Psychological approaches in pain management: what works?

Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After a Traumatic Lower-Extremity Injury: The Results of a Randomized Controlled Trial

BACKGROUND

Lower-extremity injuries can result in severe impairment and substantial years lived with a disability. Persistent pain and psychological distress are risk factors for poor long-term outcomes and negatively influence the recovery process following a traumatic injury. Cognitive-behavioral therapy (CBT) interventions have the potential to address these risk factors and subsequently improve outcomes. This study aimed to evaluate the effect of a telephone-delivered cognitive-behavioral-based physical therapy (CBPT) program on physical function, pain, and general health at 12 months after hospital discharge following lower-extremity trauma. The CBPT program was hypothesized to improve outcomes compared with an education program.

METHODS

A multicenter, randomized controlled trial was conducted involving 325 patients who were 18 to 60 years of age and had at least 1 acute orthopaedic injury to the lower extremity or to the pelvis or acetabulum requiring operative fixation. Patients were recruited from 6 Level-I trauma centers and were screened and randomized to the CBPT program or the education program early after hospital discharge. The primary outcome was the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scale. The secondary outcomes were objective physical function tests (4-square step test, timed stair ascent test, sit-to-stand test, and self-selected walking speed test), PROMIS Pain Intensity and Pain Interference, and the Veterans RAND 12-Item Health Survey. Treatment effects were calculated using targeted maximum likelihood estimation, a robust analytical approach appropriate for causal inference with longitudinal data.

RESULTS

The mean treatment effect on the 12-month baseline change in PROMIS PF was 0.94 (95% confidence interval, -0.68 to 2.64; p = 0.23). There were also no observed differences in secondary outcomes between the intervention group and the control group.

CONCLUSIONS

The telephone-delivered CBPT did not appear to yield any benefits for patients with traumatic lower-extremity injuries in terms of physical function, pain intensity, pain interference, or general health. Improvements were observed in both groups, which questions the utility of telephone-delivered cognitive-behavioral strategies over educational programs.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Outcomes associated with a cognitive-behavioral chronic pain management program implemented in three public HIV primary care clinics

In patients with HIV/AIDS, chronic pain is common and analgesics pose serious risks. Cognitive-behavioral therapies (CBT) provide an alternative. This study evaluated feasibility and impact of a CBT-based pain management program in three public primary care clinics for HIV patients. The program included a workbook and 12-weeks of group CBT sessions. HIV-positive patients with chronic moderate to severe pain were invited to participate in the program and were assessed at enrollment, 6, 12, and 24 weeks. Despite only moderate group attendance, program enrollment was associated with significant improvements in pain intensity, pain-related functioning, anxiety and acceptance, and mental health. At 24 weeks, effect sizes for pain outcomes were -0.83 for pain intensity and -0.43 for functioning. The pattern of change in outcomes was consistent with predictions based on cognitive-behavioral theory. Effects were observed at all clinics. Adding CBT-based pain management into primary care may provide important benefits for patients with HIV/AIDS.

Home visits by specially trained nurses after discharge from multi-disciplinary pain care: A cost consequence analysis based on a randomised controlled trial

OBJECTIVES

To analyse the cost consequences of a nurse follow-up intervention for chronic non-malignant pain patients discharged from multidisciplinary pain treatment.

METHODS

The cost consequence analysis was based on a prospective, randomised controlled trial where 102 consecutive patients were randomised to either an intervention group (n=52) or a control group (n=50). During the 2-year intervention period, nurses visited patients every 4th month (7 times in total). Changes in health status were measured by the 8 SF-36 sub-scales. Intervention costs were based on prospective registrations of nurses' time use. Data on health care cost and resource use were collected retrospectively from administrative registers.

RESULTS

No statistically significant differences in health status were observed between the two groups after the 2-year intervention period. The cost of the nurse intervention programme itself was 35,000 euro (2004-prices). The average cost per patient was estimated at 668 euro per patient. During the observation period the average patient in the intervention group used other health care resources worth 4004 euro, while the average patient in the control group used 7464 euro. This difference (3460 euro, 46%) was not statistically significant.

CONCLUSION

The nurse intervention did not significantly influence patients' health status. Patients in the intervention group tended to use fewer health care resources than those in the control group and the cost of the intervention was more than balanced out by savings in other health care resources.

Evaluation of a behavioral-medical inpatient rehabilitation treatment including booster sessions: a randomized controlled study

OBJECTIVES

The aim of this randomized controlled study was to investigate whether additional psychologic interventions in the context of multidisciplinary inpatient pain treatment increases treatment efficacy compared with normal orthopedic rehabilitation. In addition, we aimed to demonstrate the additional benefit of a subsequent maintenance program in further stabilizing treatment successes.

METHODS

We randomly assigned 363 chronic back pain patients to 1 of 3 treatment conditions: traditional orthopedic rehabilitation, multidisciplinary (behavioral-medical) rehabilitation alone, and multidisciplinary rehabilitation with subsequent booster sessions. Pain disability, depression, self-efficacy, health status, life satisfaction, and coping strategies were assessed at admission, discharge, and 12 months follow-up. The completion rate was 94%.

RESULTS

All 3 treatment conditions were effective in improving core outcome measures in chronic back pain patients in the short term. The results were almost maintained at follow-up (small-to-medium within-group effect sizes). Significant advantages in favor of behavioral-medical interventions were found on almost all pain coping strategies and depression compared with traditional orthopedic rehabilitation. We found only slight advantages for the behavioral-medical treatment with subsequent booster sessions compared with the condition without a further maintenance program.

DISCUSSION

The results concerning the efficacy of the multidisciplinary treatment are in accordance with former meta-analyses. Surprisingly, the findings suggest that the presented traditional orthopedic treatment was inherently very effective. The implications of these findings are discussed with respect to the benefit of additional psychologic interventions and the benefit of aftercare approaches for chronic pain patients.