Lots of people suffer from chronic back pain, and unfortunately, the treatments that doctors can offer are not particularly good. Acetaminophen (paracetamol) and NSAID’s are completely ineffective, while benzodiazepines and opioids turn people in to drug addicts.
Physiotherapists have better luck treating chronic back pain than doctors, but many people continue to suffer for years even with regular physiotherapy. So there is a need for more options.
It’s thought that there is a strong mental component involved in chronic back pain. People have catastrophic thoughts about their pain, imagining that they have some deadly disease even after that has been conclusively ruled out, and they spend an inordinate amount of time focusing their attention on their pain.
With that being the case, it stands to reason that meditation could help, both by getting people to accept their pain and thus reduce the number of catastrophic thoughts, and by getting them to strengthen their ability to focus their attention elsewhere.
Two reasonably large randomised trials were published in March 2016 that sought to determine whether meditation is an effective treatment for chronic low back pain. We’ll look at each in turn.
The first was published in JAMA (The Journal of the American Medical Association). It recruited 342 adults who suffered from chronic low back pain, and randomised them in to three different groups. One group received training in meditation, mindfulness and yoga. One recent cognitive behavioural therapy. And one was asked to just get on with life as usual.
Here we immediately hit a major problem with this trial. For natural reasons, there was no blinding of the participants, since it’s hard to prevent people from knowing whether they’re meditating, doing cognitive behavioural therapy, or doing nothing. This can’t be helped. The problem is that there were two groups receiving active interventions, both of which we think may well do something useful for pain, and a control group that was doing nothing at all.
In other words, there was no active control group receiving a placebo intervention. There is thus no ability to account for the size of the placebo effect. So, regardless of the outcome of the trial, it will be hard to separate out what is the placebo effect and what is a “real” effect. This could have been helped if the researchers had just designed their trial better.
The meditation group and the cognitive behaviour therapy group each received eight two hour education sessions spaced out over the first eight weeks of the trial. The meditation group was also invited to take part in a six hour “retreat”. Apart from that, the two groups were supposed to practice at home between the sessions, and once the sessions were complete – although the initial training lasted eight weeks, the participants were followed for a full year.
As mentioned, the meditation group didn’t just receive training in meditation, they also received training in yoga. This is another problem. If there is a benefit seen in the trial, then it becomes impossible to say whether it is thanks to the meditation, or thanks to the yoga, or thanks to the combination of the two.
Ok, so what were the results?
At one year out from the beginning of the study, 49% of participants in the meditation and yoga group had experienced at least a 30% reduction in “pain bothersomeness”, as compared with 40% of participants in the cognitive behaviour therapy group and 31% in the control group. The improvements over the control group were statistically significant, but the improvements over the cognitive behaviour therapy group weren’t.
Taken at face value, these results suggest that one in five people who do meditation plus yoga can expect to see a meaningful reduction in their chronic back pain (i.e. at least a thirty percent improvement).
There are problems though, that make it hard to that these results at face value. One is the fact that there were more drop-outs from the study in the meditation plus yoga group and the cognitive behaviour therapy group than in the control group. Only 6% of the participants in the control group dropped out, compared with 20% in the two other groups.
Who drops out of studies? People who don’t feel like they’re benefiting from the intervention, or who feel that the negative aspects outweigh the positive. The people who have stuck around to the end are the people who are most likely to feel that they benefited. This will introduce bias in to a study, making the intervention appear more effective than it is. So the real world benefit is likely to be smaller than was seen in this study.
And, as mentioned, the lack of a placebo control group makes it impossible to say whether the benefits seen in the trial are real or just the result of the placebo effect. “So what?” you might say, “if it works, it works, regardless of whether it’s due to the placebo effect or some real effect of the intervention.” That is true, but to me it would feel unethical to recommend something that relies 100% on the placebo effect. That’s what homeopaths do, not real doctors.
What can we conclude? Although this study does show some reduction in chronic low back pain in people doing meditation plus yoga, the benefit is quite modest, with only one in five benefiting noticeably, and it could easily be due entirely to the differences in drop-out rates and the placebo effect. In other words, it’s unclear whether there is any real benefit at all. I say this as someone who is a fan of both meditation and yoga, and who would love to see them show massive benefits for all human ills.
One could argue that the benefits would have been bigger with a more intensive program, say if the participants had to take part in organised group sessions multiple times per week for the whole study period, rather than just once a week for eight weeks. That is very possible, maybe even likely, but it’s entirely hypothetical, since no-one has yet done that study.
Let’s move on and look at the next trial, which was published in JAMA Internal Medicine. 282 adults aged 65 and older with chronic low back pain were randomised to receive either training in mindfulness meditation or a control intervention, and then followed for six months.
Both groups received weekly lessons over the course of eight weeks, and thereafter they received monthly booster sessions. The meditation group was taught how to meditate while sitting, walking, and lying down, and how to focus attention on breath, thoughts, and sensations.
The control group received a course called “The ten keys to healthy ageing”, which was constructed in such a way that the time requirements, both in terms of participation at lessons, and time spent doing homework, were the same as for the meditation group.
Ok, so from the information we have, it’s already clear that this study is in important ways superior to the previous one. First, it’s comparing meditation with control, not meditation plus yoga with control. So if there is a benefit, it’s easier to say that it’s actually due to the meditation. Second, the control group has received a dummy intervention, it hasn’t just been told to get on with life as usual. That should help deal with the placebo effect. So if there is a benefit to meditation, it’s easier to argue that it’s really real.
Ok, what were the results?
At six months, 37% of participants in the meditation group had achieved at least a 30% reduction in their pain level, compared with 27% of participants in the control group. In other words, you would need to give the meditation intervention to ten people for one to experience a meaningful benefit. Unfortunately, the difference wasn’t statistically significant, so it’s not clear whether it’s real or due to chance.
As with the previous study, there were significantly more drop-outs in the meditation group than in the control group (16% vs 5%), so there is likely some bias introduced as a result of this, making the meditation group’s results look better than they otherwise would.
Ok, so we have two studies that both appear to show some modest possible benefit. However the first is ruined by the fact that it mixes up meditation with yoga and by the fact that there is no placebo control, and in the second the benefit is small and fails to reach the level of statistical significance.
So, what can we conclude?
At present, the evidence does not support the notion that meditation is an effective method for treating chronic low back pain.
I found this whole article well-thought out and clearly explained. Thank you.
The one problem from my point of view was the sneer at homeopathy. I’m not a practitioner but have seen world changing improvements in a severely autistic child, and another stunning improvement (it removed the need for a scheduled surgery) in a four-year old child in my family. Placebo effect was not a factor in either case.
I agree. The whole post is – as usual – very thoroughly thought out and formulated but the remark about homeopathy was unfounded and unnecessary.
Whatever happened to Sebastian?
What a good question. On Twitter or Facebook he hasn’t been active since last summer either.
Does anyone know?
I’m still here. Just too busy with job/kids to work on the blog at present. Sorry.
That is good news. I mean, much better than something having happened to you. Being busy living life is a very good reason. Thanks for replying so quickly!
Hej. Jag är komplementärmedicinsk lärare och terapeut i massage, fysioterapi, aromaterapi mm.
Det är inte lätt att bevisa att skolmedicinsk fysioteraoi eller alternativmedicinsk fysioterapi, massage, yoga eller meditation hjälper. En svårighet är att det inte är lätt att få pengar till forskning som man inte kan tjäna pengar på. En annan svårighet är att varje terapeut är olika. Jag fick hjälp med mina ländryggsproblem av en skolmedicinsk fysioterapeut som vidareutbildat sig och forskat i fyra år efter sin sjukgymnastutbildning. Innan jag kom till honom besökte jag flera andra kollegor till honom som inte kunde hjälpa mig alls och kanske till och med ibland förvärrade ohälsan. Med det vill jag belysa att även om man i en studie får det ena eller andra resultatet så är den typen av behandlingar beroende av den enskilda fysioterapeuten, massören, yogaläraren, meditationsledaren etc. Det finns massörer och fysioterapeuter som får fantastiska resultat. En av mina tidigare elever fick på sin arbetsplats (spahotell med över hundra massörer, de flesta på deltid) smeknamnet Jesus för att hans behandlingar gav så bra resultat.
På högskolan i Miami har de en avdelning som heter Touch reserch institute, sedan mer än 30 år. Från starten sponsrades den an läkemedelsbolaget Johnsson och Johnsson (kanske fortfarande) vilket jag brukar nämna som exempel på att läkemedelsbolag ibland gör bra saker. Alla deras studier. Idag över 100 visar att massage hjälper. Vissa hälsotillstånd blir inte bättre, men patienterna upplever en bättre livskvalitet. Deras massage påminner om att klappa katten medhårs och är därmed fri från biverkningar (inga underliggande vävnader skadas). Kan jämföras med en studie som några läkare i Köpenhamn drog igång för många år sedan som visade att massage inte hjälper alls. För så är det med massage. Genom att som på Touch reserch institute massera på rätt sätt så kan man visa att det hjälper och genom att massera på andra sätt kan man lätt visa att det kanske till och med är skadligt. Så när icke insatta läser i en tidning att bindvävsmassage hjälper, som exempel, så kan det mycket väl vara så om de har turen att gå till en duktig bindvävsmassör, men hamnar de hos en annan så hjäper det inte alls. Så det är kul med studier som de i Miami, men de säger inget om det resultat man kommer att få om man går till en massör vilken som helst.
Into my 60’s I started experiencing debilitating lower back pain, consequence of excessive intensity in sport involvement. Neither physiotherapy nor chiropractic helped. I discovered Bowen Therapy and the relief has been enormous. As this does not constitute a cure, over the last 10 years I go for treatment on a 6 monthly basis and remain pain free. Bowen has been around since the 1950’s and based on personal experience I consider it worthy of further investigation.
Sebastian, I highly recommend that you read “Healing Back Pain” by Dr. Sarno. Game changer.
Keep up the good work!
From own personal experience I could not agree more. Read the book. You will find it for free online in PDF. Also, check out this clip from award winning news show:
https://www.youtube.com/watch?v=vsR4wydiIBI
Lennart
Can confirm the value of this book. It has worked for me since I read it years ago.
You state, that homeopathy is placebo.
There has been a double blind study, in Denmark I believe, that shows the significant effect of homeopathic remedies. So much so, that the highly deluted ones are now to be used by m.d.’s such as yourself only!
The result is, that the danish People no longer can get the products. Legally.
A fine example of how little faith the doctors have to what the study shows. They still believe homeopathy is “simply water”. You do not acknowledge energy, though the entire universe is made up of it 😉.
Do you have a link to the study?
That’s interesting. I bought a book about back pain a long time ago. The introduction said that most back pain is lower back pain, and that is solved by going through the pain. That’s what I did, seeking out pain until the pain went away, and it worked for me.
So AFAIK the way out of lower back pain is to have your mind focus on the part of your back that hurts, and then moving your body in ways that hurt.
Re: “they spend an inordinate amount of time focusing their attention on their pain.”
Most people spend time trying to avoid the pain, not on the pain itself. What did you mean?
Yes, they try to avoid it, for example by not doing things they think will make it worse, but they also focus on it and think about it inordinately. Most people are not very good at choosing where they focus their attention. One purpose of meditation is to increase the ability to control consciously where attention rests.
Thanks for your reply. Meditation seems to be about clearing your mind, or even not thinking at all. And in the yoga lessons I follow, the teacher encourages you to watch your body from outside.
What solves my back pain is quite the opposite: focus my thoughts on the pain in my lower back and exercise it. Possible explanations I’ve thought up is that moving finishes off a dying part of my back that is still giving pain, or that it helps my mind to adjust to a new normal level of pain.
The Dutch GP site also advises to move even if it causes pain: https://www.thuisarts.nl/pijn-onder-in-rug/ik-heb-pijn-onder-in-mijn-rug
Absolutely, it’s usually important to move in spite of pain. Avoiding using a muscle usually make the pain in the muscle worse.
I woukl have thought that if the back pan was caused by a mechanical/structural problem then it would need that to be sorted in order to improve things. In other words, poor posture is at the root of much discomfort so pilates type exercises will help. I know that a physio who treated top athletes stretched out my back over a gym ball and gently mobilised it so allowing the spine to open out a bit and sort itself out as the tight muscles released their spasm. Then it was a matter of taking care by not doing risky movements and keeping the spine long and strong by doing regular pilates and appropriate yoga postures. I also saw many people get codeine pain killers prescribed by GPS which either led to constipation or addiction, or both.
Dear Sebastian,
I always read your articles and find them very informative. Specifically I admire your capacity to bring to attention the newest and therefore sometimes controversial research, e.g. in food science and heart science.
Regarding back pain and, actually, most chronic pain, there are more and more doctors realizing that this pain is originating in the brain and not a result of wear or structural damage. If that is the correct diagnosis then we should probably also look at the brain for a cure.
Recently this article was published: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694. Admittedly the group was quite small but the results are promising.
The already mentioned Dr. Sarno was probably correct in assuming that most chronic pain originates in the brain, but he also admitted he lacked a proper explanation on the dynamics of this process. The article (there’s also a book) by Gordon et al does provide this explanation.
Thanks for the tip!
Love your honesty. Thanks for honest thinking and reporting.
How is it possible for someone to determine the percentage reduction in pain that they feel, or to determine whether the pain they feel is higher or lower than somebody else?
The standard method is to rate your pain by putting a mark on a visual analogue scale (VAS) which is basically just a long line where one end is no pain and the other end is the worst pain imaginable. Where you put your mark is then translated in to a number. You do this at the beginning and end of the study and the two numbers are compared.
The problem that any scientist will have studying homeopathy is the same problem that Jacques Benveniste had, and that is any suggestion he makes that homeopathy works will be a risk to his career. The Science Inquisition (and nobody expects the Science Inquisition) will arrive on his doorstep with nothing but ill intent. And yet, as Gerald H. Pollack has shown, water can exist in a fourth state, one that retains memory.
Homeopathy works but only in very small doses.
Surprised no reference here to John Sarno’s work
There are at least two.
I wonder what the placebo effect means in this context. Is it possible to really distinguish, even in theory, between someone whose back pain improves through meditation and someone who does the meditation and whose back pain improves, but through the placebo effect and not through the meditation?
Also it would be interesting to know just what kind of meditation these studies used – there are all sorts of meditation practices. To conclude that meditation is/is not an effective treatment based on a trial using one particular technique (and, perhaps, one particular style of teaching of the technique) would be like concluding that drugs are/are not an effective treatment based on a trial of paracetamol.
Mindfulness meditation – focusing on the breath and so on.
Exactly. There are 650 different kinds of apples in Sweden and probably more kinds of meditation in the world. And also more kinds of specialities among medical doctors.
I bent down to pick up a piece of paper in 2011 and ended up with a terrible backache that would not go away. It was profoundly painful. I could barely walk for 3 years, constant pain, until I discovered trigger points. I used a tennis ball and stood against a wall to massage the area that hurt. It relieved my pain after a day. I did some research and discovered I had torn the Quadratus Lumborum on my left side. Doctors could never diagnose what was wrong. I do not think they are taught much about muscles in Med School. I had tried yoga, meditation, and back exercises to no avail.
Doctors are not taught anything about trigger points in medical school, even though they’re extremely common.
I discovered acupuncture some years ago, and I have been treated successfully for sciatica and arthritis. It was explained to me that most skeletal pain is actually caused by muscles that have shortened and tightened. Suprisingly, pricking the muscle in question causes it to relax. It certainly worked for me, and a friend of mine who had severe pain from a break in her wrist which had healed. She was on Gabapentin, but was then able to give it up after a couple of acupuncture sessions.
I remember when I was young in the service of the usa,there was meditation and then medication.
First we have to identify the problem and then educate ourself what to do
next.
But I don’t want to say that meditation will work,it depends where the pains is,if it is related to our innerself then we have to find an inside view,if it comes from another source then we need an external view.
I love your articles. I’ve been looking at the power of the breath and I wonder what your views are on what Wim Hoff purports as he has been studied by scientists. Also the book Breath by James Nestor is really interesting, as he found real value in breathing through the nose and certain breathing techniques.
Excellent article! Good information for a common problem. I would like to suggest another topic for a future article–the use of face mask. I have read your book about Covid and many other reports about how effective or not effective the wearing of face mask are. Fauci is now back talking about how the studies that say that the 95 series of mask are very effective. From my reading of the studies, the best number obtained was 10% effectiveness, but that was suspect according to some other reports.
It would be most helpful and certainly informative to read what you think about this topic as well as your analysis of the most recent publications on the subject.
Sebastian please have a look at this new study about antidepressants. ARTICLE TITLE
The serotonin theory of depression: a systematic umbrella review of the evidence
“After decades of study, there remains no clear evidence that serotonin levels or serotonin activity are responsible for depression, according to a major review of prior research led by UCL scientists.
The new umbrella review – an overview of existing meta-analyses and systematic reviews – published in Molecular Psychiatry, suggests that depression is not likely caused by a chemical imbalance, and calls into question what antidepressants do. Most antidepressants are selective serotonin reuptake inhibitors (SSRIs), which were originally said to work by correcting abnormally low serotonin levels. There is no other accepted pharmacological mechanism by which antidepressants affect the symptoms of depression.
Lead author Professor Joanna Moncrieff, a Professor of Psychiatry at UCL and a consultant psychiatrist at North East London NHS Foundation Trust (NELFT), said: “It is always difficult to prove a negative, but I think we can safely say that after a vast amount of research conducted over several decades, there is no convincing evidence that depression is caused by serotonin abnormalities, particularly by lower levels or reduced activity of serotonin.”
https://www.nature.com/articles/s41380-022-01661-0
Thanks for sharing. The serotonin theory of depression was disproved decades ago, so I find the premise for this new article a bit weird – like this is somehow news.
I know several people who dealt with their back pain by wearing a small electroshock device. It apparently zaps an area near the pain and distracts you just enough that you can get on with life. Not sure it heals anything or is even claimed to but some minor pulls and strains go away with time and walking, i would guess.
The only thing that helped with my chronic lower back pain (hurt my back gardening and never really got over the injury) was taking 30 mg Boron daily. This got me off Diclofenac (which I’d been on for years) completely. I was very fortunate to come across someone who mentioned it, I didn’t even think it would work, but it did. Takes a couple of months to really kick in, but since then I have been very much improved. I can’t imagine meditation would have done anything for me, quite honestly. I still have back problems but at least I don’t have pain all day and can get on with some semblance of a life.
Dr. Rushworth,
I have been using EFT (Emotional Freedom Techniques) for over ten years, and almost all back pain can be eliminated by using this process. Sometimes it works in minutes, sometimes it takes a little longer. My best testimonial is when I helped a woman who had constant backpain for 16+ years. She had had 5 back surgeries and her doctor was urging her to have another one. We worked for about 15 minutes and her backpain completely disappeared.
Here are 2 short videos about EFT and pain that you’ll find intriguing:
217 How To Get Rid of Back Pain | Testimonial | No Medication Needed | DIY Technique
https://www.youtube.com/watch?v=tWAeaB7gttM
Could Tapping Be The Solution To Chronic Pain And Anxiety? | Megyn Kelly TODAY
