Primary Care Corner with Geoffrey Modest MD: Low Back Pain Improves with Stress Reduction — Mindfulness and Cognitive Behavioral Therapy

Dr. Geoffrey Modest

I recently sent out the review from AHRQ on low back pain (LBP) management, noting that psychological therapies (especially restoration or cognitive-behavioral therapies) have small-to-moderate effect for improving pain or function (for full review of pharmacologic and nonpharmacologic therapies, see https://stg-blogs.bmj.com/bmjebmspotlight/2016/03/17/primary-care-corner-with-geoffrey-modest-md-low-back-pain-treatment-per-ahrq-review/ . A new study was just published in JAMA on the efficacy of mindfulness-based stress reduction (MBSR) in reducing pain and improving function in those with chronic low back pain (see JAMA. 2016;315(12):1240). This study was sponsored by the National Center for Complementary and Alternative Medicine of the NIH.

Details:

• 342 adults aged 20-70 with chronic low back pain of at least 3 months, recruited from 2012-2014 and randomly assigned to MBSR or cognitive behavioral therapy (CBT) vs usual care
• Mean age 49.3, 65.7% women, 82.5% white/6.8% Hispanic, mean duration of LBP of 7.3 years
• Interventions:
  • 8 weekly 2-hour MBSR sessions, including education about mindfulness, increasing awareness of body sensations, techniques to promote mindful practice (yoga, meditation), learning how to understand and change how we react to stress, understand the relationship between stress and pain, etc. People were asked to practice this daily for up to 45 minutes during the intervention and afterwards. Most instructors were trained in the Center for Mindfulness at U Mass Medical School. [MBSR focuses on “increasing awareness and acceptance of moment-to-moment experiences including physical discomfort and difficult emotions”, with the hypothesis that “practicing mindfulness skills improves one’s ability to experience pain without excessive emotional reactivity, leads to cognitive changes, and promotes relaxation”.]
  • 8 weekly 2-hour CBT sessions, focusing on education about maladaptive thoughts (e.g. catastrophizing) and beliefs, education about chronic pain and the relation between thoughts and emotional and physical reactions, challenging negative thoughts, using positive coping strategies…
  • Usual care typically includes using meds, seeing primary care providers, physical therapists, etc.
• Assessed: clinically meaningful (≥ 30%) improvement in functional limitations by the Roland Disability Questionnaire (RDQ) on a scale from 0-23 (baseline mean was 11.4), and in self-reported LBP bothersomeness on a scale from 0-10 (baseline mean was 6.0)

Results:

• 53.7% of individuals (n=123) attended 6 or more of the 8 sessions
• In intention-to-treat analyses at 26 weeks
  • 60.5% assigned to MBSR and 57.7% with CBT had clinically meaningful improvements in RDQ, vs 44.1% in usual care (p=0.04)
    • RR for MBSR vs usual care was 1.37 (1.06-1.77); RR for CBT vs usual care are 1.31 (1.01-1.69)
  • 43.6% in the MBSR and 44.9% in the CBT groups had clinically meaningful improvements in pain bothersomeness at 26 weeks vs 26.6% of usual care (p=0.01)
    • RR for MBSR vs usual care was 1.64 (1.15-2.34); RR for CBT vs usual care are 1.69 (1.18-2.41)
  • At 52 weeks
    • Little change in the MBSR group for either RDQ questionnaire or pain bothersomeness symptoms; there was some deterioration of CBT for both of these outcomes, leading to their not being statistically significant
  • These differences in RDQ and bothersomeness of pain were considered to be of moderate degrees.

So, several issues:

• As we know in primary care, chronic LBP is one of the hardest and most frustrating diagnoses (for both the patients and us), since we do not have great treatments. As noted in the AHRQ review, there are remarkable limitations to both the pharmacologic and nonpharmacologic approaches. (See the blog for more details and comments)
• It is certainly impressive that both of these psychological interventions seem to work, and better than our “usual treatment”. But perhaps the most interesting point is that they work long-term, that in some ways these therapies, after only an 8-week intervention, seems to enable and empower people to take care of themselves better (in both the MBSR and CBT groups, people were given DVDs and other aids to help them continue the therapy after the intervention)
• These results were likely dwarfed by the fact that only about 1/2 of the patients actually participated fully in the psych interventions. The article did not give specific statistics about benefit in those who fully participated, but one might presume that they did especially well. And that if we were even more successful in encouraging patients in participating, we might have even better results (in fact, we as primary care clinicians with strong relationships with patients might well do better in encouraging patient participation than people hired in this study did)
• So, it seems that both MBSR and CBT are effective therapies for chronic LBP, with potentially long-lasting moderate efficacy. And, though there are other studies showing the effectiveness of CBT in patients with chronic LBP, access to CBT is not universal, so MBSR seems to provide a reasonable alternative with perhaps even better long-term benefit.