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Key mechanisms of action of psychosocial treatments for chronic pain include decreased catastrophizing and increased self-efficacy [cognitive-behavioral therapy (CBT)] and increased mindfulness and possibly pain acceptance [mindfulness-based stress reduction (MBSR)]. Greater understanding of overlap among these variables is important in understanding treatment-specific and shared mechanisms of action. We examined, in an RCT comparing group CBT (n=112), MBSR (n=116), and usual care (UC; n=113) for chronic back pain: (1) baseline relationships among the Pain Catastrophizing Scale (PCS), Pain Self-Efficacy Questionnaire (PSEQ), Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), and Five Facet Mindfulness Questionnaire-short form (FFMQ-SF); and (2) pre- to post-treatment changes in these measures. We hypothesized that: (1) at baseline, the PCS would be associated negatively with the CPAQ-8, PSEQ, and FFMQ-SF Non-Reactivity, Non-Judging, and Acting with Awareness scales, and the CPAQ-8 would be associated positively with the PSEQ; and (2) adjusting for baseline variables, FFMQ-SF and CPAQ-8 scores would increase more pre- to post-treatment in MBSR than in CBT and UC, and PCS scores would decrease more and PSEQ scores would increase more in CBT than in MBSR and UC. The hypothesized baseline associations were confirmed between the PCS and the CPAQ-8 (Spearman’s rho = -0.40 to -0.55), PSEQ (-0.57), and FFMQ (-0.22 to -0.30) scales (all Ps < 0.01), and between the CPAQ-8 and the PSEQ (0.46-0.65; all Ps < 0.01). Among all participants who completed baseline and post-treatment assessments (n = 290), catastrophizing decreased significantly more pre- to post-treatment in MBSR than in UC and CBT. Among those who attended >6 of the 8 group sessions, mindfulness increased more in MBSR than in CBT, but the groups did not differ significantly in pre- to post-treatment change on the other measures. The results suggest overlap in mechanisms of action of CBT and MBSR. Supported by NCCAM grant 1R01AT006226.
Although yoga is an effective treatment for chronic low back pain, little is known about the mechanisms responsible for its benefits. In a trial comparing yoga to intensive stretching and self-care, we explored whether physical (hours of back exercise/week), cognitive (fear avoidance, body awareness, and self-efficacy), affective (psychological distress, perceived stress, positive states of mind, and sleep), and physiological factors (cortisol, DHEA) mediated the effects of yoga or stretching on back-related dysfunction (Roland-Morris Disability Scale (RDQ)). For yoga, 36% of the effect on 12-week RDQ was mediated by increased self-efficacy, 18% by sleep disturbance, 9% by hours of back exercise, and 61% by the best combination of all possible mediators (6 mediators). For stretching, 23% of the effect was mediated by increased self-efficacy, 14% by days of back exercise, and 50% by the best combination of all possible mediators (7 mediators). In open-ended questions, >/=20% of participants noted the following treatment benefits: learning new exercises (both groups), relaxation, increased awareness, and the benefits of breathing (yoga), benefits of regular practice (stretching). Although both self-efficacy and hours of back exercise were the strongest mediators for each intervention, compared to self-care, qualitative data suggest that they may exert their benefits through partially distinct mechanisms.