Combined Internet-Based Cognitive Behavioral Therapy and Face-to-Face Physiotherapy in Primary Health Care for...

Finding successful treatments for chronic widespread pain (CWP) in primary care is challenging. Interventions addressing both stress and pain may yield synergistic effects. Internet-based cognitive behavioral therapy (iCBT) reduces stress-related pain responses, while physical activity enhances function and resilience. Combined, they may target core CWP mechanisms.

This study aimed to evaluate the effectiveness of therapist-guided iCBT for stress management combined with physiotherapist-guided physical activity, compared to stand-alone physical activity, on pain and associated symptoms in individuals with CWP.

Participants with CWP, aged 18-70 years, were recruited in this parallel, multicenter randomized controlled trial via social media in Sweden. The intervention group received a 14-module iCBT program plus a physical activity plan; the control group received the physical activity plan only. Primary outcomes were pain intensity and pain locations. Secondary outcomes included stress, fatigue, depression, and quality of life. Variables were self-assessed using paper questionnaires at baseline and 6 months. Allocation was concealed; participants and researchers were not blinded.

Of 129 participants (64 intervention, 65 control), 82 (64%) completed the 6-month follow-up. In the intervention group, 37% (16/43) completed all 14 iCBT modules. No between-group differences were observed for change in any outcome: pain intensity (mean 1.7, 95% CI -7.5 to 11.0), pain locations (mean -0.8, 95% CI -2.2 to 0.6), Stress and Crisis Inventory (mean 2.0, 95% CI -3.3 to 7.4), Fibromyalgia Impact Questionnaire (mean 2.7, 95% CI -3.7 to 9.2), global fatigue (mean 3.0, 95% CI -7.2 to 13.3), Multidimensional Fatigue Inventory (general fatigue: mean 0.1, 95% CI -1.1 to 1.3; physical: mean 0.4, 95% CI -1.1 to 1.9; mental: mean 0.4, 95% CI -1.1 to 2.0; reduced activity: mean -2.8, 95% CI -0.5 to 2.1; reduced motivation mean -0.5, 95% CI -2.2 to 1.2), Hospital Anxiety and Depression Scale (anxiety: mean -0.8, 95% CI -2.3 to 0.7; depression: mean -0.2, 95% CI -1.7 to 1.3), and Short-Form 36 subscales (physical function: mean 2.9, 95% CI -3.7 to 9.5; role physical: mean -13.1, 95% CI -28.3 to 2.0; role emotional: mean -4.0, 95% CI -22.8 to 14.8; energy/fatigue: mean 3.4, 95% CI -4.0 to 10.8; emotional well-being: mean -0.5, 95% CI -8.2 to 7.3; social functioning: mean -4.6, 95% CI -15.0 to 5.8; pain: mean -3.1, 95% CI -9.8 to 3.6; general health: mean -2.2, 95% CI -9.2 to 4.9). Both groups improved across several outcomes. Main goals were attained by 37% (17/46) in the intervention group vs 19% (8/42) in controls (P=.02), and intermediate goals by 54% (25/46) vs 36% (15/42; P=.01).

This study novelly examines stress-targeting interventions for pain. Clinicians could focus on tailored physical activity plans while considering optional stress management to support behavioral change and goal attainment. Due to high loss to follow-up, results should be interpreted cautiously.

ClinicalTrials.gov NCT04624139; https://clinicaltrials.gov/study/NCT04624139.