Early Study Feedback Suggests Virtual Cognitive Behavioral Therapy May Help Some People Working with Chronic Pain

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Can cognitive behavioral therapy (CBT) delivered virtually help people with disabilities manage their chronic pain? Early results from a study at the Shirley Ryan AbilityLab’s Center for Rehabilitation Outcomes Research suggests that it might.

The study, led by Dawn Ehde, PhD, at the University of Washington (UW) in Seattle, is still recruiting participants who are employed and are dealing with pain as a result of either multiple sclerosis (MS), traumatic brain injury (TBI), spinal cord injury (SCI) or amputation. The study is a component of the Rehabilitation Research and Training Center for Employment for People with Physical Disabilities with Allen Heinemann, PhD as project director. As of late August, staff at UW and Shirley Ryan AbilityLab had enrolled 158 people in the study. The goal is to reach 200. Half of the participants are randomly assigned to receive the CBT intervention, which consists of eight sessions of counseling delivered by telephone. The other half receive traditional care for their condition, including staying on whatever medication they already take.

“We’re studying if this treatment is better than what they were getting as their usual care for dealing with pain,” Ehde says. One of the study’s early successes, she adds, is that 96% of the people enrolled have stayed in the study and completed their outcomes assessments, an unusually high rate for healthcare research.

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Although Ehde and her team haven’t started analyzing the results, they have received many positive comments from participants. “I can’t even believe how much better I feel,” one participant said at their six-month outcome assessment. “I used to use Tramadol all the time as my backup to Tylenol and took it often. Now I can’t even remember the last time I took Tramadol.” Tramadol is an opioid pain medication used to treat moderate to moderately severe pain.

Ehde doesn’t expect every participant to experience such dramatic results. “We expect some people will do really well, some will have a mild benefit and some will not benefit at all,” she says. “One of our goals is to figure out how to identify who is most likely to benefit and, in turn, help the people who are less likely to benefit by diverting them to a different treatment.”

Jamie Tingey, PhD, a post-doctoral fellow at UW, is one of four therapists in Seattle providing the CBT therapy, which is outlined in a manual but can be tailored to individual participants’ goals and disability levels. The therapists incorporate stress-reduction and breathing techniques as well as mindfulness training, the practice of focusing attention on a person’s thoughts, feelings and behavior in the current moment without judging them. One of Tingey’s clients is a young woman with a traumatic brain injury who said she didn’t read for fun anymore because the cognitive load required was causing her pain.

“I asked her what she liked about reading and she said, ‘It helps me unwind and immerse myself in a different narrative.’ I try to avoid suggesting anything because it’s rarely helpful to tell someone what to do but helping someone explore and identify what they want to do can be impactful,” Tingey says. “We talked about how she could get back to reading. She landed on ‘I will try to read for five to 20 minutes each evening to build the practice.’ That’s what we stress: It’s not the hour sessions that are important. It’s how you build the skills outside the sessions.”

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While there’s nothing revolutionary about using CBT for pain management, Ehde says it’s not very well integrated into many rehabilitation patients’ care plans, “not because care providers don’t care but there are so many things physicians have to address in rehabilitation clinic visits.” She adds that some patients may have given up to a certain extent, assuming that being in pain is part of their condition. Ehde acknowledges that CBT is unlikely to work for everyone dealing with chronic pain but identifying which types of people do respond to CBT would be a step forward in pain management. Those participants who were randomized into the group that didn’t receive the CBT treatment are offered it when their eight-week study is complete.

Ehde originally envisioned the counseling sessions taking place via Zoom or other virtual meeting formats. But she found that many participants preferred phone calls, which are less obvious when someone is in an office setting. Because the sessions are virtual, participants can be located anywhere in the country.

She is hopeful that the study’s original target of 200 participants will be met. The recruiting got started during the COVID pandemic, which likely slowed things. Ehde was originally hoping for an even distribution among people with TBI, MS, SCI and amputation. But the researchers in Seattle and Chicago have had trouble enrolling people who have experienced amputation, while they have a waiting list for those with MS. If they open the door to those on the waiting list, Ehde is confident they will meet the number. The goal is to wrap up enrollment by the end of 2022 or the first quarter of 2023. “I’ve really been encouraged by how many people are interested once they know about the study,” Ehde says. “We have very few eligible people who hear about the study and refuse.”