Research Paper

Cognitive therapy, mindfulness-based stress

reduction, and behavior therapy for the treatment of
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chronic pain: randomized controlled trial

John W. Burnsa,*, Mark P. Jensenb, Beverly Thornb, Teresa A. Lillisc, James Carmodyd, Andrea K. Newmane,
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Francis Keefef

Abstract
Trials of cognitive therapy (CT), mindfulness-based stress reduction (MBSR), and behavior therapy (BT) suggest that all 3 treatments
produce reductions in pain and improvements in physical function, mood, and sleep disturbance in people with chronic pain
conditions. Fewer studies have compared the relative efficacies of these treatments. In this randomized controlled study, we compared
CT, MBSR, BT, and treatment as usual (TAU) in a sample of people with chronic low back pain (N 5 521). Eight individual sessions were
administered with weekly assessments of outcomes. Consistent with the prior work, we found that CT, MBSR, and BT produced similar
pretreatment to posttreatment effects on all outcomes and revealed similar levels of maintenance of treatment gains at 6-month follow-
up. All 3 active treatments produced greater improvements than TAU. Weekly assessments allowed us to assess rates of change; ie,
how quickly a given treatment produced significant differences, compared with TAU, on a given outcome. The 3 treatments differed
significantly from TAU on average by session 6, and this rate of treatment effect was consistent across all treatments. Results suggest
the possibility that the specific techniques included in CT, MBSR, and BT may be less important for producing benefits than people
participating in any techniques rooted in these evidence-based psychosocial treatments for chronic pain.
Keywords: Comparative treatments, Outcomes, Rates of change, Chronic low back pain

1. Introduction “Superiority” of beneficial effects may be defined in at least 3

Treatments such as behavior therapy (BT), cognitive therapy (CT), ways, including whether a particular treatment (1) produces
and mindfulness-based stress reduction (MBSR) have been greater improvements in outcomes, (2) produces improvements
shown to produce reductions in pain and improvements in at a faster rate than other treatments, or (3) demonstrates greater
durability of benefits. However, results of comparative outcome
physical function, mood, and sleep quality in people with chronic
pain.9,17,40 Trials of these treatments have focused on testing studies for psychosocial chronic pain treatments generally
efficacy by comparing treatments with largely inert control suggest that different treatments have similar effects on primary
conditions (eg, treatment as usual [TAU]). Although this conven- outcomes. Many of these—especially early—studies used
tional practice is an important first step, this approach does not relatively small sample sizes and are underpowered to detect
address the issue of whether existing or new treatments surpass even medium between-group differences in out-
one another on certain benchmarks. Comparative outcome comes.18,23,27,32,34,38,39,43,45,47 It is possible, therefore, that
studies between 2 or more active treatments conducted to some of the observed treatment group differences were non-
address this issue are relatively few in number. significant because of inadequate power to detect significant
differences.
Three recent comparative outcome studies used larger
samples. Cherkin et al.7 compared cognitive behavioral therapy
Sponsorships or competing interests that may be relevant to content are disclosed (CBT) with MBSR with usual care (CBT: n 5 113; MBSR: n 5 116;
at the end of this article.
a
and usual care: n 5 113), Thorn et al.37 compared CBT with pain
Department of Psychiatry and Behavioral Sciences, Rush University Medical
education with usual care (CBT: n 5 95: pain education: n 5 97;
Center, Chicago, IL, United States, b Department of Rehabilitation Medicine,
University of Washington, Seattle, WA, United States, c Department of Psychology, and usual care: n 5 98), and Lumley et al.26 compared CBT with
the University of Alabama, Tuscaloosa, AL, United States, d Division of Preventive emotional awareness and expression therapy with pain educa-
and Behavioral Medicine, University of Massachusetts Medical School, Worcester, tion (CBT: n 5 75; EAET: n 5 79; and pain education: n 5 76).
MA, United States, e Department of Rehabilitation Medicine, University of Still, all 3 studies found that different psychosocial treatments
Washington, Seattle, WA, United States, f Department of Psychiatry and Behavioral
Sciences, Duke University School of Medicine, Durham, NC, United States
produced largely similar effects on primary outcomes.
In the present study, we compared CT (n 5 129), mindfulness-
*Corresponding author. Address. Department of Psychiatry and Behavioral
Sciences, Rush University Medical Center, 1645 W. Jackson Blvd, Suite 400, based stress reduction (MBSR, n 5 143), BT (n 5 120), and TAU
Chicago, IL 60612, United States. Tel.: 312 942 0379. E-mail address: john_burns@ (n 5 129) in a sample of people with chronic low back pain.
rush.edu (J.W. Burns). Treatment consisted of 8 weekly individual sessions. Although the
PAIN 163 (2022) 376–389 study was adequately powered to reveal significant medium
© 2021 International Association for the Study of Pain effect size differences between treatment conditions, based on
http://dx.doi.org/10.1097/j.pain.0000000000002357 the predominant finding emerging from comparative studies, we

376
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 February 2022
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did not expect to find significant pretreatment to posttreatment 2.2. Procedure

differences between the 3 active treatments on the 5 outcome
Potential participants underwent a brief phone screen to determine
domains.
eligibility. If they were eligible and agreed to participate, a baseline
Instead, this study focused on 2 of the other metrics regarding
assessment appointment was made. During the assessment visit,
differential outcomes, mentioned above. First, we examined the
an RA interviewed the participant regarding inclusion and exclusion
relative rates in which change occurred between the active
criteria and the process of randomization was explained to the
treatments by assessing all outcomes weekly during the 8-week
participant. Written consent was obtained, after which pretreat-
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treatment. This strategy allowed us to examine rates of change

ment assessments were completed. They were then randomly
during treatment across each treatment and relative to TAU.
assigned to treatment condition using a customized program
Second, we wanted to highlight how durability of improvements
designed by our statistician. After these assessments, participants
may be explicitly considered as another index of superiority. To
were informed of their treatment condition by an unblinded
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this end, like most outcome studies, we assessed outcomes at a

research staff member. It was explained to participants that phone
6-month follow-up.
assessments would occur within 48 hours of each session. For
participants assigned to the TAU condition, they were told that they
would also participate in the weekly phone assessments. The
2. Methods personnel conducting these assessments were blind to participant
2.1. Participants treatment condition. The 8 therapy sessions were scheduled for
the CT, MBSR, and BT participants, and the 8 phone assessments
Figure 1 depicts the study structure and indicates the number of
were scheduled for the TAU participants.
participants who completed each part of the study and who were
Each session was 90 minutes in length, and they were
ineligible, withdrew, or declined to participate. Participants were
conducted in an individual format. Sessions for all treatment
recruited through referrals from staff at the University Pain Center,
conditions followed the same general format: (1) review of
Midwest Orthopedic Clinic and Neurosurgery Clinic at Rush
previous week’s session, (2) homework review, (3) session
University, and at Clinics at the Duke University Medical Center
treatment objectives, and (4) assign homework and conduct
Pain Clinic (eg, Pain Clinic, Spine Clinic, Neurosurgery Clinic, and
postsession assessments. Participants attended a brief visit at 6-
Orthopedic Clinic). Flyers were posted at community physician
month posttreatment.
waiting rooms, and local newspaper ads were placed. All
procedures were approved by the Rush University and Duke
University IRBs. Recruitment ran from December 1, 2014, to 2.3. Treatments
March 1, 2019, and follow-up was completed October 18, 2019. All treatments consisted of 8 weekly 90-minute individual
Using medical clinic and community physician referrals and ads sessions. For each of the 3 active conditions, the content of
allowed for recruitment of a broad array of patients. Each each session was based on a standardized treatment manual.
participant received up to $300 reimbursement for time and effort Manuals contained detailed session by session information,
on the assessments and to defray travel expenses. The instructions for therapists, and patient handouts. Manuals were
ClinicalTrials.gov Identifier is NCT02133976. based on those used in our prior studies of patients with
The inclusion criteria were as follows: (1) significant daily chronic persistent pain.5,22,36
pain intensity (rated as being at least 4 on average on a 10-point
scale; see below) and interference in performing daily activities due
2.3.1. Behavioral Therapy
to pain (rated as being at least 3 on a 6-point scale; see below) for at
least 6 months; (2) musculoskeletal pain of the low back and/or leg The BT protocol taught patients that when pain persists,
pain which may be related to the history of degenerative disk learned, maladaptive patterns of daily activity often develop
disease, spinal stenosis, or disk herniation (radiculopathy sub- (ie, “pain behaviors”)16 such as spending much time resting or
category), or muscular or ligamentous strain (chronic myofascial reclining and decreasing their involvement in pleasant and
pain subcategory); and (3) age between 18 and 80 years. The meaningful activities. The goals of BT were to help patients
exclusion criteria were as follows: (1) meet criteria for alcohol or better understand how activity patterns can contribute to pain-
substance abuse problems, (2) meet criteria for past or present related problems and to learn ways to increase their involvement
psychotic or bipolar disorders, (3) inability to understand English in activities that are important and meaningful (ie, increase “well
well enough to complete questionnaires or to participate in therapy, behaviors”).16 Patients were systematically taught how to work
(4) active suicidal ideation with intent, and (5) pain because of toward goals in areas of activity affected by pain. To enhance
cancer, rheumatoid arthritis, migraine or tension headache, their awareness of activity patterns, they kept a daily activity
fibromyalgia, or complex regional pain syndrome. Table 1 diary. They learned to set and track completion of daily activity
describes demographic characteristics of the sample. goals that were measurable and realistic. Patients were taught
Inclusion and exclusion criteria were assessed by the review of how to use a “quota system” (the activity-rest cycle) to increase
medical records by study physicians and a brief psychosocial “uptime” (time spent not reclining). An initial quota for uptime
history—including administration of relevant items from the Mood that they know they can manage despite pain was set (eg, 20
Disorder, Psychotic Screening, and Substance Use Disorders minutes walking and standing per hour). Participants were
Modules of the Structured Clinical Interview for DSM-IV Axis I taught how to reward themselves with a rest break (eg, 5
Disorders—Non-Patient Edition (SCID-IV/NP)15 by study re- minutes of sitting) after reaching the quota. During treatment,
search assistants. General health was assessed, and information the uptime activity quota was increased. Second, pleasant
was gathered about the circumstances of the onset of low back activity scheduling was used to increase the level and range of
pain, the sequence of events in medical intervention to date, daily reinforcing activities. Here, patients identified activities they
exacerbating and ameliorating factors, medications used cur- enjoy (eg, visiting friends), find meaningful (eg, helping others),
rently and in the past, previous diagnostic modalities used, and or that provided a sense of mastery (eg, learning to draw) and
previous medical interventions and their impact. then learned how to use goal setting to schedule and track levels

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Figure 1. CONSORT diagram.

of pleasure related to these accomplishments. Patients were skills, they were taught to identify possible problems and
trained in brief relaxation and taught how to use brief relaxation develop solutions to meet CT goals. Finally, patients de-
sessions (eg, 2-5 minutes) to reward their accomplishment of veloped a written maintenance plan that included a list of
their activity goals. To help patients deal with obstacles, they short-term and long-term goals for applying cognitive restruc-
were taught problem-solving skills to meet behavior change turing and a plan for dealing with possible setbacks in their
goals. Patients were also trained in communication skills to cognitive change efforts.
enable them to communicate more effectively with others about
the progress they were making and problems they were
2.3.3. Mindfulness-based stress reduction
experiencing. Finally, patients developed a written maintenance
plan that included a list of short-term and long-term activity Participants assigned to the MBSR condition received training
goals and a plan for dealing with possible setbacks. in mindfulness through (1) body scan meditation, a gradual
moving of attention through the body, accompanied by
awareness of bodily sensations including sensations of
2.3.2. Cognitive Therapy
breathing while in a lying position; (2) sitting meditation,
Cognitive therapy (also known as cognitive restructuring)35 focusing on awareness of breathing, bodily sensations,
was used to help patients recognize the relationships between thoughts, and emotions, while sitting on a chair or cushion;
thoughts, feelings, and behaviors. These techniques helped and (3) gentle movement exercises intended to develop
patients (1) identify automatic pain-related thoughts; (2) awareness (mindfulness) during movement. Each session
evaluate automatic thoughts for accuracy, identify sources of included practice of one or more of these techniques. In-
distorted thoughts, and recognize connection between auto- class didactic material and discussion of patients’ experiences
matic thoughts and emotional/physical shifts; (3) challenge of developing and applying mindfulness in everyday life were
negative, distorted automatic thoughts using “evidence”; (4) also part of each session. In-class activities included sugges-
develop new realistic alternative cognitive appraisals re- tions for application of mindfulness as a method for responding
sponses; and (6) practice applying new rational appraisals positively to stress, dealing with the challenges of pain, and
and beliefs. To help patients deal with obstacles in applying CT exercises focusing on the challenges and achievements

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Table 1
Baseline characteristics of study participants by the treatment group.
Demographics TAU (n 5 129) BT (n 5 120) CT (n 5 129) MBSR (n 5 143) All (n 5 521)
Mean age in years (SD) 52.78 (11.99) 53.39 (12.27) 52.71 (12.85) 52.71 (11.68) 52.88 (12.16)
Female, n (%) 77 (59.7) 69 (58) 72 (55.8) 83 (58) 301 (57.9)
Education, n (%)
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,High-school degree 6 (4.7) 9 (7.5) 8 (1.5) 13 (9.1) 36 (6.9)

High-school diploma 28 (21.7) 24 (20) 23 (18) 21 (14.7) 96 (18.5)
Trade/vocational/technical degree or some 49 (38) 51 (42.5) 46 (35.9) 43 (30.1) 189 (36.3)
college
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4-Year degree 32 (24.8) 20 (16.7) 35 (27.3) 37 (25.9) 124 (23.8)

Postgraduate education 14 (10.9) 16 (13.3) 16 (12.5) 29 (20.3) 75 (14.4)
Race, n (%)
Black/African American 62 (48.1) 63 (52.5) 70 (54.3) 71 (49.7) 266 (51.1)
White 46 (35.7) 41 (34.2) 48 (37.2) 55 (38.5) 190 (36.5)
Multiracial 11 (8.5) 8 (6.7) 6 (4.7) 11 (7.7) 36 (6.9)
Other races 10 (7.8) 8 (6.7) 5 (3.9) 6 (4.2) 29 (5.6)
Ethnicity, n (%)
Hispanic/Latino 22 (17.1) 9 (7.5) 6 (4.7) 10 (7) 47 (9)
Non-Hispanic/Latino 107 (82.9) 111 (92.5) 123 (95.3) 133 (93) 474 (91)
Marital status
Single 54 (41.9) 43 (35.8) 53 (41.1) 48 (33.6) 198 (38)
Married 42 (32.6) 44 (36.7) 48 (37.2) 64 (44.8) 198 (38)
Separated/divorced/widowed 33 (25.6) 33 (27.5) 28 (21.7) 31 (21.7) 125 (24)
Chronic pain history
Mean years of pain (SD) 10.82 (9.58) 12.97 (12.29) 12.08 (11.19) 11.11 (10.81) 11.70 (10.98)
Pain sites
Lower back/lumbar spine/sacrum/coccyx 87 (67.4) 80 (66.7) 71 (55) 82 (57.3) 320 (61.4)
Lower limbs/legs 11 (8.5) 14 (11.7) 14 (10.9) 18 (12.6) 57 (10.9)
Pain present in 31 sites 23 (17.8) 20 (16.7) 30 (23.3) 31 (21.7) 104 (20)
Other sites* 8 (6.2) 6 (5) 14 (10.8) 12 (8.4) 40 (7.7)
Pain treatment, n (%)
Opioids 34 (23.4) 24 (22) 28 (23.3) 36 (26.7) 122 (25.2)
Synthetic opioids 15 (12.5) 23 (21.1) 26 (21.7) 28 (20.7) 92 (19)
NSAIDs 67 (55.8) 54 (49.5) 72 (60) 73 (54.1) 266 (55)
Acetaminophen 12 (10) 18 (16.5) 19 (15.8) 26 (19.3) 75 (15.5)
Topical 10 (8.3) 15 (13.8) 17 (14.2) 20 (14.8) 62 (12.8)
Gabapentin 22 (18.3) 22 (20.2) 33 (27.5) 24 (17.8) 101 (20.9)
Anxiolytic (for pain) 0 (0) 1 (0.9) 2 (1.7) 2 (1.5) 5 (1)
Antidepressant (for pain) 12 (10.1) 5 (4.6) 9 (7.6) 9 (6.8) 35 (7.3)
Sleep medication (for pain) 3 (2.5) 2 (1.8) 6 (5.1) 4 (3) 15 (3.1)
Antiseizure (for pain) 1 (0.8) 1 (0.9) 1 (0.8) 1 (0.8) 4 (0.8)
Muscle relaxant (for pain) 34 (28.6) 30 (27.5) 40 (33.9) 40 (30.3) 144 (30.1)
* Head/face/mouth (n 5 1); cervical region (n 5 19); upper shoulder/upper limbs (n 5 14); thoracic region (n 5 4); abdominal region (n 5 1); pelvic region (n 5 1).
BT, behavioral therapy; CT, cognitive therapy; MBSR, mindfulness-based stress reduction; TAU, treatment as usual.

patients experience in integrating mindfulness into their lives 2.4. Study therapists, therapist training, adherence,
and the stressful situations they encounter. Additional discus- and quality
sion focused on stress reactivity. Patients were taught 2.4.1. Study therapists
problem-solving skills for identifying possible problems and
developing solutions for dealing with obstacles related to All study therapists were postdoctoral level clinical psychologists
practicing mindfulness. Finally, patients developed a written with prior experience delivering psychosocial interventions for
maintenance plan that included a list of short-term and long- pain. Over the course of the five-year study, 10 therapists were
term goals for applying mindfulness methods and a plan for trained to administer all 3 active treatments. We chose not to
dealing with possible setbacks. assign one therapist to perform only one treatment to avoid
confounding results of condition with results because of quality of
therapists. Instead, we closely monitored treatment integrity with
2.3.4. Treatment as usual
procedures described below.
Participants assigned to TAU did not receive any additional
psychosocial treatment beyond the other treatments they were
2.4.2. Therapist training
receiving before enrolling in this study. Treatment as usual
participants continued with their ongoing treatment regimens for All study therapists received training before conducting treatment
pain, including psychotropic and analgesic medications. sessions with study subjects. Initial training consisted of a 4-day

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J.W. Burns et al. 163 (2022) 376–389 PAIN®

didactic and experiential course conducted by the authors. research.46 In the present sample, the Cronbach’s alpha was
Therapists were provided detailed manuals and outlines of 0.88 at the baseline assessment.
treatment protocols, and the treatment strategies were taught
by didactic instruction and role-play of common scenarios. All
instruction sessions were digitally videotaped for reference and/ 2.6. Power analysis
or education of new therapists. Therapists were certified to deliver Because a closed form approximation of power calculations
each treatment by having supervisors (ie, the authors) rate audio- would be difficult to derive, we conducted a series of mathemat-
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recordings of practice role-play sessions before their working with ical simulations under a variety of situations (eg, different effect
study participants. Mastery of each protocol was required for sizes, extent of missing data, and assuming each theoretical
therapists to deliver treatment in the research protocol. model is true). Simulations were informed by our experience with
clinical trials and the outcomes under study. We originally planned
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2.4.3. Procedures to ensure consistency of treatment to recruit 460 participants, assuming 15% attrition. Assuming that
the TAU group could still exhibit a small reduction in pain
To ensure that the study therapists consistently followed the interference (d 5 0.10 SD pre–post change), whereas the other
appropriate treatment protocol, 4 steps were taken: (1) use of a treatments would exhibit larger effects (d;0.85), the omnibus
detailed treatment manual; (2) weekly supervision sessions; (3) tests of intervention effectiveness had adequate statistical power
audio recording of sessions for treatment adherence ratings (see (power $ 0.90) under all of the considered patterns of missing
below), with these recordings and feedback from the adherence data, even taking into account a 15% attrition rate.
raters reviewed during the weekly supervision meetings con-
ducted by the authors; and (4) provision of therapist feedback on
treatment consistency and further didactics and role plays to 2.7. Statistical analysis
correct “drift” if needed.
2.7.1. Primary analyses
Given the longitudinal and nested nature of the data (observations
2.4.4. Treatment adherence and quality
[level I] nested within participants [level II]), linear mixed models
Treatment adherence refers to the extent to which a therapist were conducted to examine (1) within-group and between-group
uses interventions prescribed by a protocol.41 Treatment quality changes in outcomes over time from baseline through posttreat-
refers to therapist competence in delivering the treatment. A total ment (Session #8), (2) within-group and between-group changes
of 72 sessions (20%) were rated by an author and a research from posttreatment to 6-month follow-up, and (3) within-group
assistant. The Therapy Adherence and Competence Scale is an and between-group changes from baseline through 6-month
adapted version of the Cognitive Adherence and Competence follow-up. Intent-to-treat procedures were conducted using
Scale2 and was used to measure adherence and quality of linear mixed models. These models were estimated with full
treatment. Adherence ratings were provided on the basis of maximum likelihood estimation methods; a procedure which
demonstrated delivery of unique elements and treatment allows all randomly assigned participants to be included in
components for each session. The mean adherence rating was analyses, thereby yielding unbiased parameter estimates for
98%. Each session received a quality rating based on a 4-point missing data (MCAR/MAR).1,6,14,33
scale with end points ranging from “0 5 poor to 3 5 excellent.”
The mean quality rating was 2.03 (SD 5 0.13), indicating that
ratings of all 3 conditions were in the good to excellent range. 2.7.2. Group 3 Time analyses
To determine whether groups differed significantly in degrees of
change in outcomes variables over time, linear mixed models that
2.5. Measures
included a cross-level interaction between group (level II factor;
We evaluated the effects of the treatments on 5 outcome BT, CT, MBSR, and TAU) and time (level I, covariate) were
domains: pain interference (primary outcome), pain intensity, estimated with a diagonal covariance structure and included a
depressive symptoms, physical function, and sleep disturbance fixed and random intercept for each outcome. Significant Group
(secondary outcomes). The Pain Interference Subscale of the 3 Time interactions were dissected by estimating pairwise
Multidimensional Pain Inventory24 assessed interference with comparison linear mixed models for each group pairing (BT vs
general functioning due to pain. The scale has shown excellent TAU; CT vs TAU; MBSR vs TAU; BT vs CT; BT vs MBSR; and CT
psychometric characteristics in past research.29 In the present vs MBSR). Those comparisons with a significant interaction were
sample, the Cronbach’s alpha was 0.92 at the baseline then plotted and probed to determine the significance of simple
assessment. Pain intensity was assessed with a 0 to 10 numerical slopes and the region of significance for the interaction.30
rating scale of average pain over the past week.20 It also shows
excellent psychometric characteristics. Depressive symptoms
2.7.3. Regions of significance
were assessed with the Center for Epidemiologic Studies–
Depression (CESD) Scale Short Form, also reported to have Analyzing regions of significance allowed us to examine the relative
excellent psychometric qualities in past research.8 In the present rates in which the change occurred between the active treatments.
sample, the Cronbach’s alpha was 0.83 at the baseline Although the treatments may produce similar degrees of change
assessment. The level of physical activity was assessed with by the end of treatment, a given treatment may produce the final
the PF-10 Physical Functioning scale from the SF36,42 again, a degree of posttreatment change before the final session, whereas
psychometrically excellent measure. In the present sample, the another treatment may not produce this degree of change until the
Cronbach’s alpha was 0.88 at the baseline assessment. Sleep final session. The former treatment may be seen as superior to the
disturbance was assessed with the 6-item the Patient-Reported other, slower treatment for producing the final level of pretreatment
Outcomes Measurement Information System Sleep Disturbance to posttreatment effects sooner and thus incurring less cost and
Scale. It has shown excellent psychometric characteristics in past patient burden. We hypothesized that one or more treatments

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 February 2022
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· Number 2 www.painjournalonline.com 381

could produce more rapid change than the other treatment(s). A third series of multilevel models were conducted to evaluate
“Rate of change” is defined here as how quickly a given treatment baseline to 6-month follow-up effects. These analyses were
will produce significant differences compared with TAU on a given conducted in a similar fashion to the baseline to posttreatment
outcome. For instance, CT may significantly differ from TAU on pain analyses.
intensity changes by session 5, whereas BT may not differ from
TAU until session 8. Such effects could be taken as evidence that
CT was superior to BT on this new metric. 3. Results
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3.1. Sample description

2.7.4. Within-group analyses As presented in Table 1, slightly more than half of the participants
Any significant interactions were further dissected to determine were Black/African American (51%), women (58%), and had an
average age of 52.9 years (SD 5 12.2). Over a third of the sample
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changes in outcomes over time for each group. Individual linear

mixed models were estimated for each group and outcome with a had at least a college education (38%) and were married (38%).
diagonal covariance structure and included a fixed and random Chronic pain duration was 11.7 years on average (SD 5 11.0).
intercept and a fixed effect of time (level I, covariate). Treatment groups did not differ significantly on any demographic
or pain-related variable. Means and SDs of all outcome variables
at baseline are shown in Table 2. There were no significant
2.7.5. Between-Group Effect Sizes differences between treatment conditions on these variables.
In addition, following recommendations by Feingold,13 effect
sizes for differences between treatments and TAU on outcome
measures at session 8 were calculated by transforming the 3.2. Linear mixed model treatment effects on outcomes
across eight sessions
coefficient of the slope difference into a standardized mean
difference (Cohen’s d): Figures 2–6 display the marginal means and standard errors
d 5 (b 3 duration)/SD computed by the linear mixed models for values at baseline, all 8
where b is the unstandardized coefficient of the slope sessions, and six-month follow-up for the CT, BT, MBSR, and
difference (interaction term), duration is the length of the study TAU groups.
based on units associated with the coefficient (# of sessions
minus one), and SD is the pooled within-group standard
3.2.1. Pain interference
deviation. Confidence intervals for these effect sizes were
calculated following recommendations from Feingold14 which A significant Group 3 Time interaction was observed for Pain
substitute the lower and upper confidence interval of the Interference Scale scores (F[3,1863.73] 5 4.61 P , 0.05). Pairwise
unstandardized slope difference coefficient in the following comparison analyses revealed no significant Group 3 Time
equations: interactions among treatment groups for Pain Interference Scale
LCLd 5 (LCLb 3 duration)/SD scores (range B 5 [20.01] to [20.02]), indicating that the 3 active
UCLd 5 (UCLb 3 duration)/SD treatments had similar effects on pain interference changes.
where LCLb is the lower confidence interval of the un- Significant Group 3 Time interactions were observed when each
standardized slope difference coefficient (interaction term), UCLb treatment group was compared with TAU (Table 3). Although all 4
is the upper confidence interval of the unstandardized slope groups showed significant reductions in Pain Interference over
difference coefficient (interaction term), duration is the length of time, the BT, CT, and MBSR groups showed larger reductions
the study based on units associated with the coefficient (# of when compared with the TAU group. The region of significance
sessions minus one), and SD is the pooled within-group standard calculated for each interaction indicated that Pain Interference
deviation. scores from MBSR participants differed significantly from TAU
participants beginning at session 7, BT participants did not differ
significantly from TAU until session 8, and CT participants did not
2.7.6. Posttreatment to 6-month follow-up analyses and differ significantly from TAU participants until session 8 (d 5 0.26).
baseline to six-month analyses Effect sizes comparing TAU values at session 8 with the other
A second series of multilevel models were conducted to groups ranged from Cohen’s d 5 0.25 to d 5 0.26.
evaluate posttreatment to six-month follow-up effects. Linear
mixed models that included a 2-way interaction between group
3.2.2. Pain intensity
(level II factor; BT, CT, MBSR, and TAU) and time (level II factor)
were estimated with a diagonal covariance structure and A significant overall Group 3 Time interaction was observed for
included a fixed and random intercept for each outcome. Pain Intensity ratings (F[3,1648.08] 5 11.63 P , 0.05).
Significant overall Group 3 Time interactions were dissected by Pairwise comparison analyses revealed no significant Group
estimating pairwise comparison linear mixed models for each 3 Time interactions among the 3 active treatment groups
group pairing (BT vs TAU; CT vs TAU; MBSR vs TAU; BT vs CT; (range B 5 20.01 to 20.03), indicating that the active
BT vs MBSR; and CT vs MBSR). Significant pairwise interac- treatments had similar effects on pain intensity changes.
tions were plotted and probed in a means-as-outcomes Significant Group 3 Time interactions were observed when
model.30,31 Within-group effects were estimated with linear each treatment group was compared with TAU. As shown in
mixed models for each group separately with a diagonal Table 3, all 4 groups showed significant reduction in Pain
covariance structure, a fixed and random intercept, and a fixed Intensity ratings over the 8 sessions. However, the BT, CT, and
effect of time (level II factor). Evaluation of significant within- MBSR groups showed larger reductions in Pain Intensity
group effects were based on comparing the estimated marginal ratings when compared with the TAU group. The region of
means from these models at posttreatment to six-month significance calculated for each interaction indicated that Pain
follow-up. Intensity ratings from BT participants differed significantly from

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Table 2
Baseline outcome measures, means (SDs).
Baseline Outcome Mean (SD) TAU (n 5 129) BT (n 5 120) CT (n 5 129) MBSR (n 5 143) All (n 5 521)
Pain interference 3.67 (1.24) 3.69 (1.36) 3.72 (1.21) 3.64 (1.31) 3.68 (1.27)
Pain intensity 4.54 (2.11) 5.68 (2.08) 5.48 (2.14) 5.51 (2.16) 5.55 (2.12)
Physical function 18.88 (4.97) 18.82 (5.14) 18.72 (4.86) 19.13 (4.52) 18.88 (4.85)
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Depressive symptoms 9.38 (6.04) 9.46 (5.55) 9.86 (5.95) 9.24 (5.68) 9.48 (5.81)
Sleep disturbance 57.12 (8.71) 55.09 (8.14) 56.45 (9.43) 54.95 (9.04) 55.89 (8.88)
BT, behavioral therapy; CT, cognitive therapy; MBSR, mindfulness-based stress reduction; TAU, treatment as usual.
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TAU participants beginning at session 5, that CT participants (d 5 20.21), that BT participants differed significantly from TAU
differed significantly from TAU beginning at session 6, and that participants beginning at session 7 (d 5 20.26), and that CT
MBSR participants differed significantly from TAU participants participants differed significantly from TAU participants begin-
beginning at session 6. Effect sizes comparing TAU at session ning at session 8 (d 5 20.23). Effect sizes comparing TAU at
8 to the other groups ranged from Cohen’s d 5 0.30 session 8 with the other groups ranged from Cohen’s d 5 2
to d 5 0.48. 0.21 to d 5 20.26.

3.2.3. Physical function 3.2.4. Depressive symptoms

A significant overall Group 3 Time interaction was found for the A significant overall Group 3 Time interaction was observed for
Physical Function Scale scores (F[3,1708.83] 5 3.61 P , 0.05). Depressive Symptom scores (F[3,1683.64] 5 10.41, P , 0.05).
In pairwise comparison analyses, no significant Group 3 Time Pairwise comparison analyses again revealed no significant
interactions were observed among the 3 active treatment Group 3 Time interactions among the 3 active treatment groups
groups (range B 5 0.03-0.04), indicating, again, that the 3 (range B 5 [20.01] to [20.11]). Significant interactions were
treatments showed similar effects on physical function. Signif- observed when each treatment group was compared with TAU.
icant interactions were observed when each treatment group As shown in Table 3, TAU participants did not show significant
was compared with TAU. As shown in Table 3, the TAU group changes in Depressive Symptom scores across the 8 sessions,
did not show a significant change in Physical Function Scale whereas Depressive Symptom scores for the BT, CT, and MBSR
scores across the study, but the BT, CT, and MBSR groups’ groups decreased significantly over the course of treatment. The
Physical Function scores did increase significantly over time. region of significance calculated for each interaction indicated
The region of significance calculated for each interaction that Depression scores from BT participants began to differ
indicated that Physical Function scores from MBSR participants significantly from TAU participants at session 4 (d 5 0.53), that CT
began to differ significantly from TAU participants at session 4 participants’ Depression scores differed significantly from TAU

Figure 2. Marginal means and standard errors from linear mixed models for pain interference. BT, behavioral therapy; CT, cognitive therapy; MBSR, mindfulness-
based stress reduction; TAU, treatment as usual.

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Figure 3. Marginal means and standard errors from linear mixed models for pain intensity. BT, behavioral therapy; CT, cognitive therapy; MBSR, mindfulness-
based stress reduction; TAU, treatment as usual.

participants’ beginning at session 7 (d 5 0.43), and that MBSR Group 3 Time interactions among 3 active treatment groups
participants’ Depression scores differed significantly from TAU (range B 5 [20.01] to [20.06]), but, again, significant interactions
participants beginning at session 8 (d 5 0.26). Effect sizes were observed when each treatment group was compared with
comparing TAU at session 8 with the other groups ranged from TAU. As shown in Table 3, all 4 groups demonstrated significant
Cohen’s d 5 0.26 to d 5 0.53. reductions in Sleep Disturbance over the course of treatment.
However, BT, CT, and MBSR groups showed larger reductions in
Sleep Disturbance scores at posttreatment than the TAU group.
3.2.5. Sleep disturbance
The region of significance calculated for each interaction
Finally, a significant overall Group 3 Time interaction was indicated that Sleep Disturbance scores from BT participants
observed for Sleep Disturbance scores (F[3,1730.09] 5 5.59 began to differ significantly from TAU participants after session 1,
P , 0.05). Pairwise comparison analyses showed no significant that CT participants’ Sleep Disturbance scores differed

Figure 4. Marginal means and standard errors from linear mixed models for depressive symptoms. BT, behavioral therapy; CT, cognitive therapy; MBSR,
mindfulness-based stress reduction; TAU, treatment as usual.

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Figure 5. Marginal means and standard errors from linear mixed models for physical function. BT, behavioral therapy; CT, cognitive therapy; MBSR, mindfulness-
based stress reduction; TAU, treatment as usual.

significantly from TAU participants’ beginning at session 3, and Physical Function, Depression, or Sleep Disturbance. Within-group
that MBSR participants’ Sleep Disturbance scores differed analyses showed that the MBSR group’s Pain Interference ratings
significantly from TAU participants beginning at session 2. Effect significantly increased from post-treatment to six-month follow-up
sizes comparing TAU at session 8 with the other groups ranged (mean difference 5 20.27, SE 5 0.12, 95% C.I. [20.51 to 20.03],
from Cohen’s d 5 0.26 to d 5 0.61. P , 0.05). The other groups did not have a significant difference in
marginal means between posttreatment and six-month follow-up for
any other outcome variable. The nonsignificant Group 3 Time
3.3. Treatment effects on outcomes from posttreatment to 6- interactions for the posttreatment to six-month follow-up epoch
month follow-up coupled with the mostly nonsignificant effects of time for the
There were no significant between-group interactions for posttreat- individual groups strongly suggested that the 3 active treatment
ment to six-month follow-up on Pain Interference, Pain Intensity, groups preserved their pretreatment to posttreatment gains.

Figure 6. Marginal means and standard errors from linear mixed models for sleep disturbance. BT, behavioral therapy; CT, cognitive therapy; MBSR, mindfulness-
based stress reduction; TAU, treatment as usual.

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Table 3
Linear mixed models results and effect sizes, baseline through session #8.
Variable Within-group change Treatment vs. TAU
Intercept, B Change over time, B P Effect size [95% Interaction treatment vs TAU, P Effect size of interaction Region of
(SE) [95% C.I.] (SE) [95% C.I.] C.I.] B (SE) [95% C.I.] (Cohen’s d) [95% C.I.] significance
Pain
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interference
BT 3.74 (0.12) 20.10 (0.01) 0.01 20.35 0.04 (0.01) [0.02 to 0.06] 0.01 0.25 [0.13 to 0.36] Session #8
[3.49-3.98] [20.12 to 20.08] [20.43 to 20.26]
CT 3.74 (0.11) 20.10 (0.01) 0.01 20.36 0.04 (0.01) [0.02 to 0.06] 0.01 0.26 [0.13 to 0.39] Session #8
[3.53-3.96] [20.11 to 20.08] [20.43 to 20.29]
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MBSR 3.63 (0.11) 20.10 (0.01) 0.01 20.37 0.04 (0.01) [0.02 to 0.06] 0.02 0.25 [0.13 to 0.38] Session #7
[3.41-3.84] [20.11 to 20.08] [20.45 to 20.29]
TAU 3.64 (0.12) 20.06 (0.01) 0.01 20.26
[3.41-3.88] [20.07 to 20.04] [20.35 to 20.18]
Pain
intensity
BT 5.73 (0.19) 20.17 (0.02) 0.01 20.32 0.12 (0.02) [0.08 to 0.17] 0.01 0.48 [0.32 to 0.68] Session #5
[5.36-6.09] [20.21 to 20.13] [20.39 to 20.24]
CT 5.69 (0.19) 20.16 (0.02) 0.01 20.32 0.11 (0.02) [0.07 to 0.15] 0.01 0.42 [0.27 to 0.57] Session #6
[5.30-6.07] [20.19 to 20.12] [20.39 to 20.25]
MBSR 5.54 (0.18) 20.13 (0.02) 0.01 20.29 0.08 (0.02) [0.04 to 0.13] 0.01 0.30 [0.15 to 0.49] Session #6
[5.17-5.89] [20.16 to 20.09] [20.36 to 20.22]
TAU 5.55 (0.19) 20.05 (0.01) 0.01 20.12
[5.15-5.93] [20.07 to 20.02] [20.19 to 20.04]
Physical
function
BT 18.87 (0.44) 0.18 (0.03) 0.01 0.19 20.15 (0.05) [20.24 to 20.06] 0.01 20.26 [20.41 to 20.11] Session #7
[18.00-19.75] [0.11 to 0.24] [0.11 to 0.28]
CT 18.45 (0.41) 0.16 (0.03) 0.01 0.18 20.13 (0.05) [20.22 to 20.04] 0.01 20.23 [20.39 to 20.07] Session #8
[17.65-19.25] [0.09 to 0.23] [0.10 to 0.27]
MBSR 19.41 (0.38) 0.14 (0.03) 0.01 0.15 20.11 (0.05) [20.19 to 20.02] 0.02 20.21 [20.34 to 20.04] Session #4
[18.61-20.10] [0.07 to 0.21] [0.07 to 0.23]
TAU 18.79 (0.43) 0.03 (0.03) 0.33 0.03
[17.94-19.63] [20.04 to 0.09] [20.05 to 0.11]
Depression
BT 10.39 (0.46) 20.37 (0.05) 0.01 20.27 0.33 (0.06) [0.21 to 0.46] 0.01 0.53 [0.33 to 0.73] Session #4
[9.49-11.29] [20.47 to 20.28] [20.36 to 20.19]
CT 10.76 (0.46) 20.32 (0.05) 0.01 20.25 0.28 (0.06) [0.16 to 0.39] 0.01 0.43 [0.25 to 0.61] Session #7
[9.85-11.67] [20.41 to 20.22] [20.32 to 20.17]
MBSR 10.21 (0.45) 20.21 (0.04) 0.01 20.18 0.17 (0.06) [0.05 to 0.28] 0.01 0.26 [0.08 to 0.42] Session #8
[9.32-11.09] [20.29 to 20.12] [20.26 to 20.10]
TAU 10.04 (0.51) 20.04 (0.04) 0.30 20.04
[9.04-11.04] [20.12 to 0.04] [20.11 to 0.04]
Sleep
disturbance
BT 55.83 (0.73) 20.60 (0.08) 0.01 20.24 0.44 (0.11) [0.22 to 0.65] 0.01 0.61 [0.32 to 0.90] Session #1
[54.38-57.28] [20.76 to 20.43] [20.31 to 15]
CT 56.95 (0.76) 20.46 (0.08) 0.01 20.22 0.30 (0.10) [0.10 to 0.51] 0.01 0.31 [0.10 to 0.51] Session #5
[55.46-58.44] [20.61 to 20.31] [20.30 to 20.13]
MBSR 55.61 (0.72) 20.42 (0.07) 0.01 20.22 0.26 (0.09) [0.07 to 0.46] 0.01 0.26 [0.07 to 0.45] Session #2
[54.19-57.04] [20.56 to 20.28] [20.29 to 20.15]
TAU 57.29 (0.77) 20.16 (0.07) 0.03 20.08
[55.77-58.82] [20.29 to 20.02] [20.15 to 20.01]
BT, behavioral therapy; CT, cognitive therapy; MBSR, mindfulness-based stress reduction; TAU, treatment as usual.

3.4. Treatment effects on outcomes from baseline to 6- 6.92 P , 0.05). See Table 4. Pairwise comparison analyses for all
month follow-up outcome factors revealed no significant Group 3 Time interactions
Similar to the baseline to session 8 analyses, significant Group 3 among treatment groups. Significant Group 3 Time interactions for
Time interactions were observed for Pain Interference Scale scores (F each outcome factor were observed when each treatment group
[3,2104.47] 5 4.48 P , 0.05), Pain Intensity ratings (F[3,1886.97] 5 was compared with TAU, however. Effect sizes comparing TAU
11.14 P , 0.05), Physical Function Scale scores (F[3,1934.04] 5 values at 6-month follow-up with the other groups ranged from
45.08 P , 0.05), Depressive Symptom scores [F(3,1815.28) 5 Cohen’s d 5 20.18 to d 5 0.56, which were slightly attenuated from
10.10, P , 0.05], and Sleep Disturbance scores (F[3,1822.27] 5 the effect sizes observed for baseline to session 8 comparisons.

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Table 4
Linear mixed models results and effect sizes, baseline to 6-month follow-up.
Variable Within-condition Between conditions treatment vs. TAU
Intercept, B (SE) B (SE) [95% C.I.] P Effect size Interaction treatment vs TAU, B P Effect size of interaction (Cohen’s
[95% C.I.] [95% C.I.] (SE) [95% C.I.] d) [95% C.I.]
Pain
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interference
BT 3.71 (0.12) 20.08 (0.01) 0.01 20.32 0.04 (0.01) [0.01 to 0.06] 0.01 0.27 [0.07 to 0.41]
[3.51 to 3.91] [20.10 to 20.06] [20.41 to 20.25]
CT 3.71 (0.11) 20.09 (0.01) 0.01 20.34 0.04 (0.01) [0.02 to 0.06] 0.01 0.29 [0.14 to 0.43]
[3.54 to 3.91] [20.10 to 20.07] [20.41 to 20.28]
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MBSR 3.57 (0.11) 20.07 (0.01) 0.01 20.30 0.03 (0.01) [0.01 to 0.05] 0.01 0.21 [0.07 to 0.35]
[3.53 to 3.74] [20.09 to 20.05] [20.38 to 20.23]
TAU 3.62 (0.12) 20.05 (0.01) 0.01 20.23
[3.43 to 3.80] [20.07 to 20.03] [20.31 to 20.15]
Pain
intensity
BT 5.66 (0.19) 20.15 (0.02) 0.01 20.31 0.12 (0.02) [0.07 to 0.16] 0.01 0.53 [0.31 to 0.71]
[5.35 to 5.97] [20.18 to 20.11] [20.37 to 20.23]
CT 5.63 (0.19) 20.13 (0.02) 0.01 20.31 0.10 (0.02) [0.06 to 0.14] 0.01 0.43 [0.26 to 0.61]
[5.32 to 5.94] [20.17 to 20.11] [20.36 to 20.23]
MBSR 5.05 (0.18) 20.12 (0.02) 0.01 20.29 0.08 (0.02) [0.05 to 0.12] 0.01 0.34 [0.21 to 0.51]
[5.21 to 5.81] [20.15 to 20.09] [20.35 to 20.22]
TAU 5.51 (0.19) 20.04 (0.02) 0.04 20.12
[5.20 to 5.81] [20.07 to 20.01] [20.18 to 20.02]
Physical
function
BT 18.86 (0.42) 0.18 (0.04) 0.01 0.22 20.14 (0.04) [20.22 to 20.06] 0.01 20.27 [20.42 to 20.11]
[18.17 to 19.55] [0.12 to 0.24] [0.15 to 0.29]
CT 18.46 (0.41) 0.16 (0.04) 0.01 0.21 20.14 (0.05) [20.22 to 20.06] 0.01 20.27 [20.43 to 20.12]
[17.81 to 19.11] [11 to 0.22] [0.12 to 0.27]
MBSR 19.41 (0.36) 0.12 (0.04) 0.01 0.14 20.09 (0.04) [20.18 to 20.01] 0.03 20.18 [20.36 to 20.02]
[18.81 to 19.98] [0.06 to 0.19] [0.06 to 0.22]
TAU 18.82 (0.41) 0.02 (0.04) 0.46 0.02
[18.16 to 19.47] [20.05 to 0.08] [20.06 to 0.11]
Depression
BT 10.21 (0.51) [ 20.31 (0.06) 0.01 20.25 0.31 (0.06) [0.17 to 0.41] 0.01 0.56 [0.30 to 0.73]
9.36 to 11.03] [20.40 to 20.21] [20.32 to 20.18]
CT 10.68 (0.46) 20.29 (0.05) 0.01 20.25 0.27 (0.06) [0.16 to 0.38] 0.01 0.48 [0.28 to 0.67]
[9.82 to 11.54] [20.38 to 20.20] [20.32 to 20.18]
MBSR 10.19 (0.46) 20.21 (0.04) 0.01 20.19 0.18 (0.05) [0.08 to 0.28] 0.01 0.31 [0.14 to 0.48]
[9.43 to 10.95] [20.27 to 20.13] [20.26 to 20.12]
TAU 10.02 (0.50) 20.03 (0.05) 0.56 20.03
[9.19 to 10.84] [20.12 to 0.05] [20.11 to 0.05]
Sleep
disturbance
BT 55.62 (0.71) [ 20.52 (0.09) 0.01 20.25 0.41 (0.11) [0.22 to 0.61] 0.01 0.48 [0.26 to 0.72]
54.46 to 56.78] [20.67 to 20.36] [20.32 to 20.19]
CT 56.97 (0.83) 20.46 (0.09) 0.01 20.24 0.34 (0.10) [0.15 to 0.53] 0.01 0.38 [0.17 to 0.59]
[55.61 to 58.33] [20.62 to 20.31] [20.31 to 20.18]
MBSR 55.60 (0.73) 20.41 (0.07) 0.01 20.23 0.29 (0.09) [0.11 to 0.46] 0.01 0.32 [0.12 to 0.51]
[54.40 to 56.80] [20.53 to 20.29] [20.29 to 20.17]
TAU 57.16 (0.70) 20.12 (0.07) 0.13 20.06
[56.01 to 58.32] [20.22 to 20.01] [20.12 to 0.01]
BT, behavioral therapy; CT, cognitive therapy; MBSR, mindfulness-based stress reduction; TAU, treatment as usual.

3.5. Clinically meaningful changes in pain intensity ITT approach was to include only participants who actually
participated in study procedures and who were therefore
Clinically meaningful improvement in pain intensity was assessed.
Clinically meaningful change was defined as a 30% or greater exposed to some level of dose of treatment and/or an
reduction in pain intensity from pretreatment to posttreatment. assessment session. The frequencies were as follows: TAU 5
We used a modified ITT approach in which we included in these 17.1%, BT 5 33.3%, CT 5 28.7%, and MBSR 5 24.5%.
responder analyses any participant who completed at least one Statistically significant between-group differences were found,
treatment session, or for TAU participants, who completed at such that BT and CT had a significantly larger proportion of
least one weekly assessment. The rationale for using a modified participants with 30% or greater improvement on pain intensity

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 February 2022
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· Number 2 www.painjournalonline.com 387

than TAU participants (x2 [3, 429] 5 9.42; P , 0.03). Mindfulness- noted, however, that a recent meta-analysis44 found very small
based stress reduction did not differ significantly from TAU. benefits in pain reduction for CBT compared with active control
Clinically meaningful worsening of pain intensity was also groups, such as pain education, among a collective N of 3235
assessed following recommendations of Palermo et al.34 Clini- research participants.
cally meaningful worsening was defined as a 30% or greater Condition 3 Time interaction analyses for the 8 sessions also
increase in pain intensity from pretreatment to post-treatment.17 allowed us to analyze regions of significance. These regions
The frequencies were: TAU 5 10.1%, BT 5 5.8%, CT 5 9.3%, identified the approximate treatment session at which the CT,
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and MBSR 5 7.0%. Between-group differences in these MBSR, and BT groups began to differ significantly from TAU on
increases were nonsignificant (x2 [3, 429] 5 0.41, P . 0.05]. each of the 5 outcome factors. Put otherwise, we were able to
determine the relative rates at which improvement occurred.
There was notable variability in these regions between the
4. Discussion
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conditions and among the outcome factors. Indeed, participants

Most studies of psychosocial treatments for chronic pain have in the BT and MBSR conditions differed significantly from the TAU
compared their efficacy with largely inert control groups. The group on sleep disturbance by session 2; this without any explicit
result has been a plethora of evidence indicating that people with therapeutic attention devoted to easing such problems. Across
chronic pain benefit from such treatment approaches. One outcome factors, we found that the 3 active treatments began to
implicit goal of developing new approaches to treatment is to differ significantly from TAU on average by sessions 5 or 6. On one
have the beneficial effects of the new treatments exceed the level, this finding again highlights the similarities of ostensibly
benefits of the extant treatments. To this end, fewer studies have different treatments. Here, distinct treatments showed similar
compared the effects of 2 or more active treatments; those that rates of improvements. On another level, this finding regarding
have compared active treatments have found, by and large, that the sixth session hints at the possibility that at least some
different psychosocial treatments for chronic pain produce similar psychosocial treatments for chronic pain may be reduced in
effects on primary outcomes. This observation is based on the length (eg, from 8 to 6 sessions) with only small reductions in
results of both underpowered and adequately powered compar- overall efficacy. Recent work also supports the possibility of
ison studies. Consistent with this prior research, and in an reducing treatment length.3,4 Still, it should be considered that all
adequately powered study, we found that CT, MBSR, and BT 3 active treatments had additional benefits past session 6.
produced similar pretreatment to posttreatment effects on On a third level, the finding regarding the sixth session may
primary outcomes and revealed similar levels of maintenance of invite us to entertain questions about what it is that we are actually
treatment gains at a 6-month follow-up. Proposing a new metric doing in these treatments. It is possible that 6 sessions worth of
for determining relative treatment superiority, we also examined any psychosocial treatment may be necessary but that the
whether one or more of the active treatments would produce particular therapeutic content of these 6 sessions may not be a
treatment benefits more rapidly than the other treatment(s). critical determinant of outcomes. The specific techniques in-
Although we did find that the 3 treatments differed significantly cluded in CT, MBSR, and BT may be less important for outcomes
from TAU on average by session 6, this effect emerged across all than people participating in any techniques rooted in these
3 active treatments. In summary, not only did CT, MBSR, and BT empirically supported psychosocial treatments for chronic pain.
produce similar levels of improvements and maintenance of gains We can advance at least 2 reasons to explain the bulk of our
on 5 outcome domains, they did so at approximately the same and past findings. First, it is possible that many psychosocial
rates. treatments for chronic pain are all viable treatment options by
Treatment Condition 3 Time interactions for the 8 session virtue of sharing positive effects on outcomes. Thus, people with
assessments revealed that CT, MBSR, and BT showed greater chronic pain can choose from an array of efficacious approaches.
improvements during treatment than TAU on all 5 outcome However, the quandary of equivalent outcomes leaves people to
domains, and the active treatment conditions did not differ choose from a field of winners with no clear criteria by which to
significantly from each other on any outcomes at posttreatment. select a treatment approach. Second, despite different theories
At the same time, pretreatment to posttreatment within treatment and different techniques, the equivalence of outcomes suggests
effect sizes ranged from Cohen’s d 5 0.15 to 0.37, and the possibility that extant approaches may be just so potent and
posttreatment effects comparing TAU with the other groups no more. We could therefore choose to abandon the search for
ranged from Cohen’s d 5 0.21 to d 5 0.61. These results suggest new and better treatments that developing new treatments that
that all 3 treatments produced on average small to medium effect are unlikely to be better treatments is not a valuable way to spend
size improvements on the 5 outcome variables. Regarding time, energy, and scarce resources. We could rest on our laurels
clinically meaningful changes, we found that 25% to 33% of by relying on CBT or other established psychosocial treatments
participants receiving CT, BT, and MBSR reported pain intensity as the best that we can do. However, we believe this conclusion is
reductions of 30% or greater, whereas, on average, only 7% of premature.
them reported meaningful increases in pain intensity. Moreover, One approach is to identify potential treatment moderators.10
Treatment Condition 3 Time interactions for the posttreatment to Investigators have noted that focusing only on mean levels of
6-month follow-up epoch were nonsignificant, as were all but one treatment response misses the potential information reflected in
of the within-treatment effects of time. These results indicate that variability in treatment response. Put simply, people respond to
the pretreatment to posttreatment improvements for all 3 treatments with different levels of improvement varying around
conditions were maintained, with the single exception of pain the sample mean from low to high. It may be the case that people
interference for MBSR. These results are consistent with other characterized by certain factors may respond more or less
well-powered comparison studies,7,25,37 underscoring the per- favorably to certain treatments. Thus, treatment response to, for
vasive findings that (1) different psychosocial pain treatments example, CBT could be magnified by matching people with CBT-
produce similar levels of clinically meaningful outcomes on relevant characteristics to CBT and not to another treatment. A
average and (2) psychosocial pain treatments maintain these second approach to help understand the implications of similar
improvements, for the most part, after treatment. It should be outcomes across different treatments is to determine if they

Copyright © 2021 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
 388
·
J.W. Burns et al. 163 (2022) 376–389 PAIN®

operate through different mechanisms, even when they are Accepted 23 May 2021
shown to have the same or similar effects on outcomes.11,19 If Available online 1 June 2021
different treatments are found to operate by different underlying
mechanisms, then this information could be used to inform
algorithms for better patient-treatment matching. We plan to References
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