Telehealth Outreach for Chronic Back Pain
Condition: Pain; Back Pain
MeSH terms: Back Pain
Study type: Interventional

Summary: 
      Two separate double double blind, randomized, parallel groups, two-arm, 8 week clinical
      trials with 6-moth follow-up were conducted using identical inclusion/exclusion criteria and
      assessment batteries. In both studies patients had chronic low back pain of non-neoplastic
      origin. In both studies patients were randomized to one of two conditions, either a Cognitive
      Behavioral-based Therapy or a control condition, a supportive (Rogerian) psychotherapy. Both
      the cognitive-behavioral and supportive psychotherapy conditions consisted of home-based,
      telephone supported treatment, with 10 hours of contact time delivered over 8 weeks. In the
      first study (Study 1) the behavioral and Rogerian interventions were delivered by a licensed
      psychologist. In the second (Study 2) the interventions were delivered by a medical primary
      care nurse.
    

Detailed description: 
      Chronic low back pain (CLBP) is a major medical problem for the VA, affecting up to 15% of
      all veterans in primary care. Furthermore, prior surveys indicate CLBP is a leading cause of
      medical discharge of active duty personnel, and of medical disability costs. Given current
      demands on military personnel it is likely the burden of chronic pain will increase. The VA
      has adopted the Agency for Health Care Policy and Research Guidelines for evaluation of back
      pain but these guidelines do not provide specifics for true rehabilitation. It is
      acknowledged that most back pain patients are not surgical candidates, that medications
      provide only limited analgesia, and that symptom control and improved function require a
      comprehensive approach addressing the cognitive, affective, and behavioral aspects of chronic
      pain. Fortunately, structured, specific interventions to both address the multidimensional
      nature of pain and operationalize treatment principles in primary care settings are
      available. These interventions, which reflect the VA emphasis on patient-centered care, can
      be effective in reducing disability and pain, but are a frequently overlooked component of
      effective care. One reason is that most clinics lack appropriately trained psychologists.
      Moreover, even when specialists are available, the prevailing clinic-based service model is
      either too resource-intensive, or presents barriers to access.

      One approach to addressing some these barriers is the use of "telehealth" outreach. Studies
      in diverse medical disorders and some chronic pain syndromes suggest that care can be
      delivered efficiently and effectively with minimal therapist contact in home-based treatment
      models, using telephone consultation to replace clinic visits. These approaches are fully
      congruent with recent VA telehealth initiatives to improve access and cost efficiency. In VA
      Pain Clinic settings our face-to-face, 8-week, 8-hours contact time Cognitive Behavioral
      Self-Management Skills Training (CBSST) program appears to be effective in reducing
      disability and pain, and improving mood in chronic back pain. Given the scarcity of
      specialized psychologists, a second approach is to train non-specialists (eg, primary care
      medical nurse personnel) instead of psychologists to deliver treatment, to help improve
      access to the intervention.

      We conducted two double blind, randomized assignment, two-arm, parallel groups, six-month
      clinical trials. Patients with CLBP were recruited from VA San Diego primary care clinics and
      the community. Participants received either CBSST or Rogerian Psychotherapy in a home-based,
      telephone- delivered format for a total of 10 hours of therapist contact time. The
      methodological difference between the two studies was the discipline of the interventionist.
      In Study 1 the intervention was delivered by a psychologist with specific training in
      cognitive behavioral therapy; in Study 2 the intervention was was done by a medical primary
      care nurse who had been trained to deliver a version of CBSST modified to be suitable for
      delivery by an individual without specific expertise in cognitive behavioral therapy. The
      control condition was a supportive psychotherapy, again suitably modified in the case of the
      medical nurse interventionist. Assessments were conducted at baseline and at end of
      treatment, and at one, three and six months post-treatment. The primary data analytic
      strategy was an intent-to-treat analysis (last observation carried forward) of all
      participants as randomized. The primary end point was physical function (Roland & Morris
      Disability) at end of 8-week treatment; secondary end points were pain intensity (Numeric
      Rating Scale) and patient-reported clinical global impression of change. The aim of the
      research was to develop more accessible and more cost-efficient back pain treatment.

      Key Words: Back Pain, Cognitive-Behavioral Treatment, Clinical Trial
    

Intervention name(s): Cognitive Behavioral Therapy-Psychologist-Delivered; Supportive Psychotherapy-Psychologist-Delivered; Cognitive Behavioral Therapy Nurse-Delivered; Supportive Psychotherapy-Nurse-Delivered
Intervention type(s): Behavioral; Behavioral; Behavioral; Behavioral
Intervention description(s): Cognitive behavioral self-management skills training actively teaches techniques to evaluate and manage symptoms; treatment was delivered by a psychologist; Supportive Psychotherapy was based on Rogerian Therapy techniques. Rogerian therapy encourages self-identification of goals and solutions using a supportive but not didactic approach; it was administered by a psychologist; Cognitive behavioral self-management skills training actively teaches techniques to evaluate and manage symptoms; treatment was delivered by a nurse; Supportive Psychotherapy was based on Rogerian Therapy techniques. Rogerian Therapy encourages self-identification of goals and solutions using a supportive but not didactic approach; it was delivered by a nurse
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: pain; chronic pain; chronic back pain; randomized clinical trial