Single pain management skills class shows 'meaningful reductions' in lower back pain
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A single-session class on pain management skills was noninferior to 8-week cognitive behavioral therapy, and superior to a health education class, for pain catastrophizing in patients with chronic lower back pain, according to data.
“Chronic pain impacts tens of millions of Americans, and chronic low back pain is the most prevalent chronic pain condition,” Beth D. Darnall, PhD, of Stanford University School of Medicine, told Healio Rheumatology. “Access to non-pharmacologic pain care remains limited for many patients. Even when access is possible, multi-session treatment formats can be infeasible for patients or unwanted. Efficient and accessible solutions are needed to ensure equitable access to effective pain care.”
Writing in in JAMA Network Open, Darnall and colleagues described how they developed a single-session, 2-hour class called “Empowered Relief” to rapidly equip individuals with pain self-management skills. According to the researchers, the program “incorporates pain education, self-regulatory skills (ie, relaxation, cognitive reframing and self-soothing), and mindfulness principles.”
However, a comparison of empowered relief with cognitive behavioral therapy remains untested in a randomized clinical trial, while the durability and scope of the treatment’s impacts are unknown, they wrote. To examine how the single-class empowered relief program compares to the eight-session cognitive behavioral therapy strategy, or health education, in terms of pain catastrophizing, intensity and interference, as well as other outcomes, Darnall and colleagues conducted a randomized clinical trial.
Participants were recruited from a single academic center in the San Francisco Bay area. Inclusion criteria were axial low back pain experienced during at least one-half of days in the past 6 months, average pain intensity score of at least four on a scale of 0 to 10, English fluency, age 18 to 70 years, Pain Catastrophizing Scale score of at least 20 and the ability to attend as many as eight 2-hour sessions.
Individuals with gross cognitive impairment, radicular symptoms, previous exposure to empowered relief or cognitive behavioral therapy in the previous 3 years, current substance use disorder, medicolegal factors, suicidal ideation, or severe depression were excluded.
A total of 263 participants were randomized into three groups, with 87 enrolling in the empowered relief program, 88 treated with eight sessions of cognitive behavioral therapy and another 88 receiving health education. Participants’ self-reported data were collected at baseline, prior to treatment and at months 1, 2 and 3 following treatment, from May 24, 2017, to March 3, 2020. The primary outcome was group differences in Pain Catastrophizing Scale score 3 months after treatment, with pain intensity and interference set as priority secondary outcomes.
According to the researchers, empowered relief was noninferior to cognitive behavioral therapy for pain catastrophizing scores at 3 months (difference =1.39; 97.5% CI,– to 4.24). Meanwhile, both empowered relief (difference = –5.9; 95% CI,–8.78 to –3.01) and cognitive behavioral therapy (difference = –7.29; 95% CI, –10.20 to –4.38) were superior to health education for pain catastrophizing scores.
“We also found that the single-session pain class had broad impacts, including meaningful reductions in pain intensity, pain interference, pain-related distress, anxiety, depression, sleep disturbance and fatigue at 3 months,” Darnall told Healio Rheumatology.
Pain catastrophizing score reductions for empowered relief (–9.12; 95% CI, –11.6 to –6.67) and cognitive behavioral therapy (–10.94; 95% CI, –13.6 to –8.32) at 3 months after treatment were clinically meaningful. The score reduction for health education was –4.6 (95% CI, –7.18 to –2.01).
The researchers adjusted the between-group comparisons for baseline pain catastrophizing scores and used an intention-to-treat analysis. In this analysis, empowered relief was noninferior to cognitive behavioral therapy for pain intensity and pain interference, as well as sleep disturbance, pain bothersomeness, pain behavior, depression and anxiety. However, the empowered relief program was inferior to cognitive behavioral therapy for physical function.
“Our study provides evidence that a single-session pain relief skills class — Empowered Relief — may be a highly efficient way for some patients to gain meaningful relief,” Darnall said. “We need to offer people with ongoing pain access early access to information and skills that will help them best manage pain and related symptoms. Our current model of offering behavioral pain treatments later on — or not at all — perpetuates suffering and pain care disparities. Findings from our study point to a promising solution.”
She later added: “We hope to conduct a national comparative effectiveness study of Empowered Relief in 2022, as well as test its integration into primary care settings.”
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