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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
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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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“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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“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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Citations
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Qaseem, A., Wilt, T. J., McLean, R. M., Forciea, M. A., & for the Clinical Guidelines Committee of the American College of Physicians* (2017) · Annals of Internal Medicine · doi:10.7326/m16-2367 · Cited by 3,234
“One study showed a small improvement in pain at 26 and 52 weeks and in function at 26 weeks compared with usual care (121).”
Creswell, J. D. (2017) · Annual Review of Psychology · doi:10.1146/annurev-psych-042716-051139 · Cited by 1,702
Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis
Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., Colaiaco, B., Maher, A. R., Shanman, R. M., Sorbero, M. E., et al. (2017) · Annals of Behavioral Medicine · doi:10.1007/s12160-016-9844-2 · Cited by 977
“Likewise, a trial of MBSR for back pain [38] found no significant difference between groups in self-reported use of pain medication.”
BackgroundChou, R., Deyo, R. A., Friedly, J. L., Skelly, A. C., Weimer, M. B., Fu, R., Dana, T., Kraegel, P., Griffin, J. C., & Grusing, S. (2017) · Annals of Internal Medicine · doi:10.7326/m16-2458 · Cited by 893
Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., Fu, R., Dana, T., Kraegel, P., Griffin, J., et al. (2017) · Annals of Internal Medicine · doi:10.7326/m16-2459 · Cited by 855
“Two trials were rated as good quality (45, 47) and 1 as poor quality.”
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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