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Association Between Psychological Interventions and Chronic Pain Outcomes in Older AdultsA Systematic Review and Meta-analysis

Educational Objective
To determine the efficacy of psychological interventions in older adults with chronic pain and whether treatment effects vary by participant, intervention, and study characteristics.
1 Credit CME
Key Points

Question  Do older adults with chronic pain benefit from psychological therapies?

Findings  In this systematic review and meta-analysis including 22 studies with 2608 participants, psychological interventions that used cognitive behavioral therapy modalities were associated with statistically significant benefits in terms of reduced pain and catastrophizing beliefs as well as improved self-efficacy for managing pain. Benefits were small and documented at the time of treatment completion; with the exception of pain reduction, evidence is lacking for the persistence of observed benefits in other assessments conducted up to 6 months later.

Meaning  Among older adults with chronic pain, psychological therapies have a small, but statistically significant, benefit for reducing pain and catastrophizing beliefs and improving self-efficacy for managing pain.

Abstract

Importance  Chronic noncancer pain (hereafter referred to as chronic pain) is common among older adults and managed frequently with pharmacotherapies that produce suboptimal outcomes. Psychological treatments are recommended, but little information is available regarding their efficacy in older adults.

Objective  To determine the efficacy of psychological interventions in older adults with chronic pain and whether treatment effects vary by participant, intervention, and study characteristics.

Data Sources  MEDLINE, Embase, PsycINFO, and the Cochrane Library were searched from inception to March 29, 2017.

Study Selection  Analysis included studies that (1) used a randomized trial design, (2) evaluated a psychological intervention that used cognitive behavioral modalities alone or in combination with another strategy, (3) enrolled individuals with chronic pain (pain ≥3 months) with a sample mean age of 60 years or older, and (4) reported preintervention and postintervention quantitative data.

Data Extraction and Synthesis  Two of the authors independently extracted data. A mixed-model meta-analysis tested the effects of treatment on outcomes. Analyses were performed to investigate the association between participant (eg, age), intervention (eg, treatment mode delivery), and study (eg, methodologic quality) characteristics with outcomes.

Main Outcomes and Measures  Pain intensity was the primary outcome; secondary outcomes included pain interference, depressive symptoms, anxiety, catastrophizing beliefs, self-efficacy for managing pain, physical function, and physical health.

Results  Twenty-two studies with 2608 participants (1799 [69.0%] women) were analyzed. Participants’ mean (SD) age was 71.9 (7.1) years. Differences of standardized mean differences (dD) at posttreatment were pain intensity (dD = −0.181, P = .006), pain interference (dD = −0.133, P = .12), depressive symptoms (dD = −0.128, P = .14), anxiety (dD = −0.205, P = .09), catastrophizing beliefs (dD = −0.184, P = .046), self-efficacy (dD = 0.193, P = .02), physical function (dD = 0.006, P = .96), and physical health (dD = 0.160, P = .24). There was evidence of effects persisting beyond the posttreatment assessment only for pain (dD = −0.251, P = .002). In moderator analyses, only mode of therapy (group vs individual) demonstrated a consistent effect in favor of group-based therapy.

Conclusions and Relevance  Psychological interventions for the treatment of chronic pain in older adults have small benefits, including reducing pain and catastrophizing beliefs and improving pain self-efficacy for managing pain. These results were strongest when delivered using group-based approaches. Research is needed to develop and test strategies that enhance the efficacy of psychological approaches and sustainability of treatment effects among older adults with chronic pain.

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Article Information

Accepted for Publication: January 31, 2018.

Corresponding Author: M. Carrington Reid, MD, PhD, Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065 (mcr2004@med.cornell.edu).

Published Online: May 7, 2018. doi:10.1001/jamainternmed.2018.0756

Author Contributions: Dr Reid had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Niknejad, Bolier, Henderson, Delgado, Kozlov, Reid.

Acquisition, analysis, or interpretation of data: Bolier, Henderson, Delgado, Kozlov, Löckenhoff, Reid.

Drafting of the manuscript: Niknejad, Bolier, Henderson, Delgado, Reid.

Critical revision of the manuscript for important intellectual content: Bolier, Henderson, Kozlov, Löckenhoff, Reid.

Statistical analysis: Henderson.

Administrative, technical, or material support: Niknejad, Bolier, Henderson, Delgado.

Study supervision: Bolier, Henderson, Reid.

Conflict of Interest Disclosures: None reported.

Funding/Support: Drs Löckenhoff and Reid are supported by Edward R. Roybal Translational Research on Aging award P30AG022845 from the National Institute on Aging. Dr Reid is also supported by National Institute on Aging award K24AGO53462, an investigator-initiated award from Pfizer Pharmaceuticals, and the Howard and Phyllis Schwartz Philanthropic Fund. Dr Kozlov is supported by National Institute on Aging grant T32AG049666.

Role of the Funder/Sponsor: The funders and sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data, preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or other funders.

References
1.
Makris  UE, Abrams  RC, Gurland  B, Reid  MC.  Management of persistent pain in the older patient: a clinical review.  JAMA. 2014;312(8):825-836.PubMedGoogle ScholarCrossref
2.
Patel  KV, Guralnik  JM, Dansie  EJ, Turk  DC.  Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study.  Pain. 2013;154(12):2649-2657.PubMedGoogle ScholarCrossref
3.
Gaskin  DJ, Richard  P.  The economic costs of pain in the United States.  J Pain. 2012;13(8):715-724.PubMedGoogle ScholarCrossref
4.
Savvas  SM, Gibson  SJ.  Overview of pain management in older adults.  Clin Geriatr Med. 2016;32(4):635-650.PubMedGoogle ScholarCrossref
5.
Reid  MC, Eccleston  C, Pillemer  K.  Management of chronic pain in older adults.  BMJ. 2015;350:h532.PubMedGoogle ScholarCrossref
6.
Rastogi  R, Meek  BD.  Management of chronic pain in elderly, frail patients: finding a suitable, personalized method of control.  Clin Interv Aging. 2013;8:37-46.PubMedGoogle ScholarCrossref
7.
Spitz  A, Moore  AA, Papaleontiou  M, Granieri  E, Turner  BJ, Reid  MC.  Primary care providers’ perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study.  BMC Geriatr. 2011;11:35.PubMedGoogle ScholarCrossref
8.
O’Neil  CK, Hanlon  JT, Marcum  ZA.  Adverse effects of analgesics commonly used by older adults with osteoarthritis: focus on non-opioid and opioid analgesics.  Am J Geriatr Pharmacother. 2012;10(6):331-342.PubMedGoogle ScholarCrossref
9.
Nelson  LS, Juurlink  DN, Perrone  J.  Addressing the opioid epidemic.  JAMA. 2015;314(14):1453-1454.PubMedGoogle ScholarCrossref
10.
Williams  AC, Eccleston  C, Morley  S.  Psychological therapies for the management of chronic pain (excluding headache) in adults.  Cochrane Database Syst Rev. 2012;11(11):CD007407.PubMedGoogle Scholar
11.
Lunde  LH, Nordhus  IH, Pallesen  S.  The effectiveness of cognitive and behavioural treatment of chronic pain in the elderly: a quantitative review.  J Clin Psychol Med Settings. 2009;16(3):254-262.PubMedGoogle ScholarCrossref
12.
Committee on Advancing Pain Research Care and Education.  Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 2nd ed. Washington, DC: National Academies Press; 2011.
13.
Schneiderhan  J, Clauw  D, Schwenk  TL.  Primary care of patients with chronic pain.  JAMA. 2017;317(23):2367-2368.PubMedGoogle ScholarCrossref
14.
Kerns  RD, Sellinger  J, Goodin  BR.  Psychological treatment of chronic pain.  Annu Rev Clin Psychol. 2011;7:411-434.PubMedGoogle ScholarCrossref
15.
McGuire  BE, Nicholas  MK, Asghari  A, Wood  BM, Main  CJ.  The effectiveness of psychological treatments for chronic pain in older adults: cautious optimism and an agenda for research.  Curr Opin Psychiatry. 2014;27(5):380-384.PubMedGoogle ScholarCrossref
16.
Ehde  DM, Dillworth  TM, Turner  JA.  Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research.  Am Psychol. 2014;69(2):153-166.PubMedGoogle ScholarCrossref
17.
Sturgeon  JA.  Psychological therapies for the management of chronic pain.  Psychol Res Behav Manag. 2014;7:115-124.PubMedGoogle ScholarCrossref
18.
Hofmann  SG, Sawyer  AT, Fang  A.  The empirical status of the “new wave” of cognitive behavioral therapy.  Psychiatr Clin North Am. 2010;33(3):701-710.PubMedGoogle ScholarCrossref
19.
Yu  L, McCracken  LM.  Model and processes of acceptance and commitment therapy (ACT) for chronic pain including a closer look at the self.  Curr Pain Headache Rep. 2016;20(2):12.PubMedGoogle ScholarCrossref
20.
Liberati  A, Altman  DG, Tetzlaff  J,  et al.  The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.  PLoS Med. 2009;6(7):e1000100.PubMedGoogle ScholarCrossref
21.
BMJ Clinical Evidence. Study design search filters. http://clinicalevidence.bmj.com/x/set/static/ebm/learn/665076.html. Updated September 20, 2012. Accessed August 23, 2017.
22.
Keefe  FJ, Caldwell  DS, Williams  DA,  et al.  Pain coping skills training in the management of osteoarthritic knee pain: a comparative study.  Behav Ther. 1990;21:49-62.Google ScholarCrossref
23.
Nicholas  MK, Asghari  A, Blyth  FM,  et al.  Self-management intervention for chronic pain in older adults: a randomised controlled trial.  Pain. 2013;154(6):824-835.PubMedGoogle ScholarCrossref
24.
Bennell  KL, Ahamed  Y, Jull  G,  et al.  Physical therapist–delivered pain coping skills training and exercise for knee osteoarthritis: randomized controlled trial.  Arthritis Care Res (Hoboken). 2016;68(5):590-602.PubMedGoogle ScholarCrossref
25.
Hurley  MV, Walsh  NE, Mitchell  HL,  et al.  Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial.  Arthritis Rheum. 2007;57(7):1211-1219.PubMedGoogle ScholarCrossref
26.
Vitiello  MV, McCurry  SM, Shortreed  SM,  et al.  Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: the lifestyles randomized controlled trial.  J Am Geriatr Soc. 2013;61(6):947-956.PubMedGoogle ScholarCrossref
27.
Dworkin  RH, Turk  DC, Farrar  JT,  et al; IMMPACT.  Core outcome measures for chronic pain clinical trials: IMMPACT recommendations.  Pain. 2005;113(1-2):9-19.PubMedGoogle ScholarCrossref
28.
Alonso-Fernández  M, López-López  A, Losada  A, González  JL, Wetherell  JL.  Acceptance and commitment therapy and selective optimization with compensation for Institutionalized older people with chronic pain.  Pain Med. 2016;17(2):264-277.PubMedGoogle Scholar
29.
Andersson  G, Johansson  C, Nordlander  A, Asmundson  GJ.  Chronic pain in older adults: a controlled pilot trial of a brief cognitive-behavioural group treatment.  Behav Cogn Psychother. 2012;40(2):239-244.PubMedGoogle ScholarCrossref
30.
Appelbaum  KA, Blanchard  EB, Hickling  EJ, Alfonso  M.  Cognitive behavioral treatment of a veteran population with moderate to severe rheumatoid arthritis.  Behav Ther. 1988;19(4):489-502.Google ScholarCrossref
31.
Berman  RL, Iris  MA, Bode  R, Drengenberg  C.  The effectiveness of an online mind-body intervention for older adults with chronic pain.  J Pain. 2009;10(1):68-79.PubMedGoogle ScholarCrossref
32.
Carmody  TP, Duncan  CL, Huggins  J,  et al.  Telephone-delivered cognitive-behavioral therapy for pain management among older military veterans: a randomized trial.  Psychol Serv. 2013;10(3):265-275.PubMedGoogle ScholarCrossref
33.
Cederbom  S, Denison  E, Bergland  A.  A behavioral medicine intervention for community-dwelling older adults with chronic musculoskeletal pain: protocol for a randomized controlled trial.  J Pain Res. 2017;10:845-853.PubMedGoogle ScholarCrossref
34.
Cook  AJ.  Cognitive-behavioral pain management for elderly nursing home residents.  J Gerontol B Psychol Sci Soc Sci. 1998;53(1):51-59.PubMedGoogle ScholarCrossref
35.
Ersek  M, Turner  JA, McCurry  SM, Gibbons  L, Kraybill  BM.  Efficacy of a self-management group intervention for elderly persons with chronic pain.  Clin J Pain. 2003;19(3):156-167.PubMedGoogle ScholarCrossref
36.
Ersek  M, Turner  JA, Cain  KC, Kemp  CA.  Results of a randomized controlled trial to examine the efficacy of a chronic pain self-management group for older adults [ISRCTN11899548].  Pain. 2008;138(1):29-40.PubMedGoogle ScholarCrossref
37.
Haas  M, Groupp  E, Muench  J,  et al.  Chronic disease self-management program for low back pain in the elderly.  J Manipulative Physiol Ther. 2005;28(4):228-237.PubMedGoogle ScholarCrossref
38.
Hunt  MA, Keefe  FJ, Bryant  C,  et al.  A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study.  Knee. 2013;20(2):106-112.PubMedGoogle ScholarCrossref
39.
Kwok  EYT, Au  RKC, Li-Tsang  CWP.  The effect of a self-management program on the quality-of-life of community-dwelling older adults with chronic musculoskeletal knee pain: a pilot randomized controlled trial.  Clin Gerontol. 2016;39(5):428-448.PubMedGoogle ScholarCrossref
40.
Morone  NE, Greco  CM, Weiner  DK.  Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study.  Pain. 2008;134(3):310-319.PubMedGoogle ScholarCrossref
41.
Morone  NE, Greco  CM, Moore  CG,  et al.  A mind-body program for older adults with chronic low back pain: a randomized clinical trial.  JAMA Intern Med. 2016;176(3):329-337.PubMedGoogle ScholarCrossref
42.
Nicholas  MK, Asghari  A, Blyth  FM,  et al.  Long-term outcomes from training in self-management of chronic pain in an elderly population: a randomized controlled trial.  Pain. 2017;158(1):86-95.PubMedGoogle ScholarCrossref
43.
Rini  C, Williams  DA, Broderick  JE, Keefe  FJ.  Meeting them where they are: using the internet to deliver behavioral medicine interventions for pain.  Transl Behav Med. 2012;2(1):82-92.PubMedGoogle ScholarCrossref
44.
Tse  MM, Au  EYM, Wong  AMH.  Total pain concept: multisensory stimulation, exercise therapy and coping skill training for community-dwelling older persons with chronic pain.  J Pain Manage. 2011;4(4):403-416.PubMedGoogle Scholar
45.
Yip  YB, Sit  JW, Fung  KK,  et al.  Impact of an Arthritis Self-Management Programme with an added exercise component for osteoarthritic knee sufferers on improving pain, functional outcomes, and use of health care services: an experimental study.  Patient Educ Couns. 2007;65(1):113-121.PubMedGoogle ScholarCrossref
46.
Yates  SL, Morley  S, Eccleston  C, de C Williams  AC.  A scale for rating the quality of psychological trials for pain.  Pain. 2005;117(3):314-325.PubMedGoogle ScholarCrossref
47.
Henderson  CR  Jr.  Analysis of covariance in the mixed model: higher-level, nonhomogeneous, and random regressions.  Biometrics. 1982;38(3):623-640.PubMedGoogle ScholarCrossref
48.
DerSimonian  R, Laird  N.  Meta-analysis in clinical trials.  Control Clin Trials. 1986;7(3):177-188.PubMedGoogle ScholarCrossref
49.
Egger  M, Davey Smith  G, Schneider  M, Minder  C.  Bias in meta-analysis detected by a simple, graphical test.  BMJ. 1997;315(7109):629-634.PubMedGoogle ScholarCrossref
50.
National Academies of Sciences, Engineering, and Medicine.  Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: National Academies Press; 2017.
51.
Dowell  D, Haegerich  TM, Chou  R.  CDC guideline for prescribing opioids for chronic pain—United States, 2016.  JAMA. 2016;315(15):1624-1645.PubMedGoogle ScholarCrossref
52.
Fraser  SN, Spink  KS.  Examining the role of social support and group cohesion in exercise compliance.  J Behav Med. 2002;25(3):233-249.PubMedGoogle ScholarCrossref
53.
Chou  R, Deyo  R, Friedly  J,  et al.  Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline.  Ann Intern Med. 2017;166(7):493-505.PubMedGoogle ScholarCrossref
54.
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons.  Pharmacological management of persistent pain in older persons.  J Am Geriatr Soc. 2009;57(8):1331-1346.PubMedGoogle ScholarCrossref
55.
Abdulla  A, Adams  N, Bone  M,  et al; British Geriatric Society.  Guidance on the management of pain in older people.  Age Ageing. 2013;42(suppl 1):i1-i57.PubMedGoogle ScholarCrossref
56.
Bennell  KL, Hinman  RS.  A review of the clinical evidence for exercise in osteoarthritis of the hip and knee.  J Sci Med Sport. 2011;14(1):4-9.PubMedGoogle ScholarCrossref
57.
Becker  WC, Dorflinger  L, Edmond  SN, Islam  L, Heapy  AA, Fraenkel  L.  Barriers and facilitators to use of non-pharmacological treatments in chronic pain.  BMC Fam Pract. 2017;18(1):41.PubMedGoogle ScholarCrossref
58.
Tse  MM, Wan  VT, Ho  SS.  Physical exercise: does it help in relieving pain and increasing mobility among older adults with chronic pain?  J Clin Nurs. 2011;20(5-6):635-644.PubMedGoogle ScholarCrossref
59.
Hall  A, Copsey  B, Richmond  H,  et al.  Effectiveness of tai chi for chronic musculoskeletal pain conditions: updated systematic review and meta-analysis.  Phys Ther. 2017;97(2):227-238.PubMedGoogle ScholarCrossref
60.
Cheung  C, Wyman  JF, Bronas  U, McCarthy  T, Rudser  K, Mathiason  MA.  Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial.  Rheumatol Int. 2017;37(3):389-398.PubMedGoogle ScholarCrossref
61.
Löckenhoff  CE, Rutt  JL.  Age differences in self-continuity: converging evidence and directions for future research.  Gerontologist. 2017;57(3):396-408.PubMedGoogle ScholarCrossref
62.
Mikels  JA, Reed  AE, Hardy  LN, Loeckenhoff  CE. Positive emotions across the adult life span. In: Tugade  MM, Shiota  MN, Kirby  LD, eds.  Handbook of Positive Emotions. New York: Guilford Press; 2014:256-272.
63.
Salthouse  TA.  Theoretical Perspectives on Cognitive Aging. New York: Routledge; 1991.
64.
Carstensen  LL.  The influence of a sense of time on human development.  Science. 2006;312(5782):1913-1915.PubMedGoogle ScholarCrossref
65.
Reed  AE, Carstensen  LL.  The theory behind the age-related positivity effect.  Front Psychol. 2012;3:339.PubMedGoogle ScholarCrossref
66.
Notthoff  N, Carstensen  LL.  Positive messaging promotes walking in older adults.  Psychol Aging. 2014;29(2):329-341.PubMedGoogle ScholarCrossref
67.
Parker  SJ, Jessel  S, Richardson  JE, Reid  MC.  Older adults are mobile too! identifying the barriers and facilitators to older adults’ use of mHealth for pain management.  BMC Geriatr. 2013;13(1):43.PubMedGoogle ScholarCrossref
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