Telephone-based therapy and exercise appear effective for reducing chronic widespread pain

CHICAGO – Telephone-delivered cognitive behavioral therapy and an exercise program, both separately and combined, are associated with short-term positive outcomes for patients with chronic widespread pain, and may offer benefits for patients diagnosed with fibromyalgia, according to a report published Online First by Archives of Internal Medicine, one of the JAMA/Archives journals.

"In the United States, mean [average] per-patient costs (including pain and non-pain-related medication, physician consultations, tests and procedures, and emergency department visits) in the six months following a new diagnosis of fibromyalgia were $3,481," the authors write as background information in the article. "There is a need to develop clinically effective and cost-effective, acceptable interventions at a primary care level that could potentially be available to a large number of patients."

John McBeth, M.A., Ph.D., then of the Arthritis Research U.K. Epidemiology Unit, University of Manchester, England, now of the Arthritis Research U.K. Primary Care Centre, Keele University, Staffordshire, England, and colleagues conducted a randomized controlled trial to assess the effects of a telephone-based cognitive behavioral therapy, exercise, or a combined intervention among patients with chronic widespread pain.

The authors randomized 442 patients with chronic widespread pain to receive six months of telephone-delivered cognitive behavioral therapy (TCBT), graded exercise, combined intervention, or treatment as usual (control group). The primary outcome was self-rated score measuring how patients felt their health had changed since the period prior to entering the trial, which was measured using a 7-point scale on a questionnaire or telephone interview conducted by study personnel. A "positive outcome" was defined as feeling "much better" or "very much better."

After six months (end of the intervention period), 8.1 percent of participants in the control group reported positive outcomes, compared with 29.9 percent of the TCBT group, 34.8 percent of the exercise group and 37.2 percent of the combined intervention group. Results were similar at the nine-month follow-up, with 8.3 percent of participants in the control group, 32.6 percent of the TCBT group, 24.2 percent of the exercise group and 37.1 percent of the combined intervention group reporting positive outcomes.

At the six and nine-month follow-ups, the combined intervention was associated with improvements in the 6-Item Short Form Health Questionnaire physical component score and a reduction in passive coping strategies.

"This trial demonstrates short- to medium-term improvements in patients with chronic widespread pain," the authors conclude. "Whether improvements continue in the longer term should be established. These results provide encouragement that short-term improvement is possible in a substantial proportion of patients with chronic widespread pain."

(Arch Intern Med. Published online November 14, 2011. doi:10.1001/archinternmed.2011.555. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: This trial was supported by an award from Arthritis Research U.K., Chesterfield, England. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In an accompanying editorial, Seth A. Berkowitz, M.D., and Mitchell H. Katz, M.D., both of the Los Angeles County Department of Health Services, write that "non-opioid-based alternatives to chronic pain management are desperately needed."

"Fortunately, in this issue of the Archives, McBeth et al make an important contribution by demonstrating that cognitive behavioral therapy (CBT) and exercise, either alone or in combination, are superior to usual management of chronic widespread pain, a subset of chronic nonmalignant pain," the authors write. "Using CBT and exercise, however, may offer even further advantages. While most treatments for depression are safe, all medications carry adverse effects and risk adverse events."

Berkowitz and Katz also note that CBT and exercise, "represent a management strategy that puts patients firmly in charge. The skills learned in CBT, for example, are available after hours and over long weekends and do not require monthly refills. Moreover, because CBT can be administered by telephone, this intervention is convenient and can be made available to a wide range of patients."

"As practicing physicians who treat many patients with chronic pain, we welcome additional research that seeks to minimize the use of pharmacotherapy, with its unclear efficacy and attendant consequences, in favor of a regimen that focuses in a truly patient-centered way, on teaching skills for self-management of symptoms and return to meaningful lives."

(Arch Intern Med. Published online November 14, 2011. doi:10.1001/archinternmed.2011.547. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: Please see the article for additional information, including author affiliations, financial disclosures, funding and support, etc.

To contact John McBeth, M.A., Ph.D., e-mail john.mcbeth@manchester.ac.uk. To contact editorial co-author Mitchell H. Katz, M.D., call Michael Wilson at 213-240-8059 or e-mail micwilson@dhs.lacounty.gov.