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.
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