Pain Relief Class Noninferior to CBT in Adults with Chronic Low Back Pain


Study shows single-session pain relief class noninferior to 8-session cognitive behavioral therapy for pain catastrophizing, pain intensity, and pain interference.

Beth D. Darnall, PhD

Beth D. Darnall, PhD

Although cognitive behavioral therapy (CBT) is an effective option in reduction of chronic low back pain (CLBP), there are barriers to access including time, cost, and therapist availability, creating a need for lower-intensity options.

A recent study aimed to determine if a single class in evidence-based pain management skills is non-inferior to an 8-session CBT class at 3 months after treatment.

Investigators, led by Beth D. Darnall, PhD, Stanford University School of Medicine, observed a single-session pain management class showed clinically significant improvements in pain that were non-inferior to 8-session CBT at 3 months.


The 3-arm randomized clinical trial tested for non-inferiority in comparison of empowered relief versus CBT and superiority in the comparison of empowered relief versus health education and CBT versus health education.

Data was collected from May 2017 - March 2020 with participants composed of adults with self-reported CBLP for ≥6 months.

Study participants were randomized to either empowered relief, health education, or an 8-session CBT. Investigators collected self-reported data from patients at baseline, before treatment, and month 1, 2, and 3 of post-treatment.

Empowered relief consisted of a 2-hour pain class that included pain neuroscience education, mindfulness principles, and CBT skills, while the health education class matched empowered relief through duration, structure, format, and site.

In addition, the CBT group attended a total of 8 2-hour sessions delivered by psychologists, which spanned pain topics and pain relief skills.

The primary efficacy outcomes included the 13-item Pain Catastrophizing Scale score at 3 months following treatment. The scale measured the frequency of cognitive responses to pain, with responses ranging from 0 (not at all) to 4 (all the time). Secondary outcomes included pain intensity and pain interference.


The analysis consisted of 263 individuals, with 131 women (49.8%) and a mean age of 47.9 years.  Data show 64.6% (n = 170) of patients had a CLBP duration of >5 years and 48.3% (n = 127) had ≥1 comorbid chronic pain condition.

Patients were randomized to each of the 3 arms, with 87 patients in empowered relief, 88 patients in CBT, and 88 patients in health education.

Investigators found non-inferiority for empower relief in comparison to CBT for pain catastrophizing scores 3 months following treatment (difference, 1.39; 97.5%, ∞ to 4.24).

Data show clinically meaningful pain catastrophizing scores in empowered relief (-9.12; 95% CI, -11.6 to -6.67; P <.001) and CBT (−10.94; 95% CI, −13.6 to −8.32; P < .001).

In addition, empowered relief and CBT showed superiority to health education scores in pain catastrophizing scores. Data show a difference of -5.90 (95% CI, −8.78 to −3.01; P < .00) between empowered relief and health education. In addition, a difference of -7.29 (95% CI, −10.20 to −4.38; P < .001) was observed between CBT and health education.

Furthermore, empowered relief showed non-inferiority to CBT for pain intensity and pain interference, as well as sleep disturbance or pain bothersomeness.


The team noted the single-site study consisted of mostly White patients and studied only CBLP, which may have resulted in limited results in determining pain management effectiveness.

“Future effectiveness research should include diverse patients and pain conditions, test online delivery, and address pragmatic integration into primary care,” investigators wrote.

The study, “Comparison of a Single-Session Pain Management Skills Intervention With a Single-Session Health Education Intervention and 8 Sessions of Cognitive Behavioral Therapy in Adults With Chronic Low Back Pain,” was published in JAMA Network Open.

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