Mindfulness and cognitive behavioral therapy can relieve chronic low back pain, study says
Both therapies may be more effective and last longer than usual care, such as pain relievers
It might seem too good to be true that relief from that nagging back pain could be found in meditation and yoga. But a new study suggests this approach might be just as effective as cognitive behavioral therapy, a common technique involving relaxation and education. And both could be more effective than popping an over-the-counter pain reliever.
Researchers compared the two approaches in 229 adults between ages 20 and 70 with long-term low back pain. They assigned about half to receive eight weekly sessions of mindfulness-based stress reduction, involving meditation and yoga, and the other half to receive eight sessions of cognitive behavioral therapy, which focuses on helping people change the way they think about pain. Another 113 adults continued their usual care, which often involved ibuprofen and other pain meds.
The researchers found that by the end of the eight-week course, 47% of people in the mindfulness group said their back pain was less disabling, based on factors such as difficulty walking and carrying out everyday activities. A similar number of people, 52%, in the cognitive behavioral therapy group reported less disabling pain. Both groups fared better than the group that did not change treatment, of whom only 35% had experienced improvements.
“Our results confirm what has already been found for (cognitive behavioral therapy), and we went beyond that to show this other mindfulness approach was equally effective for chronic back pain,” said Daniel C. Cherkin, a senior scientific investigator at the Group Health Research Institute in Seattle. Cherkin is the lead author of the study, which was published Tuesday in the Journal of the American Medical Association.
Cognitive behavioral therapy is already recommended in “some of the most thoughtfully developed and presented guidelines,” Cherkin said. For example, the American College of Physicians and American Pain Society guidelines suggest that doctors consider the therapy, along with other non-drug options such as acupuncture, massage therapy and exercise therapy, for patients with chronic low back pain.
The Centers for Disease Control and Prevention released guidelines last week advising primary care physicians to prescribe therapies, such as cognitive behavioral therapy and physical therapy, and medications such as Tylenol before opioids for patients with chronic pain.
“The core (of CBT) is trying to help people reframe the way in which they think about pain as being something that is horrible and will ruin their life to something that can be managed with tools and here are those tools,” which include exercise, breathing techniques and planning activities that do not aggravate the pain, Cherkin said.
There has been a lot of research suggesting a benefit for cognitive behavioral therapy in improving disability and mood in people with many types of chronic pain, including back, neck and shoulder pain, arthritis and fibromyalgia. But up until recently, there has not been a lot of research on whether mindfulness practices could also help people with chronic pain conditions.
Although CBT and mindfulness are “very overlapping,” mindfulness is a little less about changing your attitude and more about accepting it.
“With mindfulness-based stress reduction, the main focus is on increasing awareness of emotional feelings and physical feelings including pain, but changing the way in which you react and interpret (them),” Cherkin said. Instead of breathing and planning, the mindfulness group in the current study practiced different types of meditation and yoga.
Given the similarities between CBT and mindfulness in what they entail, and their apparently similar effectiveness, Cherkin said he doubts that one technique would work better for some than the other. However, CBT might not be available in an area whereas mindfulness is, and vice versa, “so having more options … is good,” he said.
“My guess is that the next iteration of guidelines will include mindfulness because of the two large trials that have just been published,” Cherkin said. In addition to the current study, one published in February suggested that mindfulness could have at least short-term benefits among adults 65 and older with chronic low back pain.
“What (the guidelines) will say is that we have limited evidence (for mindfulness) because we only have the two studies to suggest there is a modest to moderate effect, but there’s no reason that people shouldn’t do it, and it may well help people who aren’t helped by other things,” Cherkin said.
Does mindfulness really work?
“The coolest thing about this study was how the effects got stronger across the year,” said Fadel Zeidan, assistant professor of neurobiology and anatomy at Wake Forest School of Medicine, who was not involved in the current study.
The number of people in the mindfulness group who said they had improvements in their disability was 68% one year after completing the therapy sessions compared with 47% right after the eight sessions. Similarly, the people in the cognitive behavioral therapy group who reported less disability rose from 52% right after they finished the sessions to 59% a year later. There were also improvements in the control group, from 35% to 49%, but the gains were not as great as in the therapy groups.
“With traditional pain therapy like opioid therapy or other types of therapies, the effects plateau, they hit like a ceiling, but we’re seeing here the effects get stronger,” Zeidan said.
To try to understand why the participants in the current study continued to improve after mindfulness and cognitive behavioral therapy, Cherkin and his colleagues asked them whether they were practicing what they learned on their own. “The answers were, surprisingly, yes. It was well over, half even at one year,” Cherkin said.
“The ideal is that you don’t have to think about practice because it’s changed your thinking and how you feel.”
Zeidan’s research has found that meditation can change the activity of regions of the brain involved in attention and emotion. One of the biggest effects was a reduction in the activity in a part of the brain that sends information from the body to the brain, Zeidan said. The change could make it easier for people to “acknowledge and accept (pain) and not be bothered by it,” he said.
Although cognitive behavioral therapy might employ slightly different techniques, and have different effects on the brain, “the end result for both is less pain,” Zeidan said.
The long-term effect of mindfulness is still open for debate. The February study of mindfulness in older adults with back pain suggested that any benefit the participants got at the end of the eight-week course wore off by six months. It is unclear why that study failed to find long-term effects of mindfulness, but it could be because the researchers were comparing it with an education program about healthy aging that was also effective, Cherkin said.
What are the downsides to mindfulness?
About 30% of the people in the mindfulness group and 10% of those in the cognitive behavioral therapy group said they experienced an adverse effect. Often the problem was fleeting pain associated with yoga in the mindfulness group and relaxation in the CBT group.
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“Every study has had somewhere between 10% and 20% of the participants claiming that it temporarily exacerbated their pain, be it acupuncture, massage or yoga,” Cherkin said. It is probably not really a concern, and could actually have been a “good pain, in the context of doing something that they thought was good for them,” he added.
In addition to the possibility of temporary pain, practices such as mindfulness and cognitive behavioral therapy demand more of a time commitment than taking Tylenol or ibuprofen, two common drugs for low back pain. Each of the eight sessions lasted about two hours. Only 51% of the mindfulness group and 57% of the cognitive behavioral therapy group even made it through six sessions.
“That is what is going to happen in the real world; life interferes with plans,” Cherkin said. However, despite the fact that almost half of the participants made it to fewer than three quarters of the sessions, there was still an overall effect of mindfulness and cognitive behavioral therapy, he added. More studies should be done to determine what is the minimum number of sessions needed to reduce pain, or at least the perception of it, the authors of the study wrote.
In Zeidan’s research, they use a mindfulness course that involves 20-minute sessions on four consecutive days.
“I believe people can experience almost immediate results from mindfulness, but not as brief as taking an opiate pill,” or some other type of pain medication, Zeidan said.