Chronic musculoskeletal pain (CP) is a major public health concern. A number of
psychosocial treatments have emerged in recent decades to help address this problem.
These interventions have been shown to be efficacious when compared to largely inert
control conditions; however, recent meta-analyses indicate that most of these treatments
are characterized by modest effects on primary outcomes. This is a critical shortcoming
of these otherwise promising approaches. Rather than attempting to boost efficacy only by
developing new and hopefully more powerful interventions, we can also look within our
already proven treatments for ways to enhance the magnitude of treatment effects. One
strategy is to increase our understanding of treatment mediators. Studies of mediators
that directly compare different treatments with each other are needed to determine which
mediators are treatment-specific, which are shared across treatments, and which
contribute the most to clinical outcomes. The findings from such research could be used
to inform adaptations to existing treatment that enhance their benefits. A second
strategy for increasing the beneficial effects of existing treatments is to identify the
patient characteristics that moderate treatment responses. Research is needed that is
guided by theoretical models and that tests moderators across multiple treatments.
Identifying subgroups of patients more likely to respond to one or another treatment can
advance precision medicine by informing a priori patient-treatment matches that can
optimize treatment effects. To accomplish these goals, we will conduct a randomized
clinical trial to compare the mediators and moderators of the clinical effects of
Cognitive-Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and
Emotional Awareness and Expression Therapy (EAET) on adults with chronic spinal (axial)
pain. Following baseline assessment of outcome variables as well as potential mediators
and moderators we will randomize 460 participants to CBT, ACT, EAET, or
treatment-as-usual control (TAU). The three treatments will be conducted as individual
therapy provided weekly for 8 weeks via telehealth. We will conduct weekly assessments of
both potential mediators and outcomes, as well as post-treatment and 6-month follow-up
assessments. In addition to comparing the three treatments to each other (and TAU) for
overall efficacy, we focus on two specific aims: Aim 1 is to identify mediators that are
specific to treatments and those that are shared across treatments. Aim 2 is to identify
baseline moderators of specific treatments and general predictors across treatments. This
project can increase the effects of our psychosocial chronic pain treatments by
identifying the most powerful treatment mechanisms - specific and shared -- and revealing
for whom the mediator-outcome pathways are strongest. Via increased understanding of
mediator and moderators, more effective pain treatment approaches can be developed,
tested, and implemented.