Mindfulness-based approaches best for low back pain.

FROM JAMA
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, a new study shows.
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.
"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 http://www.yogadownload.com/ 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).
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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. Treatments such as yoga and
meditation are relatively widespread throughout the yoga routine United States, but
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.
"Just because something isn't covered by insurance
doesn't mean it isn't helpful and cost effective," he
explained. 'And on the opposite side, many things that are covered
by insurance are not very helpful."
Dr. Cherkin cautioned that, while the findings of this study are
promising especially as they relate to the growing desire by both
providers and patients to turn away from opioids for chronic pain
management--these findings are ultimately just one step along a longer

journey.
"Opioids are often resorted to out of desperation by both
physicians and patients who both feel there isn't any alternative,
and physicians don't like to see their patients continuing to
suffer," said Dr. Cherkin. "Things have gotten way out of
whack over the years, because there has not been an evidence-based
approach to ensuring that what is most helpful for patients is available
and offered by insurance.
"If we can look at the most effective treatment options
available to patients that have low risks of addiction, death, or other
harm and make those available so physicians can include those in their
repertoire of what they feel they can offer patients, we're going
to be in much better shape," Dr. Cherkin noted.
dchitnis@frontlinemedcom.com
http://www.thefreelibrary.com/Mindfulness-basedapproachesbestforlowbackpain.-a0452881771