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

BACKGROUND: 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. METHODS: 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). RESULTS: 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). CONCLUSIONS: 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.