Background:The aim of this study was to explore the effectiveness of Internet-delivered cognitive-behavioral therapy (iCBT) in treating fibromyalgia (FM) compared with an identical protocol using conventional group face-to-face CBT.
Methods:Sixty participants were assigned to either (a) the waiting list group, (b) the CBT group, or (c) the iCBT group. The groups were assessed at baseline, after 10 weeks of treatment, and at 3-, 6-, and 12-month follow-ups. The primary outcome measured was the impact of FM on daily functioning, as measured by the Fibromyalgia Impact Questionnaire (FIQ). The secondary outcomes were psychological distress, depression, and cognitive variables, including self-efficacy, catastrophizing, and coping strategies.
Results: In post-treatment, only the CBT group showed improvement in the primary outcome. The CBT and iCBT groups both demonstrated improvement in psychological distress, depression, catastrophizing, and utilizing relaxation as a coping strategy. The iCBT group showed an improvement in self-efficacy that was not obtained in the CBT group. CBT and iCBT were dissimilar in efficacy at follow-up. The iCBT group members improved their post-treatment scores at their 6- and 12-month follow-ups. At the 12-month follow-up, the iCBT group showed improvement over their primary outcome and catastrophizing post-treatment scores. A similar effect of CBT was expected, but the positive results observed at the post-treatment assessment were not maintained at follow-up.
Conclusions: The results suggest that some factors, such as self-efficacy or catastrophizing, could be enhanced by iCBT. Specific characteristics of iCBT may potentiate the social support needed to improve treatment adherence.
Vallejo M. A., Ortega J., Rivera J., Comeche M.I. & Vallejo-Slocker L.(2015). Internet versus face-to-face group cognitive-behavioral therapy for fibromyalgia: A randomized control trial. J Psychiatr Res. 2015 Sep;68:106-13. doi: 10.1016/j.jpsychires.2015.06.006. Epub 2015 Jun 20.
Prescription opioid misuse and addiction among chronic pain patients are problems of growing medical and social significance. Chronic pain patients often require intervention to improve their well-being and functioning, and yet, the most commonly available form of pharmacotherapy for chronic pain is centered on opioid analgesics–drugs that have high abuse liability. Consequently, health care and legal systems are often stymied in their attempts to intervene with individuals who suffer from both pain and addiction. As such, novel, nonpharmacologic interventions are needed to complement pharmacotherapy and interrupt the cycle of behavioral escalation. The purpose of this paper is to describe how the downward spiral of chronic pain and prescription opioid misuse may be targeted by one such intervention, Mindfulness-Oriented Recovery Enhancement (MORE), a new behavioral treatment that integrates elements from mindfulness training, cognitive-behavioral therapy, and positive psychology. The clinical outcomes and neurocognitive mechanisms of this intervention are reviewed with respect to their effects on the risk chain linking chronic pain and prescription opioid misuse. Future directions for clinical and pharmacologic research are discussed.
Garland, E.L. (2014). Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. Journal of Pain and Palliative Care Pharmacotherapy, 28(2), 122-129. doi: 10.3109/15360288.2014.911791.
OBJECTIVE: Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing.
METHOD: We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups.
RESULTS: Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months.
CONCLUSIONS: The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.
Lumley, M. A., Keefe, F. J., Mosley-Williams, A., Rice, J. R., McKee, D., Waters, S. J., Partridge, R. T., … Kalaj, A. (2014). The Effects of Written Emotional Disclosure and Coping Skills Training in Rheumatoid Arthritis: A Randomized Clinical Trial. Journal of Consulting and Clinical Psychology, 82, 4, 644-658.
This study investigated the effectiveness of telephone-delivered cognitive-behavioral therapy (T-CBT) in the management of chronic pain with older military veterans enrolled in VA primary-care clinics. We conducted a randomized clinical trial comparing T-CBT with telephone-delivered pain education (T-EDU). A total of 98 military veterans with chronic pain were enrolled in the study and randomized into one of two treatment conditions. Study participants were recruited from primary-care clinics at an urban VA medical center and affiliated VA community-based outpatient clinics (CBOCs). Pain management outcomes were measured at mid-treatment (10 weeks), post-treatment (20 weeks), 3-month follow-up (32 weeks), and 6-month follow-up (46 weeks). No significant differences were found between the two treatment groups on any of the outcome measures. Both treatment groups reported small but significant increases in level of physical and mental health, and reductions in pain and depressive symptoms. Improvements in all primary outcome measures were mediated by reductions in catastrophizing. Telephone-delivered CBT and EDU warrant further study as easily accessible interventions for rural-living older individuals with chronic pain.
Carmody, T. P., Duncan, C. L., Huggins, J., Solkowitz, S. N., Lee, S. K., Reyes, N., Mozgai, S., … Simon, J. A. (January 01, 2013). Telephone-delivered cognitive-behavioral therapy for pain management among older military veterans: A randomized trial. Psychological Services, 10(3), 265-275.
The importance of the bio-psychosocial model in assessment and management of chronic musculoskeletal conditions is recognized. Physical therapists have been encouraged to develop psychologically informed practice. Little is known about the process of physical therapists’ learning and delivering of psychological interventions within the practice context. The aim of this study was to investigate physical therapists’ experiences and perspectives of a cognitive-behavioral-informed training and intervention process as part of a randomized controlled trial (RCT) involving adults with painful knee osteoarthritis. A qualitative design was used. Participants were physical therapists trained to deliver pain coping skills training (PCST). Eight physical therapists trained to deliver PCST were interviewed by telephone at 4 time points during the 12-month RCT period. Interviews were audio recorded, transcribed verbatim into computer-readable files, and analyzed using Framework Analysis. Thematic categories identified were: training, experience delivering PCST, impact on general clinical practice, and perspectives on PCST and physical therapist practice. Physical therapists reported positive experiences with PCST and program delivery. They thought that their participation in the RCT had enhanced their general practice. Although some components of the PCST program were familiar, the therapists found delivering the program was quite different from regular practice. Physical therapists believed the PCST program, a 3- to 4-day workshop followed by formal mentoring and performance feedback from a psychologist for 3 to 6 months and during the RCT, was critical to their ability to effectively deliver the PCST intervention. They identified a number of challenges in delivering PCST in their normal practice. Physical therapists can be trained to confidently deliver a PCST program. The physical therapists in this study believed that training enhanced their clinical practice. Comprehensive training and mentoring by psychologists was crucial to ensure treatment fidelity.
Nielsen, M., Keefe, F. J., Bennell, K., & Jull, G. A. (January 01, 2014). Physical Therapist-Delivered Cognitive-Behavioral Therapy: A Qualitative Study of Physical Therapists’ Perceptions and Experiences. Physical Therapy, 94, 2, 197-209.
According to a recent study published in JAMA, cognitive behavior therapy (CBT) plus amitriptyline (a tricyclic antidepressant used in the treatment of migraines) may be an effective treatment for chronic migraines in children and adolescents. In the current study, researchers compared the efficacy of CBT plus amitriptyline versus headache education plus amitriptyline. Participants included 135 youth aged 10 to 17 diagnosed with chronic migraine. They were randomized to either the CBT plus amitriptyline group (n = 64) or headache education plus amitriptyline group (n = 71). Participants received either 10 CBT sessions or 10 headache education sessions involving equivalent time and therapist attention. At post-treatment, 66% in the CBT group had at least a 50% reduction in headache days versus 36% in the headache education group. At the 12-month follow up, 86% in the CBT group had at least a 50% reduction in headache days versus 69% in the headache education group. These findings support the efficacy of CBT in the treatment of chronic migraine among children and adolescents.
Powers, S. W., Kashikar-Zuck, S. M., Allen, J. R., LeCates, S. L., Slater, S. K., Zafar, M., Kabbouche, M. A., … Hershey, A. D. (December 25, 2013). Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents. Jama, 310, 24, 2622.
A recent study published in the Archives of Pediatrics & Adolescent Medicine demonstrates that a brief cognitive behavior therapy (CBT) intervention effectively treats, in the long-term, children with functional abdominal pain and improves parent’s responses to the child’s pain. This recent study investigates a randomized sample of children with functional abdominal pain (n=200) and their parents at a follow up occurring 12 months after the initial treatment. The experimental group had received a social learning and CBT intervention (SLCBT) while the control group received an education and support (ES) treatment, both lasting three sessions. The children’s symptoms and pain-coping responses were examined using standard instruments. Initial baseline measurements were collected prior to treatment.
The results from the parent study were maintained at the 12-month follow-up. Children in the SLCBT intervention group showed greater baseline to 12 month reductions in symptom severity and greater improvements in pain-coping responses as compared to those in the ES group. Moreover, parents of the children in the SLCBT group showed greater baseline to 12 month decreases in their solicitous responses to their child’s symptoms and in their maladaptive beliefs regarding their child’s pain compared to parents with children in the control group.
These results indicate that a brief CBT intervention can provide significant improvements for children with functional abdominal pain and their parents in several areas including symptom severity, coping mechanisms, and parental response. The researchers suggest that future studies test whether a longer intervention would increase efficacy of symptom reduction and coping, or if perhaps a group intervention setting would be as effective, thus reducing cost and time.
Levy, R. L., Langer, S.L., Walker, L.S., Romano, J.M., Christie, D.L., Youssef, N., DuPen, M.M., Ballard, S.A., Labus, J., Welsh, E., Feld, L.D., & Whitehead, W.E. (2012). Twelve-Month Follow-up of Cognitive Behavioral Therapy for Children With Functional Abdominal Pain. Archives of Pediatrics & Adolescent Medicine.
According to a recent study published in PAIN, group cognitive behavioral intervention (CBI) is effective in reducing low back pain (LBI) and disability over a 12-month period. The results indicate that the effects of CBI are maintained for up to an average of 34 months.
Participants (701, ages 18 and older), recruited from primary care settings in England who were experiencing at least moderately troublesome lower back pain for at least six weeks, participated in a randomized control trial. They received either 10-15 minute sessions of best-practice advice from a trained health professional or a cognitive behavioral intervention (one-hour individual assessment and six 90-minutes sessions of group therapy.) At 20-50 month follow ups, returning participants (395 participants) noted less disability and pain than the original sample. The effects of CBI are reported to reduce lower back pain and sustain reductions over a length of time ranging from an average of 34 months up to 50 months. Improvements do occur when using best-practice advice, however they are slower and often less substantial, leading to minimal impact on disability. The sustainability of CBI may be attributed to the acquisition of skills needed to challenge negative thoughts and beliefs and become more physically active.
Lamb, S. E., Mistry, D., Lall, R., Hansen, Z., Evans, D., Withers, E. J., & Underwood, M. R. (February 01, 2012). Group cognitive behavioural interventions for low back pain in primary care: Extended follow-up of the Back Skills Training Trial (ISRCTN54717854). Pain, 153, 2, 494-501.
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