Beverly E. Thorn, PhD; Joshua C. Eyer, PhD; Benjamin P. Van Dyke, MA; Calia A. Torres, MA; John W. Burns, PhD; Minjung Kim, PhD; Andrea K. Newman, MA; Lisa C. Campbell, PhD; Brian Anderson, PsyD; Phoebe R. Block, MA; Bentley J. Bobrow, MD; Regina Brooks; Toya T. Burton, DC, MPH; Jennifer S. Cheavens, PhD; Colette M. DeMonte, PsyD; William D. DeMonte, PsyD; Crystal S. Edwards; Minjeong Jeong, PhD; Mazheruddin M. Mulla, MA, MPH; Terence Penn, BS; Laura J. Smith, BA; Deborah H. Tucker, MBA *
Disclaimer: The statements presented in this work are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its board of governors, or the methodology committee.
Acknowledgment: The authors thank the many persons who assisted with this study, particularly Madison Anzelc, Jacob Baxter, Julie Cunningham, Laura M. Daniels, Julia Dodd, Courtney Harhay, Tyler Jones, Wesley Korfe, Shweta Kapoor, Megan Lyons, Hylton Molzof, Ian Sherwood, and Bryan Valladares.
Financial Support: Funded partially by a PCORI Research Award (contract 941) and partially by the University of Alabama.
Disclosures: Dr. Thorn reports grants from PCORI and indirect cost recovery for research expenses from the University of Alabama during the conduct of the study and personal fees from Guilford Publications outside the submitted work. Drs. Eyer and Burns, Mr. Van Dyke, Ms. Newman, and Mr. Penn report grants from PCORI during the conduct of the study. Dr. Campbell reports grants from the University of Alabama and PCORI during the conduct of the study. Dr. Cheavens reports personal fees from the University of Alabama during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0972.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: See . Statistical code: Not available. Data set: Available from Dr. Thorn (e-mail, email@example.com).
Requests for Single Reprints: Beverly E. Thorn, PhD, University of Alabama, 348 Gordon Palmer Hall, Tuscaloosa, AL 35487; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Thorn, Mr. Van Dyke, Ms. Torres, Ms. Newman, Ms. Block, and Mr. Mulla: University of Alabama, 348 Gordon Palmer Hall, Tuscaloosa, AL 35487.
Dr. Eyer: University of Alabama, 650 University Boulevard East, Tuscaloosa, AL 35401.
Dr. Burns: Rush University Medical Center, 1645 West Jackson Boulevard, Suite 400, Chicago, IL 60612.
Dr. Kim: Ohio State University, 127 Arps Hall, 1945 North High Street, Columbus, OH 43210.
Dr. Campbell: East Carolina University, Rawl Building Room 104, Greenville, NC 27858.
Dr. Anderson: 1303 Stagecoach Village, Little Rock, AR 72210.
Dr. Bobrow: University of Arizona, Department of Emergency Medicine, 1501 North Campbell Avenue, P.O. Box 245057, Tucson, AZ 85724.
Ms. Brooks, Dr. Burton, Ms. Edwards, and Ms. Tucker: Whatley Health Services, 2731 Martin Luther King Boulevard, Tuscaloosa, AL 35401.
Dr. Cheavens: Ohio State University, 147 Psychology Building, Columbus, OH 43210.
Dr. C.M. DeMonte: Pacific Rehabilitation Centers, 126 15th Street Southeast, Puyallup, WA 98372.
Dr. W.D. DeMonte: Franciscan Medical Pavilion, 16045 1st Avenue South, Burien, WA 98148.
Dr. Jeong: University of California, Los Angeles, 3141 Moore Hall, 457 Portola Avenue, Los Angeles, CA 90024.
Mr. Penn: University of Alabama at Birmingham, 201 Campbell Hall, Birmingham, AL 35294.
Ms. Smith: 806 West Franklin Street, Box 842018, Richmond, VA 23284.
Author Contributions: Conception and design: B.E. Thorn, J.C. Eyer, B.P. Van Dyke, C.A. Torres, J.W. Burns, L.C. Campbell, P.R. Block.
Analysis and interpretation of the data: B.E. Thorn, J.C. Eyer, B.P. Van Dyke, C.A. Torres, J.W. Burns, M. Kim, A.K. Newman, B.J. Bobrow, J.S. Cheavens, M. Jeong.
Drafting of the article: B.E. Thorn, J.C. Eyer, B.P. Van Dyke, C.A. Torres, J.W. Burns, A.K. Newman, L.C. Campbell, J.S. Cheavens.
Critical revision for important intellectual content: B.E. Thorn, J.C. Eyer, B.P. Van Dyke, C. Torres, L.C. Campbell, P.R. Block, T.T. Burton.
Final approval of the article: B.E. Thorn, J.C. Eyer, B.P. Van Dyke, C.A. Torres, J.W. Burns, M. Kim, A.K. Newman, L.C. Campbell, B. Anderson, P.R. Block, B.J. Bobrow, R. Brooks, T.T. Burton, J.S. Cheavens, C.M. DeMonte, W.D. DeMonte, C.S. Edwards, M. Jeong, M.M. Mulla, T. Penn, L.J. Smith, D.H. Tucker.
Provision of study materials or patients: B.E. Thorn, J.C. Eyer, B. Anderson, T.T. Burton.
Statistical expertise: J.C. Eyer, B.P. Van Dyke, M. Kim, M. Jeong.
Obtaining of funding: B.E. Thorn, J.C. Eyer.
Administrative, technical, or logistic support: B.E. Thorn, J.C. Eyer, C.A. Torres, L.C. Campbell, B. Anderson, P.R. Block, T.T. Burton, C.M. DeMonte, W.D. DeMonte, M.M. Mulla, T. Penn, D.H. Tucker.
Collection and assembly of data: B.P. Van Dyke, B. Anderson, P.R. Block, R. Brooks, T.T. Burton, C.M. DeMonte, W.D. DeMonte, C.S. Edwards, L.J. Smith.
Chronic pain is common and challenging to treat. Although cognitive behavioral therapy (CBT) is efficacious, its benefit in disadvantaged populations is largely unknown.
To evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care.
Randomized controlled trial. (ClinicalTrials.gov: NCT01967342)
Community health centers serving low-income patients in Alabama.
Adults (aged 19 to 71 years) with mixed chronic pain.
CBT and EDU delivered in 10 weekly 90-minute group sessions.
Self-reported, postintervention pain intensity (primary outcome) and physical function and depression (secondary outcomes).
290 participants were enrolled (70.7% of whom were women, 66.9% minority group members, 72.4% at or below the poverty level, and 35.8% reading below the fifth grade level); 241 (83.1%) participated in posttreatment assessments. Linear mixed models included all randomly assigned participants. Members of the CBT and EDU groups had larger decreases in pain intensity scores between baseline and posttreatment than participants receiving usual care (estimated differences in change scores—CBT: −0.80 [95% CI −1.48 to −0.11]; P = 0.022; EDU: −0.57 [CI, −1.04 to −0.10]; P = 0.018). At 6-month follow-up, treatment gains were not maintained in the CBT group but were still present in the EDU group. With regard to physical function, participants in the CBT and EDU interventions had greater posttreatment improvement than those receiving usual care, and this progress was maintained at 6-month follow-up. Changes in depression (secondary outcome) did not differ between either the CBT or EDU group and the usual care group.
Participants represented a single health care system. Self-selection bias may have been present.
Simplified group CBT and EDU interventions delivered at low-income clinics significantly improved pain and physical function compared with usual care.
Patient-Centered Outcomes Research Institute.
Appendix Table 1. IRB Modifications Throughout the LAMP Trial
Flow of participants through the trial with usual care, CBT, and EDU.
CBT = cognitive behavioral therapy; EDU = pain education.
Appendix Table 2. Summary of Treatment Integrity Process for the LAMP Protocol*
Table 1. Baseline Characteristics of Study Participants, by Treatment Group
Table 2. Estimated Differences in Change Scores for CBT and EDU vs. UC From Baseline to Posttreatment and Posttreatment to 6-Month Follow-up*
Predicted mean pain intensity (BPI-Intensity), physical function (BPI-Interference), and depression (PHQ-9) scores, by treatment group and time point from mixed linear models.
BPI = Brief Pain Inventory; CBT = cognitive behavioral therapy; EDU = pain education; PHQ-9 = Patient Health Questionnaire–9.
Appendix Table 3. Effect Size Estimates (Hedges δT) of Baseline to Posttreatment and Posttreatment to 6-Month Differences in Change Scores for CBT and EDU vs. UC and Associated 95% CIs*
Cumulative proportion of responders analysis of percent change in pain intensity (BPI-Intensity) scores per treatment group.
BPI = Brief Pain Inventory; CBT = cognitive behavioral therapy; EDU = pain education.
Table 3. CMI and Differences Among Treatments, by Treatment*
Appendix Table 4. Comparison of Change Estimates for Pain Intensity (BPI-Intensity Score) and Physical Function (BPI-Interference Score) to Minimally Important Change Criteria*
Appendix Table 5. Numbers (Percentages) of the Sample With PHQ-9 Scores Above the “Probable Depression” Cutoff (≥10) at Baseline, Posttreatment, and 6-Month Follow-up Compared Across Treatment Conditions
Appendix Table 6. Comparison of Estimated Effects From Linear Mixed Models to Results of Sensitivity Analyses Using Pattern-Mixture Analysis
Appendix Table 7. Effects of Dropout Dummy Variable Parameters in Sensitivity Analysis Using Pattern-Mixture Modeling*
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Katherine Rediger, D. R. Bailey Miles
Johns Hopkins Community Physicians
April 26, 2018
Cognitive "bandwidth" and treatment of chronic pain
To the editor: We appreciate Dr. Thorn and colleagues’ randomized control trial comparing literacy-adapted, simplified group cognitive behavioral therapy (CBT) to group pain education and usual care (1). As the authors point out, chronic pain is a common problem that disproportionately affects low socioeconomic status (SES) groups; therefore finding an effective intervention for these individuals is essential (1,2). Behavioral economics is a useful lens through which to examine the treatment of chronic pain in a low SES population. Individuals who face scarcity (including those struggling with poverty) are mentally taxed and may have reduced cognitive capacity or “bandwidth” (3). While cognitive capacity is traditionally thought of as fixed, research has demonstrated that multiple factors can reduce an individual’s bandwidth, including poverty (4). An individual who struggles with poverty will have decreased mental resources to devote to issues aside from finances and basic needs (4), and in the case of therapy or education, may not have the available cognitive capacity to focus if they are struggling to make ends meet. For example, we have noted that low SES patients with limited literacy struggle with the idea of differentiating thoughts, feelings, and actions, which is a seminal theory underlying CBT. This consideration of bandwidth also is important as the amount required to attend 6 or more CBT sessions, defined as an adequate dosage in the study, is considerable for a vulnerable population. We admire the 75% uptake rate of Thorn’s CBT intervention in this study and wish to highlight steps that might economize bandwidth and promote the uptake of CBT interventions in low SES patients. For example, programs can be simplified to reduce the cognitive burden on available bandwidth while still maintaining the benefits of an intervention (3). In this study, by utilizing a “literacy-adapted” CBT program, the investigators reduced required bandwidth for participants. Anecdotally, the Learning About Managing Pain modules include content that has resonated during individual CBT sessions with our low SES patients, including the connection between stress and pain, as well as the “pain and fear cycle”. Additionally, we suggest that interventions take place at the beginning of the month after individuals receive paychecks to avoid the decreased bandwidth that can occur towards the end of the month as budgets are stretched (4). Overall, we believe that this low literacy adaptation of CBT is an important step forward in treating chronic pain in a population that is disproportionately affected.1. Thorn BE, Eyer JC, Van Dyke BP, Torres CA, Burns JW, Kim M, et al. Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial. Annals of Internal Medicine. 2018 Apr 3;168(7):471. 2. Janevic MR, McLaughlin SJ, Heapy AA, Thacker C, Piette JD. Racial and Socioeconomic Disparities in Disabling Chronic Pain: Findings From the Health and Retirement Study. J Pain. 2017 Dec;18(12):1459–67. 3. Mullainathan S, Shafir E. Scarcity: Why Having Too Little Means So Much. 4. Mani A, Mullainathan S, Shafir E, Zhao J. Poverty Impedes Cognitive Function. Science. 2013 Aug 30;341(6149):976–80.
Beverly Thorn, Lisa Campbell, Benjamin Van Dyke, Andrea Newman, Calia Torres
The University of Alabama, East Carolina University
June 8, 2018
To the editor: We thank Drs. Rediger and Miles for their comments on our trial of literacy-adapted cognitive behavioral therapy (CBT) for chronic pain in disadvantaged populations (1). We appreciate them noting that our simplified materials and approaches resonate with their patients with low-socioeconomic status, and wish to respond to some of their observations. We sought to test our simplified CBT within low-income clinics, where multiple health and treatment disparities often exist. Although the multiple challenges associated with poverty can limit patients’ ability to understand and utilize psychosocial treatments, we propose that simplifying our treatments makes sense for everyone with a chronic illness. The multiple stressors (and medications) associated with chronic health conditions drain one’s cognitive capacity, leaving fewer resources available to understand, remember, and adhere to treatment regimens. Pain itself demands attention. Many individuals of all literacy and economic levels struggle with chronic illness. In our experience, this adapted intervention is more accessible to individuals from all backgrounds, including low-income, which has long been a goal of psychosocial pain treatment. Furthermore, while recognizing that poverty poses challenges, therapists took a strengths-based, collaborative stance with patients. By making patients’ strengths explicit in therapy, we empowered them to apply the skills to the realities of their own lives rather than just being mental exercises for them in session. We frequently observed how our participants brought their personal strengths to bear in applying CBT to their pain problems and supporting group members, in spite of their own economic challenges. Rediger and Miles make the suggestion to reduce session frequency and link session timing to monthly financial inflow to minimize potential interference of financial worries in treatment. Having “more month than money” is a reality for many low- and, increasingly, even middle-SES households. However, it is important to balance this reality with the need to maintain frequent enough “dosing” of treatment to achieve and maintain therapeutic gains. Further, when patients are experiencing heightened financial stress, it might be especially important to have group sessions for social support. Healthcare systems (and insurance companies) could also help by investing financially in these programs as prevention of further costly unnecessary healthcare utilization that comes from inadequate pain management. We believe that adapted-psychosocial treatments provide a foundation to guide clinicians as they meet patients where they are and build on their personal strengths to understand, learn, and apply pain-related knowledge and skills to their daily lives. 1. Thorn BE, Eyer JC, Van Dyke BP, Torres CA, Burns JW, Kim M, et al. Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial. Annals of Internal Medicine. 2018 Apr 3;168(7):471.
Thorn BE, Eyer JC, Van Dyke BP, Torres CA, Burns JW, Kim M, et al. Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial. Ann Intern Med. ;168:471–480. doi: 10.7326/M17-0972
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Published: Ann Intern Med. 2018;168(7):471-480.
Published at www.annals.org on 27 February 2018
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