Cognitive Therapy, Mindfulness-Based Stress Reduction, and Behavior Therapy for the Treatment of Chronic Pain: Predictors and Moderators of Treatment Response

John W Burns; Mark P Jensen; Beverly E Thorn; Teresa A Lillis; James Carmody; James Gerhart; Francis Keefe

doi:10.1016/j.jpain.2024.01.003

Cognitive Therapy, Mindfulness-Based Stress Reduction, and Behavior Therapy for the Treatment of Chronic Pain: Predictors and Moderators of Treatment Response

J Pain. 2024 Jan 8:104460. doi: 10.1016/j.jpain.2024.01.003. Online ahead of print.

Authors

John W Burns¹, Mark P Jensen², Beverly E Thorn³, Teresa A Lillis¹, James Carmody⁴, James Gerhart⁵, Francis Keefe⁶

Affiliations

¹ Department of Psychiatry & Behavioral Sciences, Rush University Medical Center.
² Department of Rehabilitation Medicine, University of Washington.
³ Department of Psychology, The University of Alabama.
⁴ Department of Preventive and Behavioral Medicine, University of Massachusetts Medical School.
⁵ Department of Psychology Central Michigan University.
⁶ Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine.

PMID: 38199593
DOI: 10.1016/j.jpain.2024.01.003

Abstract

Psychosocial interventions for people with chronic pain produce significant improvements in outcomes, but these effects on average are modest with much variability in the benefits conferred on individuals. To enhance the magnitude of treatment effects, characteristics of people that might predict the degree to which they respond more or less well could be identified. People with chronic low back pain (N = 521) participated in a randomized controlled trial which compared cognitive therapy, mindfulness-based stress reduction, behavior therapy and treatment as usual. Hypotheses regarding predictors and/or moderators were based on the Limit, Activate, and Enhance model; developed to predict and explain moderators/predictors of psychosocial pain treatments. Results were: 1) low levels of cognitive/behavioral function at pre-treatment predicted favorable pre- to post-treatment outcomes; 2) favorable expectations of benefit from treatment and sound working alliances predicted favorable pre- to post-treatment outcomes; 3) women benefited more than men. These effects emerged without regard to treatment condition. Of note, high levels of cognitive/behavioral function at pre-treatment predicted favorable outcomes only for people in the treatment as usual condition. Analyses identified a set of psychosocial variables that may act as treatment predictors across cognitive therapy, mindfulness-based stress reduction and behavior therapy, as hypothesized by the Limit, Activate, and Enhance model if these 3 treatments operate via similar mechanisms. Findings point toward people who may and who may not benefit fully from the 3 psychosocial treatments studied here, and so may guide future research on matching people to these kinds of psychosocial approaches or to other (eg, forced-based interventions) non-psychosocial approaches. TRIAL REGISTRATION: The ClinicalTrials.gov Identifier is NCT02133976. PERSPECTIVE: This article examines potential predictors/moderators of response to psychosocial treatments for chronic pain. Results could guide efforts to match people to the most effective treatment type or kind.

Keywords: Chronic pain; Moderators; Outcomes; Predictors; Psychosocial treatments.

Associated data

ClinicalTrials.gov/NCT02133976