Wednesday March 23 2016
Mindfulness makes use of some yoga techniques
"Meditation could ease the agony of back pain, a study suggests," the Daily Mirror reports.
A US study compared a technique called mindfulness-based stress reduction (MBSR) with usual care and cognitive behavioural therapy (CBT) for long-term non-specific lower back pain. The term "non-specific" refers to when there are no obvious causes, such as a slipped disc.
MBSR is based on yoga methods, such as meditation, yoga postures and an increased self-awareness of your thought patterns.
Participants were split into three groups. Those allocated to either MBSR or CBT were given eight weekly training sessions. Follow-up was performed after six months and 12 months.
At both of these time points, MBSR significantly improved functional disability and pain compared with usual care – but not when compared with CBT. Both MBSR and CBT were as effective as each other.
Access to NHS-funded CBT can be limited in some parts of the country. A practical advantage of MBSR is that you can learn more about it without a therapist, such as by watching an online video or reading a training manual.
Despite the media headlines, the study did not compare these therapies with painkillers directly – only "usual care" which, frustratingly, was not further described.
Nor do the findings suggest that people with identified causes for their back pain – such as a slipped disc, trapped nerve or inflammatory disease – should just meditate and it'll all go away. These conditions would need investigation and treatment appropriate to the underlying cause.
Where did the story come from?
The study was carried out by researchers from the Group Health Research Institute in the US and the University of Washington.
It was funded by the National Center for Complementary and Integrative Health of the US National Institutes of Health.
The study was published in the peer-reviewed journal JAMA on an open access basis, so it is free to read online.
The Mail Online's headlines could lead to a few misinterpretations. MBSR was not the "most effective" treatment – it was equal to CBT. It was also not compared directly with painkillers, and did not include back pain with any identified cause.
Similarly, the Daily Mirror overstates the finding by claiming that, "A simple exercise could cure back pain". While improvements in mobility and reported pain are always welcomed, this does not amount to a permanent cure.
What kind of research was this?
This randomised controlled trial (RCT) aimed to examine the effectiveness of MBSR for chronic lower back pain compared with the widely used CBT, which is a talking therapy.
As the researchers say, chronic lower back pain is a leading cause of disability in western countries. There is a need for effective treatments that can be widely accessible to the large number of people affected.
Psychological factors are believed to play an important role in chronic pain, and CBT has often been used in the treatment of chronic lower back pain.
This trial aimed to see whether the mind-body approach of MBSR, which aims to increase awareness and acceptance of discomfort and difficult emotions, could help people – particularly when access to CBT may be limited. An RCT is the best way to assess the effectiveness of a new intervention.
What did the research involve?
The study recruited people from the community who were aged 20 to 70 years old and had non-specific lower back pain lasting for more than three months – that is, pain that does not have a specific cause, such as a slipped disc, inflammatory disease or cancer.
They were told they would be randomised to receive one of "two different widely used pain self-management programmes that have been found helpful for reducing pain and making it easier to carry out daily activities, or to continued usual care plus $50".
A total of 342 participants with an average age of 49 were enrolled and then randomised to the three groups: MBSR, CBT, or usual care.
The two interventions lasted for eight weeks, with two-hour group sessions every week, though the MBSR group also had the option of a longer six-hour retreat.
They were delivered according to a manual, and participants in both groups received workbooks and instructions for home practise.
In brief, the interventions included meditation, a body scan (designed to increase awareness of your physical body), and yoga in MBSR.
In CBT, the intervention included education about pain, relationship to thoughts, and instructions on ways to change this pattern.
Follow-up of all participants was performed by assessors blinded to the treatment group at four and eight weeks, then six and 12 months.
The validated Roland Disability Questionnaire (RDQ) was used to assess functional limitation as a result of back pain. The main outcome was the percentage of people with a 30% or greater improvement from study start.
Other (secondary) outcomes examined included depression and anxiety symptoms, and pain intensity.
What were the basic results?
The main outcome of 30% functional improvement was achieved by 60.5% of the MBSR group, 57.7% of the CBT group, and 44.1% of the usual care group at six months. These proportions had increased to 68.6%, 58.7% and 48.6%, respectively, at 12 months.
Significantly more people saw improvement in the MBSR group compared with usual care at both six and 12 months – but not at the earlier assessments at four and eight weeks.
Meanwhile, significantly more people in the CBT group had improved at eight weeks and six months compared with usual care, but not four weeks or 12 months.
Similarly, significantly more people in the MBSR group had meaningful improvement in pain at six and 12 months compared with usual care (CBT only at six months).
Looking at the actual disability and pain scores, both MBSR and CBT gave significant score improvement compared with usual care at eight weeks, six months and 12 months.
There was no significant difference between MBSR and CBT at any time point.
How did the researchers interpret the results?
The researchers concluded that, "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."
This RCT aimed to review the alternative mind-body therapy of MBSR for the treatment of chronic lower back pain.
The trial has many strengths, including:
- delivery of both interventions by trained and experienced professionals
- long follow-up period
- blinded assessment of outcomes using validated scales
- adequate sample size – prior calculations were performed to ensure sufficient people were recruited to make the outcome assessment reliable
- intention to treat analysis – where all people were assessed in their assigned groups, regardless of whether they completed the intervention or follow-up
There are a few key points to bear in mind when reviewing this study and the media's interpretation of it:
- The study does not show that MBSR is better than CBT for chronic lower back pain – there was no significant difference between the two groups for improvement in function or pain.
- Nor does the study show that MBSR is better than painkillers, as the media suggests – yes, MBSR was better than usual care, but the content of this is not specified in the study. We don't know what care this may have involved; use of painkillers is only assumed.
- "Lower back pain" could encompass a variety of conditions. This study only included people with the non-specific lower back pain, sometimes called mechanical back pain. This is when no cause can be identified. It does not include people with prolapsed ("slipped") disc and nerve compression, or people with other causes for their back pain, including traumatic, infective, inflammatory, or cancer causes. Therefore, it should not be taken to mean that people with serious causes for their back pain only need to meditate and it'll all go away.
With these limitations in mind, the study suggests that the mind-body therapy of MBSR could be another psychological therapy for chronic lower back pain that is just effective as the widely used therapy of CBT.
Read more about how mindfulness can improve your mental wellbeing.