近日，美国Kaiser Permanente健康研究中心Andrea J. Cook研究组分析了远程医疗和在线认知行为治疗为基础治疗高影响慢性疼痛的疗效。该研究于2025年7月24日发表在《美国医学会杂志》上。

认知行为疗法（CBT）技能训练干预被推荐为慢性疼痛的一线非药物治疗，但它们并没有广泛使用。

为了与常规护理相比，研究远程、可扩展的基于CBT的慢性疼痛（CBT-CP）治疗（远程医疗和在线自我完成）对高影响慢性疼痛个体的有效性，研究组进行了一项比较有效的3组3期随机临床试验，于2021年1月至2023年2月在美国4个地理位置不同的医疗保健系统中招募了2331名符合条件的高影响慢性肌肉骨骼疼痛患者。后续工作于2024年4月结束。

将参与者以1:1:1的比例随机分配到2个远程、8个会话、基于CBT的技能培训治疗中的1个：健康教练通过电话/视频会议(健康教练；n=778)或在线自学课程(painTRAINER；n = 776)；或常规护理加上资源指南（n=777）。主要结局是达到或超过疼痛严重程度评分的最小临床重要差异（MCID）(降低≥30%；从基线到3个月的11项简短疼痛量表得分范围（0-10）；距基线6个月和12个月为次要时间点。第3、6和12个月的次要结局包括疼痛强度、疼痛相关干扰、PROMIS（患者报告的结局测量信息系统）社会角色和身体功能。

在2331名符合条件的随机个体中(平均年龄58.8 [SD， 14.3]岁；1712[74%]名女性）1030人（44%）（农村/医疗服务不足），2210人（94.8%）完成了试验。3个月时，健康教练组疼痛严重程度评分降低30%或以上的调整后百分比为32.0 (95% CI, 29.3-35.0)， painTRAINER组为26.6 (95% CI, 23.4-30.2)，常规护理组为20.8 （95% CI, 18.0-24.0）。与对照组相比，两个干预组在疼痛严重程度上达到MCID的可能性显著更高(健康教练vs常规护理：相对风险[RR]， 1.54；painTRAINER与常规护理：RR， 1.28)，健康教练计划比在线自我完成的painTRAINER计划更有效（健康教练与painTRAINER: RR， 1.20）。在随机分组后的6个月和12个月，在疼痛严重程度结局和其他继发性疼痛和功能结局方面，两个干预组与常规护理相比均观察到统计学上显著的益处。

研究结果表明，与常规治疗相比，远程、可扩展的CBT-CP治疗（通过远程医疗或在线自行完成的模块提供）在高影响慢性疼痛患者中导致疼痛和相关功能/生活质量结果的适度改善。这些低资源CBT-CP治疗可以提高卫生保健系统中基于证据的非药物疼痛治疗的可用性。

附：英文原文

Title: Telehealth and Online Cognitive Behavioral Therapy–Based Treatments for High-Impact Chronic Pain: A Randomized Clinical Trial

Author: Lynn L. DeBar, Meghan Mayhew, Robert D. Wellman, Benjamin H. Balderson, John F. Dickerson, Charles R. Elder, Morgan Justice, Francis J. Keefe, Carmit K. McMullen, Ashli A. Owen-Smith, Christine Rini, Michael Von Korff, Stephen Waring, Anusha Yarava, Ziling Shen, Richard E. Thompson, Amy E. Clark, T. Charles Casper, Andrea J. Cook

Issue&Volume: 2025-07-23

Abstract:

Importance  Cognitive behavioral therapy (CBT) skills training interventions are recommended first-line nonpharmacologic treatment for chronic pain, yet they are not widely accessible.

Objective  To examine effectiveness of remote, scalable CBT-based chronic pain (CBT-CP) treatments (telehealth and self-completed online) for individuals with high-impact chronic pain, compared with usual care.

Design, Setting, and Participants  This comparative effectiveness, 3-group, phase 3 randomized clinical trial enrolled 2331 eligible patients with high-impact chronic musculoskeletal pain from 4 geographically diverse health care systems in the US from January 2021 through February 2023. Follow-up concluded in April 2024.

Interventions  Participants were randomized 1:1:1 to 1 of 2 remote, 8-session, CBT-based skills training treatments: health coach–led via telephone/videoconferencing (health coach; n=778) or online self-completed program (painTRAINER; n=776); or to usual care plus a resource guide (n=777).

Main Outcomes and Measures  The primary outcome was attaining or exceeding the minimal clinically important difference (MCID) in pain severity score (≥30% decrease; score range, 0-10) on the 11-item Brief Pain Inventory–Short Form from baseline to 3 months; 6 and 12 months from baseline were secondary time points. Secondary outcomes at 3, 6, and 12 months included pain intensity, pain-related interference, PROMIS (Patient-Reported Outcomes Measurement Information System) social role and physical functioning; and patient global impression of change.

Results  Among 2331 eligible randomized individuals (mean age, 58.8 [SD, 14.3] years; 1712 [74%] women; 1030 [44%] rural/medically underserved), 2210 (94.8%) completed the trial. At 3 months, the adjusted percentage of participants achieving 30% or greater decrease in pain severity score was 32.0 (95% CI, 29.3-35.0) in the health coach group, 26.6 (95% CI, 23.4-30.2) in the painTRAINER group, and 20.8 (95% CI, 18.0-24.0) in the usual care group. Both intervention groups were significantly more likely to attain an MCID in pain severity compared with control (health coach vs usual care: relative risk [RR], 1.54 [95% CI, 1.30-1.82]; painTRAINER vs usual care: RR, 1.28 [95% CI, 1.06-1.55]), and the health coach program was more effective than the online self-completed painTRAINER program (health coach vs painTRAINER: RR, 1.20 [95% CI, 1.03-1.40]). Statistically significant benefits were observed for both intervention groups vs usual care at 6 and 12 months after randomization for the pain severity outcomes and for other secondary pain and functioning outcomes.

Conclusions and Relevance  Remote, scalable CBT-CP treatments (delivered either via telehealth or self-completed modules online) resulted in modest improvements in pain and related functional/quality-of-life outcomes compared with usual care among individuals with high-impact chronic pain. These lower-resource CBT-CP treatments could improve availability of evidence-based nonpharmacologic pain treatments within health care systems.

DOI: 10.1001/jama.2025.11178

Source: https://jamanetwork.com/journals/jama/fullarticle/2836795