Randomized trial of group cognitive behavioral therapy compared with a pain education control for low-literacy rural people with chronic pain

Abstract

Chronic pain is a common and costly experience. Cognitive-behavioral therapies (CBT) are efficacious for an array of chronic pain conditions. However, the literature is based primarily on urban (white) samples. It is unknown whether CBT works in low-socioeconomic (SES), minority and non-minority groups. To address this question, we conducted a Randomized Controlled Trial within a low-SES, rural chronic pain population. Specifically, we examined the feasibility, tolerability, acceptability, and efficacy of group CBT compared to a group education intervention (EDU). We hypothesized that while both interventions would elicit short- and long-term improvement across pain-related outcomes, the cognitively-focused CBT protocol would uniquely influence pain catastrophizing. Mixed design ANOVAs were conducted on the sample of eligible participants who did not commence treatment (N=26), the intent-to-treat sample (ITT; N=83), and on the completer sample (N=61). Factors associated with treatment completion were examined. Results indicated significantly more drop-outs occurred in CBT. ITT analyses showed that participants in both conditions reported significant improvement across pain-related outcomes, and a nonsignificant trend was found for depressed mood to improve more in CBT than EDU. Results of the completer analyses produced a similar pattern of findings; however, CBT produced greater gains on cognitive and affect variables than EDU. Treatment gains were maintained at 6-month follow-up (N=54). Clinical significance of the findings and the number of treatment responders is reported. Overall, these findings indicate CBT and EDU are viable treatment options in low-SES, minority and non-minority groups. Further research should target disseminating and sustaining psychosocial treatment options within underserved populations.

Is reduction in pain catastrophizing a therapeutic mechanism specific to cognitive-behavioral therapy for chronic pain?

“…The current research examines the relations evaluated by Smeets et al [34], in another sample and with a different comparison condition. The recently reported RCT examined the feasibility and efficacy of a literacyadapted, culturally sensitive group CBT program in comparison to a similarly adapted Pain Education intervention [35]. Participants were rural, predominantly African-American people with chronic pain, and characterized by low socioeconomic status (SES) and low literacy [36].…”

“…Typically found to be largely inert, systematic reviews have reported no clinically significant effect of group education-based programs, such as "back schools [37][38][39]." Notable exceptions include studies in which the educational intervention is based on the biopsychosocial model rather than a biomedical model [35,[40][41][42], which was the case in this RCT. Speaking to the active nature of our Pain Education condition, we found that participants in the Pain Education condition significantly improved on primary outcomes to the same degree as those in the CBT condition [35].…”

“…Notable exceptions include studies in which the educational intervention is based on the biopsychosocial model rather than a biomedical model [35,[40][41][42], which was the case in this RCT. Speaking to the active nature of our Pain Education condition, we found that participants in the Pain Education condition significantly improved on primary outcomes to the same degree as those in the CBT condition [35]. The CBT intervention was cognitively focused and designed to specifically target maladaptive cognitions, whereas the Pain Education intervention was designed to provide factual, biopsychosocial knowledge about pain, without explicit focus on cognitive change.…”

“…In the original study [35], 61 people completed the 10-week interventions. Pre-and posttreatment measures of pain-related outcomes and the pain catastrophizing scale (PCS) [43] were taken.…”

Should evidence or sound clinical reasoning dictate patient care?

“…These designs, although traditionally considered lower rigor, often reside closest to clinician's practice realities by: (1) embellishing variance richness; (2) offering consideration to rare conditions or unique clinical combinations; and (3) supporting practice patterns that provide immediate solutions for exploratory processes. The 'rim' (biopsychosocial constructs) that undergirds patient management progress includes emotional (anxiety, frustration, anger), 10 cognitive (illogic, distrust, catastrophizing), 11 psychological (depression, bipolar tendencies, personality disorders, psychosis), 12 contextual (goals, settings, background, circumstances), 13 sociocultural (race, culture, gender, ethnicity), 14 economic (employment/work status, socioeconomic group), 15 and/or communication (observing, listening, perceiving, expressing, responding, reporting) 16 influences. Patient care that considers these influences may require effort outside of contemporary evidence, where the patient's perception of care may be as important as what is actually delivered.…”