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Self-Management Combined with Telecare Improves Pain and Mood Symptoms

October 28, 2019
VA study shows that automated surveys, backed by nurse-led symptom management, make a difference in treating comorbid pain, anxiety, and depression.

with Kurt Kroenke, MD, and Elmer Pinzon, MD, MPH

Chronic pain is often accompanied by depression and anxiety. When musculoskeletal pain, anxiety, and depression co-occur (sometimes called PAD), they often play a part in six  of the nine leading causes of disability in the US: low back pain, neck pain, osteoarthritis, other musculoskeletal or MSK disorders, major depressive disorder, and anxiety disorders.1 The presence of one symptom, if left untreated, may negatively affect the response to treatment of the other two symptoms.2

In a recent 12-month Veterans Health Administration (VA) trial, web-based self-management, which involves combination of symptom surveys and a self-management course, improved chronic MSK pain and mood symptoms among patients. The addition of nurse telecare to the web-based program resulted in even further improvement.3

Treating MSK pain and mood symptoms together makes sense, said Elmer G. Pinzon, MD, MPH, a physiatrist at the University Spine & Sports Specialists in Knoxville, TN, and a member of PPM’s Editorial Advisory Board. “Depression and anxiety go with the territory of having pain, and they can interfere with care or outcomes of the care that you give patients with musculoskeletal pain.”

Comorbid mood symptoms such as depression and anxiety are often found in those with chronic pain. (Image: iStockPhoto)

Despite the prevalence of PAD, few clinical trials have examined interventions that simultaneously target both MSK pain and mood conditions, lead study author Kurt Kroenke, MD, research scientist at the Regenstrief Institute in Indianapolis, IN, told PPM.

“We’d done a number of trials, including collaborative telecare on depression, and we’ve done several on pain. We haven’t done one where patients had both and [were treated for] both,” explained Dr. Kroenke. Such was the impetus for his team’s recent VA trial, the Comprehensive vs Assisted Management of Mood and Pain Symptoms (CAMMPS) trial,3 which tested alternative interventions for PAD.

Which is Better: Self-Management Alone or Self-Management with Telecare

The trial compared automated self-management (ASM) versus comprehensive symptom management (CSM) combined with ASM in six primary care VA clinics over 12 months. In the study, 294 patients with chronic MSK pain of at least moderate intensity and clinically significant depressive and/or anxiety symptoms were randomly assigned to ASM or CSM regimens. Assessments were conducted at baseline and at 1, 3, 6, and 12 months.

The ASM program consisted of automated symptom monitoring in which participants completed regular surveys about their symptoms either by interactive voice recorded telephone calls or through the internet, along with pain and mood self-management modules. Participants regularly completed surveys to self-assess their pain, anxiety, depression, sleep, fatigue, irritability, global change, and symptom-related impairment. The web-based self-management program was a 12-hour course with 9 modules:

  • coping with pain
  • pain medications
  • communicating with providers
  • depression
  • anxiety
  • sleep
  • anger management
  • cognitive strategies
  • and problem-solving.

The CSM arm consisted of the ASM program in addition to collaborative care management by a nurse-physician team. For instance, if a patient experienced medication side effects, e-mail alerts were sent to a nurse; patient- as well as nurse-based requests for a change in treatment were also enabled. The participants’ ASM responses were tabulated into a trend report that the nurse could review on a secure website. The nurse made scheduled telephone calls to the participants at 1, 4, and 12 weeks, and contacted participants based on the trend reports. The care team met weekly to discuss new patients as well as patients not responding to treatment.

Patients were offered the option of psychotropic medications, referral to a psychologist, or combined therapy for mood symptoms. For pain symptoms, the care team used an evidence-based, stepped care algorithm that included acetaminophen/NSAIDs; tricyclic antidepressants; muscle relaxants; gabapentinoids or serotonin-norepinephrine reuptake inhibitors; and topical analgesics. Opioids were not part of the algorithm, but they were not tapered or discontinued for patients already taking them.

Treatment was adjusted if there was less than a 30% improvement in PAD symptoms, failure to report global improvement of at least moderate or better, or the patient’s desire to change treatment.

Improvement of Symptoms: CSM Shows Superiority

To measure MSK pain, anxiety, and depression symptoms, the study used a composite PAD z-score, which averaged the z-scores of the following scales:

  • Brief Pain Inventory (BPI)
  • GAD-7 anxiety scale
  • PHQ-9 depression scale.

At the end of the 12-month trial, both the ASM and CSM interventions demonstrated moderate PAD score improvement:

  • ASM z-score was -0.52
  • CSM z score was -0.65.

The CSM group had a -0.23 (95% CI, -0.38 to -0.08; overall P = 0.003) greater decline in composite PAD z-score. Additionally, the CSM patients were more likely to report global improvement and less likely to report worsening at 6 and 12 months.

The researchers noted that the small but clinically significant superiority of CSM over ASM may be due to the combined effect of several small advantages, including the use of more analgesics, greater perceived value of self-management modules and monitoring, and the highly valued nurse contacts and care coordination.

Dr. Kroenke’s team also noted several limitations, including predominantly male veteran subjects from a single medical center, and that the VA environment, which offers nationwide primary care-mental health integration, may differ from those delivery systems without integrated mental health.

Practical Takeaways

Dr. Kroenke believes that the findings of the study offer clinicians better options for treating patients living with MSK pain and comorbid mood symptoms—that is, automated interventions along with care management interventions.

“Pain and mood symptoms hang together. Often, the patient might principally complain of one, but it’s easy to ask or screen for the other,” suggested Dr. Kroenke. He noted that such screenings may be especially helpful for patients who are not getting better. “[When] it doesn’tseem to be enough treating the pain—[those are the patients] who you would want to screen for depression and anxiety, and the brief self-administered questionnaire can do it. Once it’s recognized, if you can treat both you’ll be better off,” he added.

These therapeutic and diagnostic interventions may be helpful in outpatient pain clinics as well, added Dr. Pinzon. “Anything that will improve the evaluation of the chronic pain patient is welcome, especially with the limited amount of time that pain practitioners have to spend discussing and treating this patient population.”

Last updated on: March 16, 2020
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