Interactive Voice Response–Based Self-management for Chronic Back Pain

Abstract

IMPORTANCE Recommendations for chronic pain treatment emphasize multimodal approaches, including nonpharmacologic interventions to enhance self-management. Cognitive behavioral therapy (CBT) is an evidence-based treatment that facilitates management of chronic pain and improves outcomes, but access barriers persist. Cognitive behavioral therapy delivery assisted by health technology can obviate the need for in-person visits, but the effectiveness of this alternative to standard therapy is unknown. The Cooperative Pain Education and Self-management (COPES) trial was a randomized, noninferiority trial comparing IVR-CBT to in-person CBT for patients with chronic back pain. OBJECTIVE To assess the efficacy of interactive voice response-based CBT (IVR-CBT) relative to in-person CBT for chronic back pain. DESIGN, SETTING, AND PARTICIPANTS We conducted a noninferiority randomized trial in 1 Department of Veterans Affairs (VA) health care system. A total of 125 patients with chronic back pain were equally allocated to IVR-CBT (n = 62) or in-person CBT (n = 63). INTERVENTIONS Patients treated with IVR-CBT received a self-help manual and weekly prerecorded therapist feedback based on their IVR-reported activity, coping skill practice, and pain outcomes. In-person CBT included weekly, individual CBT sessions with a therapist. Participants in both conditions received IVR monitoring of pain, sleep, activity levels, and pain coping skill practice during treatment. MAIN OUTCOMES AND MEASURES The primary outcome was change from baseline to 3 months in unblinded patient report of average pain intensity measured by the Numeric Rating Scale (NRS). Secondary outcomes included changes in pain-related interference, physical and emotional functioning, sleep quality, and quality of life at 3, 6, and 9 months. We also examined treatment retention. RESULTS Of the 125 patients (97 men, 28 women; mean [SD] age, 57.9 [11.6] years), the adjusted average reduction in NRS with IVR-CBT (−0.77) was similar to in-person CBT (−0.84), with the 95% CI for the difference between groups (−0.67 to 0.80) falling below the prespecified noninferiority margin of 1 indicating IVR-CBT is noninferior. Fifty-four patients randomized to IVR-CBT and 50 randomized to in-person CBT were included in the analysis of the primary outcome. Statistically significant improvements in physical functioning, sleep quality, and physical quality of life at 3 months relative to baseline occurred in both treatments, with no advantage for either treatment. Treatment dropout was lower in IVR-CBT with patients completing on average 2.3 (95% CI, 1.0-3.6) more sessions. CONCLUSIONS AND RELEVANCE IVR-CBT is a low-burden alternative that can increase access to CBT for chronic pain and shows promise as a nonpharmacologic treatment option for chronic pain, with outcomes that are not inferior to in-person CBT. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01025752

Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain

“…Kroenke et al, 65 for example, used automated symptom monitoring to prioritize care manager contacts with patients. Another VHA trial by Heapy et al 67 found improvements in pain-related outcomes (including satisfaction with care) from interactive voice response (IVR)-based selfmanagement for chronic back pain on par with CBT delivered in individual, in-person sessions. In addition, adherence to care was better with IVR delivered, weekly feedback in conjunction with a self-guided, pain self-management manual.…”

Internet‐Based Pain Self‐Management for Veterans: Feasibility and Preliminary Efficacy of the Pain EASE Program

“…Given that participants logged onto the website an average of 17 minutes at each use, it is possible that they accessed more than 1 (or several) modules at each logon, as they were not restricted to certain modules or a certain number of modules in any given week of the program. In addition, the average number of skill modules completed is consistent with a “dose” of CBT, (ie, 3 sessions, as defined in other trials by this group using the same CBT content) …”

“…In addition, the average number of skill modules completed is consistent with a "dose" of CBT, (ie, 3 sessions, as defined in other trials by this group using the same CBT content). 18,19,34,35 Engaging participants in the program is an important task. It is likely beneficial that the Pain EASE program is device agnostic (ie, as readable and usable on a mobile device as it is on a computer), providing flexibility for using the program without requiring a desktop or laptop computer.…”

“…Pain EASE contains 10 pain coping skills modules, which were slightly modified from those developed and tested in the Cooperative Pain Education and Self‐Management (COPES) program, a CBT‐CP program for veterans with chronic back pain delivered using interactive voice response technology . Each module (see Table for a list of modules) adheres to a common structure: (1) brief content presented with graphics and/or audio, (2) an opportunity for self‐assessment (ie, “Test Your Knowledge” quizzes) of the module content followed by automated feedback, and (3) tools for identifying and overcoming barriers to change and module‐specific resource materials (eg, self‐monitoring forms and skill‐specific information that can be printed and shared with a physician).…”

Randomized controlled trial of motivational interviewing for psychogenic nonepileptic seizures

“…Future research might focus on the development and testing of automated electronic interventions that can bridge and enhance the transition from neurologic to behavioral health care for patients with PNES. Automated CBT for patients with substance use disorder and chronic pain has been shown to be similarly effective to in‐person, one‐on‐one CBT . Similar interventions could be adapted for patients with PNES.…”