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Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial
Open accessAbstract
IMPORTANCE: Mindfulness-based stress reduction (MBSR) has not been rigorously evaluated for young and middle-aged adults with chronic low back pain. OBJECTIVE: To evaluate the effectiveness for chronic low back pain of MBSR vs cognitive behavioral therapy (CBT) or usual care. DESIGN, SETTING, AND PARTICIPANTS: Randomized, interviewer-blind, clinical trial in an integrated health care system in Washington State of 342 adults aged 20 to 70 years with chronic low back pain enrolled between September 2012 and April 2014 and randomly assigned to receive MBSR (n = 116), CBT (n = 113), or usual care (n = 113). INTERVENTIONS: CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever care participants received. MAIN OUTCOMES AND MEASURES: Coprimary outcomes were the percentages of participants with clinically meaningful (≥30%) improvement from baseline in functional limitations (modified Roland Disability Questionnaire [RDQ]; range, 0-23) and in self-reported back pain bothersomeness (scale, 0-10) at 26 weeks. Outcomes were also assessed at 4, 8, and 52 weeks. RESULTS: There were 342 randomized participants, the mean (SD) [range] age was 49.3 (12.3) [20-70] years, 224 (65.7%) were women, mean duration of back pain was 7.3 years (range, 3 months-50 years), 123 (53.7%) attended 6 or more of the 8 sessions, 294 (86.0%) completed the study at 26 weeks, and 290 (84.8%) completed the study at 52 weeks. In intent-to-treat analyses at 26 weeks, the percentage of participants with clinically meaningful improvement on the RDQ was higher for those who received MBSR (60.5%) and CBT (57.7%) than for usual care (44.1%) (overall P = .04; relative risk [RR] for MBSR vs usual care, 1.37 [95% CI, 1.06-1.77]; RR for MBSR vs CBT, 0.95 [95% CI, 0.77-1.18]; and RR for CBT vs usual care, 1.31 [95% CI, 1.01-1.69]). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 43.6% in the MBSR group and 44.9% in the CBT group, vs 26.6% in the usual care group (overall P = .01; RR for MBSR vs usual care, 1.64 [95% CI, 1.15-2.34]; RR for MBSR vs CBT, 1.03 [95% CI, 0.78-1.36]; and RR for CBT vs usual care, 1.69 [95% CI, 1.18-2.41]). Findings for MBSR persisted with little change at 52 weeks for both primary outcomes. CONCLUSIONS AND RELEVANCE: 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. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01467843.
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“However, these effects do not seem to be maintained in the long term [32,42].”
From Prevention of non-specific back pain through exercise and education: A systematic review and meta-analysis (2024) · cites this paper as [32]
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“The disability variable also showed a strong effect in the meta-analysis [28,29,30,31,32,33,36,37,39,40,41,43].”
From Prevention of non-specific back pain through exercise and education: A systematic review and meta-analysis (2024) · cites this paper as [32]
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“One article had a high drop-out rate (61% adherence) (Cherkin et al., 2016)”
From What works in mindfulness interventions for medically unexplained symptoms? A systematic review (2020) · cites this paper as Cherkin et al., 2016
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“Mindfulness-based interventions (MBIs) such as mindfulness-based stress reduction (MBSR) 1 and mindfulness-based cognitive therapy (MBCT) 2 are efficacious for improving patient-reported outcomes such as pain interference, pain intensity, and psychological distress for people living with chronic pain.3–5”
From Are Formal and Informal Home Mindfulness Practice Quantities Associated With Outcomes? Results From a Pilot Study of a Four-Week Mindfulness Intervention for Chronic Pain Management. (2024) · cites this paper as [3]
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“Attendance averaged ∼75%, or three out of four sessions, which is within the range of 5.5 to 7.6 sessions attended (out of eight) found in previous studies of MBIs for chronic pain [19, 47–49].”
From Feasibility and Acceptability of an Abbreviated, Four-Week Mindfulness Program for Chronic Pain Management. (2020) · cites this paper as [19]
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“In the Mind-body Approaches to Pain (MAP) randomized controlled trial (RCT), we found both CBT and mindfulness-based stress reduction (MBSR) to have benefits for pain and function among individuals with chronic low back pain (CLBP).13”
The cited source says what the claim attributes to it.
In the citing paper
“Both mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) are effective for chronic low back pain (CLBP)”
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In the citing paper
“and retreat attendance rate (26% of participants randomized to MBSR),13”
From Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain (2023) · cites this paper as [13]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
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“These results suggest that the finding in the MAP RCT of CBT having greater benefit than MBSR for depression post-treatment13 may have been due largely to treatment differences among those who were more depressed.”
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In the citing paper
“session attendance rates (56.6% and 50.9% of randomized participants attended at least 6 sessions of CBT and MBSR, respectively)”
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In the citing paper
“research demonstrating that MM can lead to reductions in pain intensity,[16] pain interference,[15, 29] and pain-related affect,[30, 31]”
From The chronic pain skills study: Protocol for a randomized controlled trial comparing hypnosis, mindfulness meditation and pain education in Veterans (2020) · cites this paper as [15]
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“Two self-management approaches, hypnosis (HYP)[12–14] and mindfulness meditation(MM)[15–17], show promise across a range of chronic pain conditions and have been identified as priorities for further study and dissemination.[18]”
From The chronic pain skills study: Protocol for a randomized controlled trial comparing hypnosis, mindfulness meditation and pain education in Veterans (2020) · cites this paper as [15]
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In the citing paper
“Relevant trials have suggested that MBSR may be an effective treatment option for patients with chronic low back pain [14–16].”
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In the citing paper
“The combination of exercise therapy and health education has a strong effect on the pain variable compared to exercise therapy alone or health education alone [31,32,33,34,35,36,37,38,39,40,43].”
From Prevention of non-specific back pain through exercise and education: A systematic review and meta-analysis (2024) · cites this paper as [32]
Experimental — accuracy not yet measuredIn the citing paper
“By contrast, in a seminal study, Cherkin et al.19 found that both MBSR and CBT significantly improved ratings of functional limitations, pain-related distress, and pain intensity in chronic lower back pain patients when compared with standard of care.”
From The neural mechanisms of mindfulness-based pain relief: a functional magnetic resonance imaging-based review and primer (2019) · cites this paper as [19]
In the citing paper
“In the same study, findings persisted for MBSR and CBT at 8-, 26-, and 52-week follow-up, demonstrating the durability of mindfulness on certain pain-related outcomes over time.”
From The neural mechanisms of mindfulness-based pain relief: a functional magnetic resonance imaging-based review and primer (2019) · cites this paper as [19]
In the citing paper
“There is reliable and growing evidence demonstrating that long-term mindfulness practice can lead to significant increases in pain threshold values and lower pain sensitivity even when participants are not explicitly practicing mindfulness.13,19,43,46,82,83”
From The neural mechanisms of mindfulness-based pain relief: a functional magnetic resonance imaging-based review and primer (2019) · cites this paper as [19]
In the citing paper
“The MBSR and CBT programs were found to be significantly more effective at reducing pain intensity and reports of pain being bothersome when compared to usual care after 8, 26, and 52 weeks.71”
From Mindfulness meditation-based pain relief: a mechanistic account (2016) · cites this paper as [71]
In the citing paper
“While there were no significant differences between the CBT and MBSR programs in pain-related outcomes”
From Mindfulness meditation-based pain relief: a mechanistic account (2016) · cites this paper as [71]
In the citing paper
“In recent years, MBI has been successfully implemented to improve psychological health and coping skills 8 in a range of clinical populations, including chronic disease 9 , pain disorders 10 and cancer 11 .”
From Effects of mindfulness-based intervention on glycemic control and psychological outcomes in people with diabetes: a systematic review and meta-analysis (2021) · cites this paper as [10]
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“Mindfulnessmeditation is a promising, cost-effective pain therapy, although the specific mechanisms supporting mindfulness have not comprehensively identified.(22,35,37,38,39,50,56,62,81,89) As adapted in our laboratory, mindfulness-based pain-relief is associated with”
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“Mindfulness-based interventions (MBIs) represent one class of promising treatments for response inhibition deficits in this patient population due to their demonstrated ability to reduce chronic pain symptoms [27], attenuate risk of opioid misuse [28], and strengthen multiple domains of cognitive control [29].”
BackgroundBrintz, C. E., Roth, I., Faurot, K., Rao, S., & Gaylord, S. A. (2020) · Pain Medicine · doi:10.1093/pm/pnaa208 · Cited by 37
“In a rigorous three-arm randomized controlled trial (RCT) for patients with chronic low back pain, MBSR demonstrated similar efficacy as cognitive behavioral therapy, the psychosocial treatment with the largest evidence base for chronic pain, compared with usual care, for reducing back pain bothersomeness, back pain–r…”
MethodStrand, N. H., D'Souza, R. S., Gomez, D. A., Whitney, M. A., Attanti, S., Anderson, M. A., Moeschler, S. M., Chadwick, A. L., & Maloney, J. A. (2024) · Maturitas · doi:10.1016/j.maturitas.2024.108135 · Cited by 30
Self-citationCan Acupuncture Improve Chronic Spinal Pain? A Systematic Review and Meta-Analysis
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Lin, T.-H., Tam, K., Yang, Y., Liou, T., Hsu, T.-H., & Rau, C.-L. (2022) · Pain Medicine · doi:10.1093/pm/pnac037 · Cited by 33
Association Between Pain and Mindfulness in Multiple Sclerosis
Senders, A., Borgatti, A., Hanes, D., & Shinto, L. (2018) · International Journal of MS Care · doi:10.7224/1537-2073.2016-076 · Cited by 28
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“…Complementary Medicine, Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany, 7 Institute for Transcultural Health Studies, European University Viadrina, Frankfurt (Oder), Germany Background: Research has demonstrated that short meditation training may yield higher pain…”
BackgroundInfluentialChavez, J. L., Porucznik, C. A., Gren, L. H., Guan, J., Joyce, E. J., Brodke, D. S., Dailey, A. T., Mahan, M. A., Hood, R. S., Lawrence, B. D., et al. (2020) · World Neurosurgery · doi:10.1016/j.wneu.2020.03.186 · Cited by 29
Thorn, B. E. (2020) · Pain · doi:10.1097/j.pain.0000000000001839 · Cited by 30
Cost-effectiveness of Yoga for Chronic Low Back Pain in Veterans
Groessl, E. J., Liu, L., Richard, E., & Tally, S. R. (2020) · Medical Care · doi:10.1097/mlr.0000000000001356 · Cited by 28
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“Relevant trials have suggested that psychotherapies such as cognitive behavioral treatment (CBT) [16, 17], mindfulness-based stress reduction (MBSR) [18] and self-compassion training (SCT) [19, 20] can be effective treatment options for patients with NCLBP.”
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Mindfulness, Stress, and Aging
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“In addition, with more control over intervention content, Cherkin et al. were able to draw more definite conclusions than with MBSR practitioners who all followed their own treatment preferences.”
MethodInfluentialSelf-citationPotential novel therapeutic strategies for neuropathic pain
Du, Z., Zhang, J., Han, X., Yu, W., & Gu, X. (2023) · Frontiers in Molecular Neuroscience · doi:10.3389/fnmol.2023.1138798 · Cited by 31
“MBSR treatment had a greater improvement at 26 weeks in low back pain compared with usual care (NCT01467843) (Cherkin et al., 2016).”
BackgroundContemporary management of pain in cirrhosis: Toward precision therapy for pain
Holman, A., Parikh, N. D., Clauw, D. J., Williams, D. A., & Tapper, E. B. (2022) · Hepatology · doi:10.1002/hep.32598 · Cited by 26
“[68,73] Methods like pleasant activity scheduling[74] and mindfulness techniques[75] to improve mood and reduce stress may optimize the conditions under which nociception and, subsequently, pain is experienced by the individual.”
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Opioid Prescribing for Low Back Pain
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Hadley, G. R., & Novitch, M. B. (2021) · Current Pain and Headache Reports · doi:10.1007/s11916-021-00948-1 · Cited by 31
“Previous studies have shown that CBT is effective for depression, anxiety, stress, and chronic pain [3].”
BackgroundGreco, C. M., Gaylord, S. A., Faurot, K. R., Weinberg, J., Gardiner, P. M., Roth, I., Barnhill, J. L., Thomas, H. N., Dhamne, S. C., Lathren, C., et al. (2021) · Contemporary Clinical Trials · doi:10.1016/j.cct.2021.106545 · Cited by 25
Systematic Review for the Medical Applications of Meditation in Randomized Controlled Trials
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“Chronic low back pain [35] MBSR (M) 341 (3, CBT, usual care) 8 pain A, disability A, global impression depressive mood, feeling anxious, QoL Chronic low back pain [36] Jyoti meditation (Y) 68 (2, exercise) 8 stress depressive mood, feeling anxious, QoL, pain A, disability”
BackgroundMindfulness Meditation in the Treatment of Chronic Pain
Brandel, M. G., Lin, C., Hennel, D., Khazen, O., Pilitsis, J. G., & Ben‐Haim, S. (2022) · Neurosurgery Clinics of North America · doi:10.1016/j.nec.2022.02.005 · Cited by 25
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Evaluation of a Psychological Intervention for Patients with Chronic Pain in Primary Care
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“…(APA, 2016), evidence is particularly strong for two types of psychological intervention: cognitive-behavioral therapy (Morley et al., 1999; Huguet et al., 2014; Cherkin et al., 2016; Kroner et al., 2016) and Acceptance and Commitment Therapy (Veehof et al., 2011, 2016; Hann and McCracken, 2014).”
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“Therapies such as cognitive behavioral therapy for chronic pain, mindfulness-based stress reduction [10,11], and acceptance and commitment therapy [12] have been shown to modify cognitions and behaviors that influence the perception of pain.”
Fragile X Premutation: Medications, Therapy and Lifestyle Advice
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A mind-body program for older adults with chronic low back pain: A randomized clinical trial
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The Role of Cognitive Content and Cognitive Processes in Chronic Pain
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“Black/African American/Caribbean 82 (48) White—not Hispanic or Latino 54 (32) White—Hispanic or Latino 13 (7) Asian 4 (2) American Indian/Alaska Native 1 (1) > 1 race/ethnicity 12 (7)”
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“, physical therapy,[26] cognitive behavioral therapy,[27] yoga,[26] and mindfulness based stress reduction[27]) and how opioid”
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Gray Matter Changes in Adolescents Participating in a Meditation Training
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Diagnosis and Treatment of Low Back Pain
Macedo, F. J., Annaswamy, T. M., Coller, R., Buelt, A., Glotfelter, M. A., Heideman, P. W., Kang, D. G., Konitzer, L. N., Okamoto, C. S., Olson, J. L., et al. (2023) · American Journal of Physical Medicine & Rehabilitation · doi:10.1097/phm.0000000000002356 · Cited by 27
Vulvodynia is not created equally: empirical classification of women with vulvodynia
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“A recent study by Cherkin et al reported that 8 weeks of a mindfulness-based stress reduction, including yoga, for people with chronic low back pain resulted in similar reductions in pain bother and pain-related disability compared to CBT. 55 This group also reported similar reductions in catastrophizing and improveme…”
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Cognitive Behavioral Therapy for Chronic Pain—One Therapeutic Approach for the Opioid Epidemic
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Cost-Effectiveness of a Team-Based Integrative Medicine Approach to the Treatment of Back Pain
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“28 For both RDQ and BOP, we defined patients with a clinically meaningful ‡ 30% improvement as responders.”
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Digital cognitive behavioral therapy vs education for pain in adults with sickle cell disease
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Metadata
- Authors
- Cherkin, D. C., Sherman, K. J., Balderson, B. H., Cook, A. J., Anderson, M. L., Hawkes, R. J., Hansen, K. E., & Turner, J. A.
- Affiliations
- Kaiser Permanente Washington Health Research Institute (US)
- University of Washington (US)
- Corresponding author
- Cherkin, Daniel C.
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2016-03-22
- Volume
- 315
- Issue
- 12
- Pages
- 1240
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC4914381
- OpenAlex
- W2304035054
- Cited by
- 729
- References
- 42
- Citations by year
- 2026: 53 · 2025: 71 · 2024: 82 · 2023: 66 · 2022: 72 · 2021: 80 · 2020: 81 · 2019: 65 · 2018: 54 · 2017: 72 · 2016: 31
- FWCI
- 59.82
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health
- National Center for Complementary and Integrative Health (R01AT006226)
- Topics
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Keywords
- mindfulness-based stress reduction, cognitive behavioral therapy, chronic low back pain, functional limitations, pain-related disability, mindfulness meditation, yoga, usual care, young and middle-aged adults, treatment effectiveness comparison, integrated health system, pain catastrophizing, pain acceptance, pain-related hopelessness, pain-related helplessness
- MeSH terms
- Adult, Female, Humans, Male, Middle Aged, Stress, Physiological, Stress, Psychological, Washington, Yoga, Cognitive Behavioral Therapy, Treatment Outcome, Low Back Pain, Sample Size, Young Adult, Intention to Treat Analysis, Mindfulness
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