Randomized controlled trial of medical assistant-coached behavioral intervention for chronic pain

Chronic spinal pain with widespread symptoms often responds poorly to peripherally focused treatments. Cognitive-behavioral therapy (CBT) can help but typically yields modest effects. This trial evaluated whether adding resilience-enhancing activities to medical assistant-coached CBT (PRISM-CBT) improves outcomes.

Adults with spinal pain and fibromyalgia symptoms were randomized to PRISM-CBT (n=119), standard CBT (n=120), or usual care (UC; n=60). The primary outcome was the Fibromyalgia Impact Questionnaire-Revised (FIQR) global impact score at 8 weeks (0-100; higher=worse). Secondary outcomes were pain interference and pain severity measured with the Brief Pain Inventory (BPI) (0-10; higher=worse).

The primary outcome showed no difference between PRISM-CBT and usual care at 8 weeks, with an adjusted between-group difference of 0.20 points (95% CI -4.81 to 5.20, p=0.939). Yet, by 12 months, PRISM-CBT demonstrated a 7.4-point greater improvement compared with usual care (95% CI 0.15 to 14.64, p=0.045) and a 4.8-point greater improvement versus CBT at 8 weeks (95% CI 0.00 to 9.57, p=0.050). PRISM-CBT produced the most consistent benefit in BPI pain interference. Compared with usual care, interference was lower by 0.88 points at both 8 weeks (95% CI 0.25 to 1.50, p=0.006) and 6 months (95% CI 0.23 to 1.54, p=0.009) and by 1.42 points at 12 months (95% CI 0.53 to 2.32, p=0.002). Compared with standard CBT, interference was lower at 8 weeks (0.98 points, 95% CI 0.38 to 1.57, p=0.001), 6 months (0.63 points, 95% CI 0.01 to 1.25, p=0.045), and 12 months (1.92 points, 95% CI 1.09 to 2.76, p<0.001). BPI pain severity also favored PRISM-CBT, with greater improvements of 0.56 points vs usual care at 6 months (95% CI 0.03 to 1.08, p=0.039) and 0.86 points vs CBT at 12 months (95% CI 0.19 to 1.53, p=0.011).

This scalable, medical assistant-coached digital program shows promising benefits, including greater reductions in pain interference and a long-term improvement in global symptom burden, despite no difference at the primary endpoint.