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Over the past decade, there is a drastically hype in the prevalence of chronic back pain (CBP) in the US population, advising a need for more treatment resources.
Home-based,
telephone-delivered Cognitive-Behavioral Therapy (CBT) and Supportive
Care (SC) treatments did not significantly differ in their benefits for back
pain severity and disability, and may warrant further research for applications
to hospital settings.
Over the past decade, there is a drastically hype in
the prevalence of chronic back pain (CBP) in the US population, advising a need
for more treatment resources. Further, the most commonly used pharmacological
drugs for CBP such as opioids are associated with the number of adverse events
that may limit the treatment option. The use of telehealth therapy is an
alternative approach for treating chronic pain. Telehealth technologies include
telephone, internet-based, and smartphone applications. The number of previous
reviews supported the efficacy of telehealth modalities for the management of
pain, but the limited evidence is available regarding how telehealth treatments
compare to traditional in-person therapies.
The present research evaluated the efficacy of
telehealth adaptation of CBT for CBP in comparison to SC psychotherapy. The
study hypotheses were that, relative to the SC condition, CBT treated patients
would demonstrate significantly higher improvements in back pain disability
(Roland Morris Disability Questionnaire), pain severity (Visual Rating Scale),
and greater levels of improvement as defined by ≥25% patient-rated improvement
on the Patient Clinical Global Impressions Scale.
Rationale behind the research:
The effectiveness of CBT for chronic pain has been established in prior
research, but its efficacy relative to therapies that control for nonspecific
factors in a telehealth format are unknown.
Therefore, Thomas Rutledge et al evaluated the efficacy of telehealth
adaptation of CBT for CBP in comparison to SC psychotherapy.
Objective:
To evaluate the efficacy of a telephone-delivered, home-based
cognitive-behavioral intervention for CLBP in comparison to a matched SC
treatment.
Study outcome measures:
Time period: Baseline,
and 8 weeks
Figure 1: Flowchart of patient enrollment patterns across screening, randomization, and treatment completion stages
Participants
completed >90% of planned telephone treatment sessions in
both conditions. SC participants completed an average of 10.8 (0.76) out of a
maximum of 11 telephone sessions, whereas CBT participants completed an average
of 10.0 (2.2) of 11 sessions. The median and modal average attendance values
were 11 of 11 for both conditions. Participants in the SC condition (mean= 3.2 [0.60]) reported
treatment satisfaction levels similar to those in the CBT treatment (mean= 3.5 [0.60]); p>0.05. Among a total of 9 randomized participants that withdrew
during the treatment, 6 of 9 were because of protocol violations (e.g.,
initiating new pain therapies) or new medical concerns; the other 3
participants dropped for unspecified reasons. Fifty of the 66 randomized participants
completed the 8-week treatment (75.7% overall completion rate; 66.7% completion
among CBT participants versus 84.8% completion among SC participants; p>0.10 for difference). There were no differences between the
completers and non-completers of the treatment on demographic characteristics
or RMDQ/NRS scores (all p>0.05).
Although participants in both treatment groups showed within group
statistically significant pre-treatment to post-treatment improvements, there were no
significant between group
differences on these measures. Effect sizes (Cohen d values) for both
groups were in the moderate range. Differences in self-rated improvement on the
CGI were also non-significant (p>0.10).
In this
clinical trial of patients with CBP receiving 1 of 2 telephone-adapted forms of
psychotherapy treatment showed treatment satisfaction and patient improvements
as compared to patients receiving a parallel SC treatment. In both conditions,
the significant reductions in back pain disability and pain severity were
observed. The results of the current study also support the feasibility and
potential efficacy of phone-adapted psychotherapy treatments among patients
with CBP, and encourage further research.
The
current study included the participants with acute LBP, and they received a CBT
treatment. The telephone methods used in the present study was designed to evaluate
the CBT treatment in a modality reflecting current treatment trends towards
technology-based interventions. As summarized in recent reviews of telehealth
interventions for pain telephone therapies such as those employed here are just
one of a growing number of evolving smartphone, video-based, and internet and
social media modalities. In contrast, the present study, unlike some other
recent telehealth trials did not contain an in-person CBT or SC arm against
which to compare the interventions or incorporate technologies such as
smartphones, health sensors, or internet-based applications popular in current
mobile health research.
There
are a handful of clinical trials using psychotherapies to date targeting
populations with CBP using a telephone treatment format against which to
compare our population and findings. For example, relative to a 2014 telecare
intervention for chronic pain in primary care trial, the baseline pain severity
and reductions in pain severity we observed in response to treatment were
similar (mean 5.3/10 to 4.5/10 after 3mo7 vs. a mean of 5.3/10 to 4.1/10 in the
current study). Similarly, the baseline severity of pain disability measured by
the RMDQ was comparable to normative data CLBP populations (mean of 12.1 and SD
of 4-7-6.2, vs. a baseline mean and SD of 10.2 [4.5] in the current study)
published by the instrument authors. Finally, in a 2012 trial of
telephone-adapted
CBT26 that targeted patients with widespread chronic pain (fibromyalgia), the authors reported significantly better treatment outcomes relative to treatment as usual control group at the end of treatment and 3 months’ post-treatment. The latter study also included a third group, exercise treatment condition, involving an in-person orientation with a personal trainer and monthly in-person follow-up visits with the trainer to reinforce progress, observing similar improvements in the telephone CBT treatment and exercise program. Combining this latter trial and the present study results, there is accumulating data to suggest that telephone forms of CBT and SC therapy are effective and well tolerated by patients for a range of chronic pain diagnoses.
The CBP patients receiving a
telephone-delivered form of CBT showed significant improvement in back pain
disability, pain severity, and self-rated improvement as compared to SC
treatment. Both treatments were well-tolerated, with active participation and
treatment satisfaction ratings.
This
home-based, telephone-delivered CBT and SC treatments did not significantly
differ in their benefits for back pain severity
and disability, and may warrant further research for applications to hospital
settings.
The Clinical Journal of Pain 2018;34(4): 322–327
Randomized Controlled Trial of Telephone-delivered Cognitive Behavioral Therapy Versus Supportive Care for Chronic Back Pain
Rutledge Thomas et al.
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