The medicinal benefits of mindfulness meditation have newly been established in scientific literature. Low back pain is a leading cause of disability in the United States according to the US Burden of Disease Collaborators. Despite numerous treatment options and increased medical care resources to alleviate this problem, the functional capacity of individuals with back pain in the United States has deteriorated. There is a need for effective treatments that are low risk and have potential for widespread availability.
According to the American Pain Society Low Back Pain Guidelines Panel, psychosocial factors play important roles in pain and associated physical and psychosocial disability. In fact, 4 of the 8 nonpharmacologic treatments recommended for persistent back pain include mind-body components. Cognitive behavioral therapy (CBT), has demonstrated effectiveness for various chronic pain condition and is widely recommended for patients with chronic low back pain. However, patient access to CBT is limited.
Mindfulness-based stress reduction (MBSR), an alternative mind-body approach, focuses on increasing awareness and acceptance of moment-to-moment experiences including physical discomfort and difficult emotions. MBSR is becoming increasingly popular and available in the United States. This study, conducted by the University of Washington, hopes to identify if MBSR is beneficial for chronic low back pain. MBSR and other mindfulness-based interventions have been recognized as helpful for a range of conditions including chronic pain. Only 1 large randomized clinical trial (RCT) has evaluated MBSR for chronic low back pain (Morone NE, et. al.), and that trial was limited to older adults.
The study compared MBSR with CBT and with usual care. The study hypothesized that adults with chronic low back pain randomized to receive MBSR would show greater short- and long-term improvement in back pain–related functional limitations, back pain bothersomeness, and other outcomes as compared with those randomized to usual care. The study also hypothesized that MBSR would be superior to CBT because it includes yoga, which has been found to be effective in treating chronic low back pain according to this study.
THE STUDY AND PARTICIPANTS
Between September 2012 and April 2014, the study recruited individuals 20 to 70 years of age with nonspecific low back pain that persisted at least 3 months.A total of 342 participants were randomized to achieve a target sample size of 264 with complete outcome data at 26 weeks.All but 7 participants were recruited from Group Health. There were 203 (88.6%) participants randomized to receive MBSR and CBT who attended at least 1 session, but only 59 (50.9%) in the MBSR group and 64 (56.6%) in the CBT group attended at least 6 sessions. Only 30 (26%) participants randomized to receive MBSR attended the 6-hour retreat. Participants were then randomized in equal proportions to the MBSR, CBT, or usual care group.
The Mind-Body Approaches to Pain (MAP) trial protocol has been previously published. The primary source of participants was Group Health, a large integrated health care system in Washington State. Potential participants were told that they would be randomized to receive one of “two different widely-used pain self-management programs that have been found helpful for reducing pain and making it easier to carry out daily activities” or to continued usual care plus $50. Those assigned to receive MBSR or CBT were not informed of their treatment allocation until they attended the first session. Participants were recruited from 6 cities in 10 separate waves.
All participants received any medical care they would normally receive. Those randomized to the usual care group received $50 but no MBSR training or CBT as part of the study and were free to seek whatever treatment, if any, they desired.
The interventions were comparable in format (group), duration (2 hours/week for 8 weeks, although the MBSR program also included an optional 6-hour retreat), frequency (weekly), and number of participants per group. Participants in both interventions were given workbooks, audio CDs, and instructions for home practice (eg, meditation, body scan, and yoga in MBSR; relaxation and imagery in CBT). MBSR was delivered by 8 instructors with 5 to 29 years of MBSR experience. Six of the instructors received training from the Center for Mindfulness at the University of Massachusetts Medical School. CBT was delivered by 4 licensed PhD-level psychologists experienced in group and individual CBT for chronic pain. In addition, sessions were audio recorded and a study investigator monitored instructors’ adherence to the protocol.
MBSR was modeled closely after the original MBSR program adaptated from the 2009 MBSR instructor’s manual by a senior MBSR instructor. All classes included didactic content and mindfulness practice (body scan, yoga, meditation [attention to thoughts, emotions, and sensations in the present moment without trying to change them, sitting meditation with awareness of breathing, and walking meditation]).
The CBT protocol included CBT techniques most commonly applied and studied for chronic low back pain. The intervention included (1) education about chronic pain, relationships between thoughts and emotional and physical reactions, sleep hygiene, relapse prevention, and maintenance of gains; and (2) instruction and practice in changing dysfunctional thoughts, setting and working toward behavioral goals, relaxation skills (abdominal breathing, progressive muscle relaxation, and guided imagery), activity pacing, and pain-coping strategies. Mindfulness, meditation, and yoga techniques were also proscribed in CBT while methods to challenge dysfunctional thoughts were proscribed in MBSR.
RESULTS
Overall, 269 (78.9%) reported at least 1 year since a week without back pain and most reported pain on at least 160 of the previous 180 days. Mean duration of back pain was 7.3 years. ). Among adults with chronic low back pain, both MBSR and CBT resulted in greater improvement in back pain and functional limitations at 26 and 52 weeks when compared with usual care. There were no meaningful differences in outcomes between MBSR and CBT.
The findings of this study are consistent with the conclusions of a 2011 systematic review, which reported that “acceptance-based” interventions such as MBSR have beneficial effects on the physical and mental health of patients with chronic pain, comparable to those of CBT.
Although the study lacked a condition controlling for nonspecific effects of instructor attention and group participation, CBT and MBSR have been shown to be more effective than control and active interventions for pain conditions. In addition to the trial of older adults with chronic low back pain, which found MBSR to be more effective than a health education control condition. Further research is needed to identify moderators and mediators of the effects of MBSR on function and pain, evaluate benefits of MBSR beyond 1 year, and determine its cost effectiveness.
The study’s finding of increased effectiveness of MBSR at 26 to 52 weeks contrasts with findings of a previous study on acupuncture, massage, and yoga conducted in the same population as the current trial. Long-lasting effects of CBT for chronic low back pain have been reported. This suggests that mind-body treatments such as MBSR and CBT may provide patients with long-lasting skills effective for managing pain.
CONCLUSIONS
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.
Not only does MBSR present itself as a remedy for back pain, it also has a multitude of benefits that bring clarity and attention to your daily life.
Mindfulness-Based Stress Reduction Facilities and Resources in the Seattle area:
- Cascadia Mindfulness
- Seattle Mindfulness Center
- Swedish Hospital – MBSR Program
- Mindfulness Northwest
- Center for Child and Family Well-Being
To view the entire study, click here.
[Photo by: Alexis Mire | CC BY]
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