Back pain is among the most common reasons (second only to the common cold) that people visit their doctor. But how to best treat it remains an open question.
For years — as the opioid epidemic has grown — evidence has been building in favor of non-medication treatments including cognitive and mind-body therapies. Until recently, relatively few people have used these therapies, largely because:
But that may be changing.
The Institute for Clinical and Economic Review recently published a report, Cognitive and Mind-Body Therapies for Chronic Low Back and Neck Pain: Effectiveness and Value, concluding that yoga, mindfulness-based stress reduction (or MBSR), cognitive behavioral therapy (or CBT) and acupuncture can provide added benefit for relieving pain and boosting function — safely and at a reasonable cost.
We interviewed three Kaiser Permanente research scientists who are expanding the evidence base about integrative therapies and the treatment of back pain.
Daniel C Cherkin, PhD, is a senior investigator (emeritus) at Kaiser Permanente Washington Health Research Institute and a co-author of a March 5 editorial in JAMA Internal Medicine: Evidence to Practice: the ICER Report on Cognitive and Mind-Body Therapies for Chronic Low Back and Neck Pain: Effectiveness and Value . Karen J. Sherman, PhD, is a senior investigator at the Health Research Institute. Andrew L. Avins, MD, MPH, is a research scientist at the Kaiser Permanente Division of Research in Oakland, California. All three have conducted much of the research included in the ICER report, including key studies of MBSR, CBT and acupuncture for back pain.
Why is the ICER report important?
Cherkin: The report concludes that the evidence supports coverage of yoga, MBSR, CBT and acupuncture for chronic low back pain that is “nonspecific,” with no clearly identifiable cause that can be treated. And the report estimates that coverage for any of these treatments would cost at most 23 cents per member per month, around 5 percent of the estimated costs of pain and inflammation medications. I feel gratified that we’ve contributed to the knowledge base that has the potential to improve access to safer and more effective treatment options for people who have persistent back pain.
Sherman: I’m delighted that patients with chronic low back pain now have more evidence-based options for management that are safer and more empowering than before. Some of these therapies may even have additional healthy benefits: for instance, giving patients insights and skills useful for dealing with future pain and other health problems. This means these therapies may have benefits for other conditions from which people may suffer.
Dr. Avins: The report underscores the value of what we clinicians have often viewed as outside our normal toolbox for chronic pain. I’m proud that researchers and clinicians in Kaiser Permanente are part of a growing trend to examine all the options we can provide to our patients who have chronic pain. At Kaiser Permanente, chronic pain patients have access to complementary and alternative therapies. Services may include chiropractic care, acupuncture and yoga classes. We’ve been extremely well supported by very open-minded clinicians and leaders throughout Kaiser Permanente. This is a partnership.
What about conventional treatments for back pain?
Cherkin: Current clinical practice for chronic low back pain is often ineffective, unsatisfying, costly and sometimes harmful.
Dr. Avins: All the conventional and integrative therapies that we now have to offer our patients with chronic nonspecific back pain are only modestly effective at best. But the evidence base for yoga, MBSR, CBT and acupuncture has grown substantially in the past few years and it’s clear that they provide meaningful benefits for many patients. Their side effects are minimal, in contrast to many conventional treatments such as surgery and opioids, which often carry greater risks.
Sometimes, when chronic back pain has an identifiable cause, surgery can treat that cause. But surgery’s role is extremely limited for most back pain, which tends to be nonspecific, with no known cause. Most people with back pain are prescribed medications for their pain, most often nonsteroidal anti-inflammatory drugs and opioids, but these medications often don’t provide adequate pain relief, and all are associated with potentially serious side effects. Integrative therapies can help reduce the use of conventional therapies, although not completely replace them. And many of these integrative therapies have collateral benefits such as addressing anxiety and depression.
What are the next steps?
Cherkin: Bridging the huge gap between what we now know is best for patients and current medical practice will require a major transformation of how people — including health care providers — think about chronic pain and how the health care world responds to it. Substantial improvement will require changing policies about insurance coverage and reimbursement, as well as workforce training and licensure. The ongoing opioid crisis has fostered an unprecedented interest in non-drug treatment options for pain.
Sherman: We also need more research about what works best for patients who have not been studied as often, for example older adults or patients who might otherwise have been prescribed opioids. And we need to learn more about various treatments for neck pain. Our measurements of treatment effectiveness should include outcomes that matter, for example what percentage of patients achieve meaningful pain relief and functional improvement. Some therapies work well for some patients, but no one treatment is superior for everyone.
Cherkin: Ideally, future research will improve our ability to predict who will respond to which kind of therapy. In the meantime, it’s important for health care providers to have several safe and effective treatment options they can recommend to their patients and to engage their patients in selecting the treatment they believe would be most helpful.
Dr. Avins: The holy grail is highly effective therapy that works for all patients with chronic low back pain. But that’s a difficult nut to crack, because our understanding of the causes of “nonspecific” low back pain (which by definition has no known cause) is still so limited. I think it’s possible to reach that goal, but much more research lies ahead.