Telephone-Based vs In-Person CBT for Chronic Back Pain

Phone triage leaves too much room for error
Phone triage leaves too much room for error
Interactive voice response-based CBT is as effective as in-person CBT for patients with chronic back pain.

Findings of a randomized trial published in JAMA Internal Medicine demonstrated the noninferiority of interactive voice response-based cognitive behavioral therapy (IVR-CBT) vs in-person CBT in patients with chronic back pain.

Because of the drastic increase in opioid abuse and associated complications such as addiction and death, the Centers for Disease Control and Prevention (CDC) and other public health organizations now recommend the use of evidence-based non-pharmacologic approaches over opioids whenever possible.2

CBT consists of teaching patients cognitive (eg, reframing maladaptive thoughts) and behavioral coping skills (eg, relaxation strategies). The technique was shown to improve pain and function in patients with a number of pain modalities, including back pain and pain associated with arthritis and fibromyalgia.3-5 However, access to CBT may be hampered by difficulties traveling to appointments, scheduling issues, and the limited number of trained therapists outside of urban areas.

In the current study, IVR refers to an automated system that “allows patients to report symptoms, functioning, and pain coping skill use and receive pre-recorded information and feedback via their telephone.” The researchers sought to evaluate the effectiveness of IVR-CBT in patients with moderate-intensity chronic back pain (ie, with a pain score ≥4 on a 0 to 10 rating scale, for ≥3 months). 

Patients from the Department of Veterans Affairs (VA) healthcare system (22.4% women; mean age, 57.9) were randomly assigned to 10 sessions of IVR-CBT (n=62) or in-person CBT (n=63). Study participants received a treatment manual that included an introduction to CBT, 8 modules pertaining to pain coping skills, and a relapse prevention module. Patients also engaged in a walking program and continued to consult with their primary care provider.

Pain, coping skills practice, step count, and sleep were assessed daily via IVR in all participants for 11 weeks. In the IVR-CBT group, therapists reviewed this information and provided recorded, personalized feedback, while the in-person group received feedback in their weekly sessions.

The following tools were used to assess outcomes: the interference subscale of the West Haven-Yale Multidimensional Pain Inventory; the Roland and Morris Disability Questionnaire (to assess physical functioning); the Beck Depression Inventory-II for depressive symptoms; the Pittsburgh Sleep Quality Index; and the Veterans 36-item short-form (SF-36) questionnaire (to assess physical and mental health-related quality of life).

At 3 months post-baseline, a similar adjusted average reduction in numerical rating scale was observed between IVR-CBT (−0.77; 95% CI, −1.39 to −0.29) and in-person CBT (−0.84; 95% CI, −1.29 to 0.26). The 95% CI for the between-groups difference (−0.67 to 0.80) fell below the pre-specified noninferiority margin of 1, which supports the noninferiority of IVR-CBT.

In addition, both groups had significant and similar improvements in physical functioning, sleep quality, and physical quality of life. The IVR-CBT group completed an average of 2.3 (95% CI, 1.0-3.6) sessions more than the in-person group.

“Given that IVR-CBT can be offered more widely and at lower burden to patients, it shows promise as a scalable and population-based treatment,” the researchers concluded.

Summary and Clinical Applicability

In patients with chronic pain, interactive voice response-based CBT resulted in similar improvements compared with in-person CBT.

Limitations and Disclosures

Limitations include the lack of a placebo arm and the specific demographic characteristics of most participants.

Dr Heapy and Dr Higgins report the receipt of consulting fees from Magellan Health for developing an online CBT program for chronic pain. The remaining authors report no disclosures.

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