Expanding access to effective psychologically based treatments: Training nurse practitioners yields dividends

The value of cognitive behavioral therapy (CBT) in the self-management of chronic pain is well established. In fact, a recent commentary on the research needs for psychologically based treatments concluded that CBT has been demonstrated as “a useful approach to the management of chronic pain” and “there is no need for more general RCTs [randomized controlled trials] reporting group means” [11]. Instead, Williams et al. [11] called for research that identified the effective components of CBT, for which type of patient, in relation to which outcomes, and to understand why. While these recommendations are an important development, it is noticeable that they do not mention “by whom.” Like all psychological treatments, CBT is highly “operator dependent” for its implementation. Examination of the RCT studies of CBT-based treatments for chronic pain reveals that the overwhelming majority have been conducted by psychologists or by psychologists working with other health practitioners. Arguably, if the research on CBT-based approaches is to have any translational value in terms of accessible health care for people with disabling chronic pain conditions, it needs to be shown that the skills required can be taught to a range of health practitioners and that they can conduct CBT-based methods for pain effectively. While many psychologists have been the primary drivers of the research and development of CBT-based pain management approaches, relying on having sufficient numbers of psychologists to deliver this modality of treatment in clinical practice is, in most countries, quite unrealistic. In this context, the paper by Broderick et al. (this issue) [1] on the use of CBT methods by nurse practitioners to treat patients with troubling pain associated with osteoarthritis has important implications for extending the accessibility of this evidence-based treatment for people with chronic pain generally. Multidisciplinary pain programs that are CBT based do have a strong record of training non-psychology health practitioners in the use of CBT skills in that context [12]. But this is not the same as having non-psychology health practitioners conduct the CBT-based treatment independently. Several studies have reported outcomes by physical therapists integrating selected CBT methods within their treatments, especially techniques like graded activity and graded exposure [5,10], but accounts of the training provided and competency evaluation have not been well described. Given that competence in treatment skills has been repeatedly raised as a key question by reviewers of CBT-based pain management studies [9], it is noticeable that the topic has received relatively little attention in the pain literature. In a study by Pengel et al. [10] that evaluates advice and graded activities for low back pain patients, the physical therapists were asked to read a book chapter on the techniques and to attend a 1-hour small group session to discuss and briefly practice specific skills. Other than an oral test and discussion of the principles on which the treatment was based, competency wasn’t evaluated and there was no extended supervised practice. George et al. [5] described a similar 1-session training course for the physical therapists used in a series of studies on graded exposure with low back pain patients, and they did have to pass a written test of their knowledge. They also used a study protocol to guide the treatment program. Kroenke et al. [7] described a series of studies with patients identified as having both musculoskeletal pain and elevated depression severity using nurses trained in the pain self-management methods described earlier by Lorig and Holman [8]. The training process is well described, but a meta-analysis of these methods for osteoarthritis concluded they seemed to have no clinically beneficial effects on pain or function [3]. The series of studies reported by Kroenke et al. [7] involve a combination of both optimised (individually titrated) antidepressant medication and 6 sessions of nurse-conducted pain self-management training. However, it is not clear how much the self-management training contributed to the outcomes. In sum, while there is accumulating evidence that CBT can be provided with some effect by nonpsychologists, there is wide variance in the training methods and assessment of competence. Also, as most of the reported trials with nonpsychologists as the therapist have used physical therapists, it is a welcome development to see nurse practitioners being included in both the Kroenke and Broderick studies, as this group are in a position to really expand accessible pain management services internationally, consistent with the Declaration of Montreal [4]. The paper in this issue by Broderick et al. [1] describes the use of a structured training program for nurses that used a psychologist with extensive experience in pain management and training, a manual, opportunities for discussion, mandatory rehearsal of the methods, and a behavioural assessment of competence. The same training methods have recently been successfully applied, by the same psychologist, in Australia, with physical therapists [2]. In their multi-site RCT study with osteoarthritis patients who had chronic pain of the knee or hip, Broderick et al. [1] found that relative to a usual care control group, a 10-session intervention utilising manualised Pain Coping Skills Training [6] resulted in significant improvements on a range of patient-relevant measures. These included pain intensity, physical functioning, psychological distress, use of pain-coping strategies, and self-efficacy, as well as fatigue, satisfaction with health, and reduced use of pain medication. Importantly for the significance of the trial, the treatment effects were robust to the covariate of clinical sites. At 12-month follow-up, all gains, except for self-efficacy, were maintained. Importantly also for the self-management skills taught, the researchers found that those patients who were more adherent had greater benefits than those who were less adherent. In summary, this study indicates that nurse practitioners can be taught to use CBT-based pain management methods and they can use these methods to achieve outcomes as good as any reported by other health practitioners using similar approaches. This finding has important implications for improving the access to this form of treatment for chronic pain in the community generally, but it also points to the value of investing in carefully structured training in the use of CBT methods in chronic pain management. Conflict of interest statement The author has no conflicts of interest to report.

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