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Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy for Chronic Low Back Pain.

Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy for Chronic Low Back Pain To the Editor In a randomized clinical trial of adults with chronic low back pain, Dr Cherkin and colleagues1 found that treatment with mindfulness-based stress reduction (MBSR) or cognitive behavioral therapy (CBT) vs usual care resulted in greater improvement in back pain and function at 26 weeks. However, several important issues need to be considered. The authors noted that not all participants attended all group sessions, but it was not stated whether the techniques taught were implemented daily or practiced at home. Also, although only 26% attended the optional MBSR retreat, the CBT group was not offered such a retreat. To add to these limitations is the important issue of fidelity of the protocol’s administration, which is of paramount importance in clinical trials. The authors indicated that: “Checklists of treatment protocol components were completed by a research assistant at each session and reviewed weekly by a study investigator to verify that all treatment components were delivered. In addition, sessions were audio recorded and a study investigator monitored instructors’ adherence to the protocol ... for at least 1 session per group.” However, the results of these methods to ensure fidelity were never presented. Were there differences between the 2 groups and across sessions? How many protocol deviations were found, and were therapists recalibrated on a regular basis to be certain that they remained reliable over time when administering the protocols? Monitoring at least 1 session per group is inadequate for maintaining fidelity. Conducting high-quality clinical trials is important to advancement of the evidence-based literature regarding the huge economic burden of chronic low back pain. If MBSR provided no clear advantage over CBT, why deviate from the wellestablished intervention?