IMPORTANCE Chronic low back pain (CLBP), the most prevalent chronic pain condition, imparts substantial disability and discomfort. Cognitive behavioral therapy (CBT) reduces the effect of CLBP, but access is limited.OBJECTIVE To determine whether a single class in evidence-based pain management skills (empowered relief) is noninferior to 8-session CBT and superior to health education at 3 months after treatment for improving pain catastrophizing, pain intensity, pain interference, and other secondary outcomes. DESIGN, SETTING, AND PARTICIPANTS This 3-arm randomized clinical trial collected data fromMay 24, 2017, to March 3, 2020. Participants included individuals in the community with selfreported CLBP for 6 months or more and an average pain intensity of at least 4 (range, 0-10, with 10 indicating worst pain imaginable). Data were analyzed using intention-to-treat and per-protocol approaches.Author affiliations and article information are listed at the end of this article.
BACKGROUND : Randomized clinical trials (RCT) suggest a multidisciplinary approach to pain rehabilitation is superior to other active treatments in improving pain intensity, function, disability, and pain interference for patients with chronic pain, with small effect size (ds= 0.20–0.36) but its effectiveness remains unknown in real-world practice. OBJECTIVE: The current study examined the effectiveness of a multidisciplinary program to a cognitive and behavioral therapy (pain-CBT) in real-world patients with chronic back pain. METHODS: Twenty-eight patients (M𝑎𝑔𝑒= 57.6, 82.1% Female) completed a multidisciplinary program that included pain psychology and physical therapy. Eighteen patients (M𝑎𝑔𝑒= 58.9, 77.8% Female) completed a CBT-alone program. Using a learning healthcare system, the Pain Catastrophizing Scale, 0–10 Numerical Pain Rating Scale, and Patient-Reported Outcomes Measurement Information System® measures were administered before and after the programs. RESULTS: We found significant improvement in mobility and pain behavior only after a multidisciplinary program (p’s < 0.031; d= 0.69 and 0.55). We also found significant improvement in pain interference, fatigue, depression, anxiety, social role satisfaction, and pain catastrophizing after pain-CBT or multidisciplinary programs (p’s < 0.037; ds = 0.29–0.73). Pain ratings were not significantly changed by either program (p’s > 0.207). CONCLUSIONS: The effect of a multidisciplinary rehabilitation program observed in RCT would be generalizable to real-world practice.
Introduction Chronic pain and insomnia are highly comorbid, and CBT is a recommended treatment for both. CBT protocols that treat these conditions together, however, show improvements in sleep but not pain. As mindfulness, an acceptance-based approach, has been used successfully to treat chronic pain, integrating mindfulness into a combined CBT treatment protocol may help improve outcomes for chronic pain as well as insomnia. Methods An integrated CBT/Mindfulness weekly 6-session group protocol for chronic pain and insomnia was developed and piloted. Treatment components included education about pain neuroscience as well as sleep and circadian biology, relaxation, time-based pacing, tracking 24-hour time in bed, sleep compression, stimulus control, cognitive reframing, and mindfulness. Pre-post measures evaluating insomnia symptoms, sleep hygiene, pain acceptance, pain catastrophizing, and unhelpful beliefs about sleep and pain were analyzed using frequency analyses and paired sample t-tests. Results Two groups were completed for a total of 16 participants, 94% of whom attended at least 5 sessions. Average age was 56 years, 75% of the sample was female, 88% were White, 6% Asian, and 6% Latino. Post-treatment outcomes showed significant improvement in insomnia symptoms (ISI Mdiff=6.6, SDdiff=5.3, p=.01, ES=1.2), sleep hygiene (SHI Mdiff=3.8, SDdiff=4.6, p=.02, ES=.83), pain acceptance (CPAQ Mdiff=5.2, SDdiff=7.8, p=.03, ES=.67), pain catastrophizing (PCS Mdiff=5.1, SDdiff=7.5, p=.03, ES=.68), and unhelpful beliefs about sleep (DBAS Mdiff=31.4, SDdiff=21.2, p=.009, ES=1.5) and pain (PBAS Mdiff=11.6, SDdiff=10.7, p=.02, ES=1.1). Conclusion An integrated CBT/Mindfulness group protocol for chronic pain and insomnia showed significant improvements in post-treatment sleep and pain measures. As previous combined CBT-only protocols showed pre-post improvement in sleep but not pain, the current study demonstrates that including mindfulness might improve outcomes for chronic pain. Future studies should compare CBT protocols for chronic pain and insomnia with and without mindfulness to determine the clinical benefits of including an acceptance-based component. Support Poster presented as part of collaborative conversation with Skye Margolies, PhD, Department of Anesthesiology, University of North Carolina School of Medicine.
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