mental Component measures at eight weeks (P ≤ 0.001 and 0.004, respectively). Those randomized to CBT improved more than those randomized to MBSR on depression at eight weeks and anxiety scores at 26 weeks (a -1.48 between-group mean difference vs. a -2.17 between-group difference at eight weeks, and a -0.68 between-group mean difference vs. a -1.16 between-group mean difference at 26 weeks). These participants also improved more than the usual care group at eight and 26 weeks on all three measures.
Characteristic pain intensity scores differed significantly between groups at all time points — eight, 26, and 52 weeks (P = 0.002, 0.04, 0.007, respectively). MBSR and CBT groups showed the greatest improvements in comparison to usual-care group participants at all time points. Self-reported global improvement scores showed greater improvement in the MBSR and CBT groups than the usual care group at 26 and 52 weeks, but did not differ significantly from each other at the other times. No differences were observed for SF-12 Physical Component score or self-reported use of medications for back pain at any time point.
Twenty-nine percent of participants attending at least one MBSR session reported an adverse event (mostly temporarily increased pain with yoga), and 10% of participants attending at least one session of CBT reported an adverse event (mostly temporarily increased pain with progressive muscle relaxation). No serious adverse events were reported. Attrition rates were higher in the intervention groups than in the usual care group (79% of participants in the MBSR group and 81% of participants in the CBT group followed up at week 52 compared to 98% in the usual care group).
Results of this study showed varied significance between time points, with a trend toward improvement in all groups. Participants in both intervention groups showed significantly greater improvement in symptomatology and mental health measures at numerous time points, but mostly did not vary significantly between themselves. This shows that both interventions can be helpful with treating symptoms of chronic low back pain, but that one intervention may not be significantly better than the other.
It is unclear why results varied between time points. Perhaps this was because of follow-up within the groups and/or participants’ ability to practice the skills they were learning. Despite the relatively small size of the study, it was methodologically sound with both a control group and two intervention groups. The study’s main limitations were its modest sample size and that participants were a homogeneous population (from the same health group and well educated). Additionally, many participants in the intervention groups were lost to follow-up, limiting conclusions.
Attrition rates in the intervention groups were significantly higher than in the usual care group, likely because of the number of sessions involved in the interventions. Despite this, an impressive part of the results was that the interventions were effective, despite almost half of the participants’ lack of completion (51% of MBSR and 57% of CBT participants completed six out of eight sessions). This finding suggests that there is an effect on back pain with just a few MBSR or CBT sessions or that the non-attenders’ results were washed out by large improvements in those who attended all sessions. It is not clear if a sub-group analysis was done to further elucidate this finding.
The results of this study are exciting, yet not surprising. The power of MBSR has been well documented for a variety of medical problems.1,2,5 Given the trend toward overall improvement in symptomatology for chronic low back pain, clinicians can recommend both MBSR and CBT for this condition. It would work best in patients who are able to attend up to eight weeks of group or one-on-one sessions and may not be suitable for those who cannot commit to a lengthy program, either for lack of time or insurance copays. Both MBSR and CBT provide insight and coping mechanisms for patients suffering with chronic pain and may be used best in conjunction with each other and in conjunction with other pain-relieving techniques, such as epidural steroid injections, acupuncture, chiropractic, and massage.
I have seen positive results from such practices among patients with chronic pain. Given the current opioid overdose epidemic, the trend toward using opioids less, and their side effect profile, it is important that healthcare practitioners gain knowledge in the use and benefit of complementary therapies, such as MBSR, for chronic low back pain.
- Gotink RA, Chu P, Busschbach JJ, et al. Standardised mindfulness-based interventions in healthcare: An overview of systematic reviews and meta-analyses of RCTs. PLoS One 2015;10:e0124344.
- Simpson J, Mapel T. An investigation into the health benefits of mindfulness-based stress reduction (MBSR) for people living with a range of chronic physical illnesses in New Zealand. N Z Med J 2011;124:68-75.
- Center for Mindfulness in Medicine, Health Care, and Society. Mindfulness-Based Programs. Available at: http://www.umassmed.edu/cfm/mindfulness-based-programs/. Accessed May 20, 2017.
- Elias M. ‘Mindfulness’ meditation being used in hospitals and schools. Available at: https://usatoday30.usatoday.com/news/health/2009-06-07-meditate_n.htm. Accessed May 22, 2017.
- Crowe M, Jordan J, Burrell B, et al. Mindfulness-based stress reduction for long-term physical conditions: A systematic review. Aust N Z J Psychiatry 2016;50:21-32.
Low back pain and functional limitation scores in adults with chronic low back pain improved among those randomly assigned to receive either cognitive behavioral therapy or mindfulness-based stress reduction interventions when compared to usual care.
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