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Mindfulness, cognitive therapy top conventional care for low back pain

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Shift to mind-body approach for chronic low back pain?

The potential relevance of mind-body interventions for chronic low back pain derives from the tremendous individual and societal burden caused by this disabling, costly, and increasingly prevalent condition.

[Increasingly], chronic pain management demands shifting away from the biomedical disease model focused on cure to a biopsychosocial model in which physicians and other clinicians guide patient-centered care that emphasizes patient engagement in daily self-management using a range of tools.

A critical component of self-management includes home practice and the daily implementation of skills learned. Although it does not appear that this component was assessed in this trial, future studies should examine the relationship of home practice and skill development with clinical outcomes to enhance understanding of how these interventions work and help identify the most appropriate candidates for these treatments.

Dr. Madhav Goyal and Dr. Jennifer A. Haythornthwaite are both at Johns Hopkins University in Baltimore. These remarks come from their editorial accompanying the study (JAMA. 2016 Mar;315[12]:1236-7).


 

FROM JAMA

References

Adults suffering from chronic lower back pain may be better off pursuing mindfulness-based stress reduction or cognitive behavioral therapy rather than more standard, conventional treatments for pain alleviation, according to a new study published in JAMA.

However, the relatively limited availability of cognitive and mindfulness-based approaches to stress reduction in many parts of the country, coupled with the uncertainty about insurance providers covering such treatments, put the viability of such treatments receiving widespread acceptance and use in question.

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“Low back pain is a leading cause of disability in the United States, [and] psychosocial factors play important roles in pain and associated physical and psychosocial disability,” said Daniel C. Cherkin, Ph.D., of the Group Health Research Institute in Seattle, and his associates. “Cognitive behavioral therapy [CBT] has demonstrated effectiveness for various chronic pain conditions and is widely recommended for patients with chronic low back pain, [but] patient access to CBT is limited.”

Dr. Cherkin and his coinvestigators recruited subjects from Group Health, an integrated health care system in Washington state, looking for patients between the ages of 20 years and 70 years with low back pain persisting for at least 3 months that was both nonspecific and had not been given a specific diagnosis (JAMA. 2016 Mar;315[12]:1240-9).

Of 1,767 patients evaluated, 342 patients were enrolled and randomized into one of three cohorts: those receiving mindfulness-based stress reduction (MBSR) (116 patients), those receiving CBT (113 patients), and those receiving “usual care,” defined as “whatever care participants received” prior to enrollment (113 patients).

Those randomized to receive usual care received $50 toward whichever pain management option they chose to receive. Those receiving MBSR or CBT were not aware of which they were receiving until they attended the first group session.

A total of 8 sessions, each 2 hours long and offered weekly, were conducted for patients in each cohort, although attendance at each session was not mandatory. Follow-up with patients in each cohort was conducted at 4 weeks (halfway through treatment), 8 weeks (post-treatment), 26 weeks (primary endpoint of the study), and 52 weeks, with the number of patients in each cohort varying at each follow-up; patients who attended follow-up interviews were compensated $20.

Improvements in functional limitations of at least 30% and intensity of back pain were the primary outcomes measured. The former was measured via a modified Roland Disability Questionnaire (RDQ), which assessed patients’ physical limitations brought on by low back pain on a scale of 0-23, with 0 being the least intense and 23 being the most intense. The latter outcome was measured on a simple scale of 0-10, 0 being the least intense and 10 being the most intense.

At 26 weeks, RDQ scores for MBSR and CBT patients were significantly higher than for those patients receiving usual-care treatment options. Mean percentage improvement in the MBSR cohort was 60.5% and 57.7% in the CBT cohort. Comparatively, patients receiving usual care improved by an average of 44.1% (P = .04). MBSR showed the highest percentage improvement at all four follow-up intervals except 8 weeks, when CBT had a higher percentage. However, both were consistently higher than usual care throughout.

When it came to the second primary outcome, MBSR and CBT were again shown to be significantly more effective, registering mean percentage improvements of 43.6% and 44.9% at 26-week follow-up, respectively. The usual care cohort, on the other hand, improved by 26.6% (P = .01).

Regarding study limitations, Dr. Cherkin and his coinvestigators noted that “participants were enrolled in a single health care system and generally highly educated. [Also] the generalizability of findings to other settings and populations is unknown, [and] approximately 20% of participants randomized to the MBSR and CBT groups were lost to follow-up.”

The pressing question, however, is the viability of MBSR and CBT therapies, particularly the former. While treatments such as yoga and meditation are relatively widespread throughout the United States, getting insurance providers to cover such treatments may be a roadblock for doctors looking to prescribe such therapies to their chronic back pain patients.

Because CBT and MBSR have been around for more than 30 years, they are accessible mostly in urban areas of the country, usually through programs run by hospitals, and “reaches [that] are more open to the idea of mindfulness and meditation concepts,” Dr. Cherkin explained in an interview. However, he added, “they are not generally covered [by] insurance, but we’re hoping that studies like ours will help change that.”

The problem, said Dr. Cherkin, is the allocation of resources by insurance and health care providers to certain treatment and therapies that aren’t necessarily the most effective.

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