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Group CBT and Education May Improve Chronic Pain Among Low-Literacy Patients

Physicians may break down therapeutic access barriers with a few simple interventions.

With Beverly E. Thorn, PhD, ABPP, and David Cosio, PhD, ABPP

Recent clinical practice guidelines1,2,3 emphasized the role of nonpharmacologic and evidence-based alternatives to pain medications, including cognitive behavioral therapy (CBT). Findings from Thorn et al,4 demonstrated that CBT and patient education about self-managing their pain may be successfully tailored to lower literacy groups of patients for the most effective outcomes.

Both approaches also have been found to lower pain intensity, improve physical function, and reduce levels of depression even beyond the treatment period. Pilot research5 has further suggested that group-administered CBT and pain education tailored for audiences with low socioeconomic status and chronic pain may be efficacious. However, access to CBT continues to be limited for many individuals living in low-income communities.4

Comparing the Two Interventions

The findings are the result of a randomized controlled trial of the two interventions compared with usual care involving approximately 300 individuals with chronic pain from lower socioeconomic groups based in western Alabama. Within-group scores for pain intensity, interference in physical function, and depression decreased substantially from pre- to post-treatment for individuals who received cognitive behavioral therapy (CBT) or patient education aimed at self-management (EDU). In a few of the patients, these improvements continued through to the follow-up period (6 months afterward). However, those in the usual-care groups did not see improvements in these measures over time.

Participants were recruited to the Learning About My Pain (LAMP) study (read more about this study in our APS 2018 Meeting Highlights) from four clinics at community health centers administered by a single health service. At each site, they were randomly assigned to receive group-based CBT, EDU, or usual care in cohorts of seven to nine participants. Overall, 95, 97, and 98 participants were enrolled and analyzed in the CBT, EDU, and usual care groups, respectively.

Primary literacy was assessed with the Wide Range Achievement Test-4 Reading subtest (WRAT-4 Reading), with 35.8% of participants reading below the fifth-grade level. To make the CBT and EDU materials more accessible, researchers lowered the literacy level of the patient workbooks to a fifth-grade reading level by “removing all ‘fancy’ words or technical jargon,” lead author Beverly E. Thorn, PhD, professor emerita of psychology at the University of Alabama, told Practical Pain Management. They also increased the font size and amount of white space in the workbook and added key illustrations. “We reduced the actual cognitive demands of the treatment, especially in CBT, by providing specific, directive, and structured skills training with audio recordings to assist people as they learned the new skills,” she said.

The CBT intervention was conducted by trained co-therapists using a treatment manual. Individuals participated in 10 weekly group sessions of 90 minutes. Likewise, co-therapists for the EDU intervention conducted 10 weekly group sessions of 90 minutes in which they provided information about pain self-management. Those in the usual care groups had parallel contact with coordinators and assessors and received periodic phone calls to encourage continued participation. Participants were interviewed during 90-minute face-to-face sessions at baseline, at 5 weeks after the start of treatment (mid-treatment), at 10 weeks (post-treatment), and at 6 months after treatment (follow-up) to evaluate chronic pain, focusing on patient perceptions of pain intensity, physical function and depression using validated measures.

Implications for Clinical Appliance

The findings suggest that CBT and pain education interventions could be added to pain management strategies either as alternatives or additions to pain medications for patients who often have limited access to nonpharmacologic pain treatments. “We have been offering low-literacy individuals CBT groups and pain education programs for the past 10 years. This patient population may have fragmented care as a result of their socioeconomic status. This can have a negative impact on their health since most pain management is self-management,” noted David Cosio, PhD, a psychologist in the pain clinic and interdisciplinary pain program at the Jesse Brown VA Medical Center in Chicago.

According to Dr. Thorn, “These treatments would be ideally suited in situations where group medical visits are already taking place for medication monitoring and prescription renewal, and could become part of the normal expectation of integrated care in such settings.” She added, “Alternatively, ongoing biomedical pain management (for example, medication management) could be made contingent on participation in self-management skills training such as that offered by these programs. These cost-effective programs would likely save on overall health care costs of more invasive treatments.”


Read about the use of CBT for insomnia in patients living with chronic pain.

Last updated on: July 29, 2019
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Behavioral Medicine: How to Incorporate CBT Into Pain Management
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