March 22, 2016

A call for a more patient-centered approach to treating back pain



Dr. Dan Cherkin reflects on three decades of research to improve care for back pain, concluding a supportive, healing context may be key

by Daniel C. Cherkin, PhD, senior investigator at Group Health Research Institute

Over the past 30 years, our research team has conducted many studies aimed at finding treatments that can relieve pain and improve the lives of the millions of Americans who suffer from the most common form of chronic back pain, “nonspecific” back pain. That is, pain without a specific cause (like cancer or a fracture) that lasts at least three months. We have studied a broad range of nondrug treatments including physical therapy, chiropractic, acupuncture, massage, and yoga.

JAMA published our most recent completed study on March 22, 2016. In contrast to our earlier studies, this one focused on treatments targeting the mind, rather than the body. We compared usual care (mostly medications and physical therapy) to two different “mind-based” treatments for chronic back pain: mindfulness-based stress reduction and cognitive behavioral therapy. We found that the two mind-body therapies were equally effective, and both were better than usual care.

Is there a pattern here?

It is intriguing to compare the results of this recent trial with those of our previous trials evaluating the effects of physical treatments for nonspecific chronic low back pain. All of our studies used similar study methods and populations. Remarkably, the results of this trial of “mind-based” approaches were similar to those of our previous trials that focused on treating the body:

  • We compared two types of massage—structural massage specifically addressing painful tissues in the back and a general relaxation (“spa”) massage—with usual care. We found the two different types of massage equally effective, and both were better than usual care.
  • We compared a type of gentle yoga (Viniyoga) with an equally intensive stretching exercise program delivered by a physical therapist and with usual care. We found yoga and stretching exercise equally effective, and both were better than usual care.
  • We compared usual care for back pain with three different methods of stimulating acupuncture points: inserting needles into places (“acupoints”) that the acupuncturist believed would be best for that particular patient, inserting needles into “standard” acupoints believed to be generally helpful for people with chronic back pain, and superficially stimulating the “standard” acupoints with a toothpick. We found all three types of acupuncture equally effective, and all were more effective than usual care alone.

The bottom line

We keep finding that the treatments we have studied—be they focused on the body or on the mind—are consistently better than usual care alone. And these treatments were no more effective than comparison treatments we included that might have been expected to be less effective, such as superficial acupuncture or relaxation massage. We designed these comparison treatments to appear to realistic and reasonable to participants and ensured they were delivered in as caring and intentional a manner as the treatments of primary interest.

So all the treatments we have studied have been found to be more effective than usual care for nonspecific chronic low back pain, no matter what those treatments happen to be. This suggests that clinicians and researchers have been underestimating the benefits to patients of receiving care within a credible and supportive context—and overestimating the importance of the specific effects of treatments.

“To reduce the impact of pain and the resultant suffering will require a transformation in how pain is perceived and judged both by people with pain and by the health care providers who help care for them.” That’s what the National Academies of Sciences, Engineering, and Medicine’s Health and Medicine Division (then the Institute of Medicine) concluded in 2011 in the Relieving Pain in America report. I couldn’t agree more.

It is time for all stakeholders making or influencing health and medical care decisions to step back, take a collective breath, and consider what they can do to restructure the highly reductionist biomedical approach to health, illness, and disease that continues to fall short of meeting the needs of many Americans suffering from chronic back pain and other health problems.

In the meantime, back pain remains a widespread problem: the most common form of pain, the second leading cause of all doctor visits, and a frequent reason for missing work. The United States keeps spending more money on back pain treatments, but with worse outcomes. Continuing to fail to address this enormous and growing problem is not acceptable.

That’s why we are motivated to work with health care systems, insurers, and clinicians to expand our current conceptualization of back pain as primarily a physical problem with specific physical solutions.  Our research team is working with Group Health to provide our clinicians with a better understanding of the psychological and social factors that often affect recovery from back pain and with tools that make it easier for them to match the treatments they offer that are most appropriate for each patient. 

You can read more about our new trial in our news release: Mindfulness meditation eases chronic low back pain.