1. 2022;25;E959-E968Nurse-Supported Web-Based Cognitive Behavioral Therapy for Chronic Musculoskeletal Pain: A Randomized Controlled Trial
   Randomized Controlled Trial
   Rami Diab, MD, Rebecca Bomar, MD, James Slaven, MS, Sebastian Kaplan, PhD, and Dennis Ang, MD.

BACKGROUND: Web-based cognitive behavioral therapy (CBT) has increased access to effective pain management. Though efficacy of web-based and face-to-face CBT may be comparable, fewer studies have examined whether remote clinical support in addition to web-based CBT can improve pain-related outcomes.

OBJECTIVES: The objectives of this study were to determine if the addition of phone-based support to web-based CBT could enhance pain-related outcomes in patients with chronic musculoskeletal pain (CMP).

STUDY DESIGN: Randomized controlled clinical trial.

SETTING: The internal medicine and rheumatology clinics at Atrium Health Wake Forest Baptist.

METHODS: Patients were recruited from a major academic medical center. Sixty patients were randomized to web-based CBT with 6 phone calls (nurse support group, n = 30) vs web-based CBT alone (control group, n = 30). The purpose of the calls was to enhance patients’ engagement in the online program. All patients had access to the program from baseline to week 16. Outcome measures were collected at baseline, week 8, and week 16. Adjusting for baseline measurements, analysis of covariance  was used to determine within- and between-group differences.

RESULTS: Both nurse support and control groups demonstrated significant within-group improvements in Brief Pain Inventory (BPI) pain interference (-1.3 [-2.0, -0.7, P < 0.05] and -1.7 [-2.3, -1.0, P < 0.05]), BPI pain intensity (-1.2 [-1.7, -0.6, P < 0.05] and -1.3 [-1.8, -0.8, P < 0.05]), Patient-Reported Outcomes Measurement System (PROMIS) pain interference (-5.0 [-6.9, -3.2, P < 0.05] and -5.4 [-7.2, -3.5, P < 0.05]), and PROMIS pain intensity (-1.4 [-2.0, -0.9, P < 0.05] and -1.4 [-1.9, -0.8, P < 0.05]), respectively. However, there were no significant between-group differences amongst the 2 treatment groups in all measures, except PROMIS sleep disturbance that favored the nurse support group (50.5 ± 1.3 vs 54.3 ± 1.3, P < 0.05).

LIMITATIONS: Small sample size and lack of treatment fidelity assessment.

CONCLUSIONS: Web-based CBT was effective with and without motivational support from nurses. Phone-based support did not enhance pain-related outcomes of web-based CBT. If confirmed in a larger study, web-based CBT without motivational support may be considered as a low-cost treatment intervention for patients with CMP.

KEY WORDS: Chronic musculoskeletal pain, web-based cognitive behavioral therapy, Brief Pain Inventory pain interference, BPI pain intensity, Patient-Reported Outcomes Measurement System pain interference, PROMIS pain intensity, Pain Catastrophizing Scale, painTRAINER program, Patient Health Questionnaire 8-Item Depression Scale