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Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain

Published:September 27, 2022DOI:https://doi.org/10.1016/j.jpain.2022.09.014

      Highlights

      • Few patient characteristics predicted benefits of cognitive-behavioral therapy (CBT) versus mindfulness-based stress reduction (MBSR).
      • Nonjudging of one's thoughts/feelings predicted greater benefit from MBSR versus CBT.
      • Less nonjudging of thoughts/feelings predicted greater benefit from CBT versus MBSR.
      • Pain control beliefs and lower anxiety predicted improvement regardless of treatment.

      Abstract

      Both mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) are effective for chronic low back pain (CLBP), but little is known regarding who might benefit more from one than the other. Using data from a randomized trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with CLBP (N = 297), we examined baseline characteristics that moderated treatment effects or were associated with improvement regardless of treatment. Outcomes included 8-week function (modified Roland Disability Questionnaire), pain bothersomeness (0–10 numerical rating scale), and depression (Patient Health Questionnaire-8). There were differences in the effects of CBT versus MBSR on pain based on participant gender (P = .03) and baseline depressive symptoms (P = .01), but the only statistically significant moderator after Bonferroni correction was the nonjudging dimension of mindfulness. Scores on this measure moderated the effects of CBT versus MBSR on both function (P = .001) and pain (P = .04). Pain control beliefs (P <.001) and lower anxiety (P < .001) predicted improvement regardless of treatment. Replication of these findings is needed to guide treatment decision-making for CLBP.

      Trial Registration

      The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT01467843).

      Perspective

      Although few potential moderators and nonspecific predictors of benefits from CBT or MBSR for CLBP were statistically significant after adjustment for multiple comparisons, these findings suggest potentially fruitful directions for confirmatory research while providing reassurance that patients could reasonably expect to benefit from either treatment.

      Key Words

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      References

        • Anheyer D
        • Haller H
        • Barth J
        • Lauche R
        • Dobos G
        • Cramer H
        Mindfulness-based stress reduction for treating low back pain: A systematic review and meta-analysis.
        Ann Intern Med. 2017; 166: 799
        • Artus M
        • Campbell P
        • Mallen CD
        • Dunn KM
        • van der Windt DAW
        Generic prognostic factors for musculoskeletal pain in primary care: A systematic review.
        BMJ Open. 2017; 7e012901
        • Blacker M
        • Meleo-Meyer F
        • Kabat-Zinn J
        • Santorelli S
        Stress Reduction Clinic Mindfulness-Based Stress Reduction (MBSR) Curriculum Guide.
        Center for Mindfulness in Medicine, Health Care and Society, University of Massachusetts Medical School, Worcester, MA2009
        • Bohlmeijer E
        • ten Klooster PM
        • Fledderus M
        • Veehof M
        • Baer R
        Psychometric properties of the Five Facet Mindfulness Questionnaire in depressed adults and development of a short form.
        Assessment. 2011; 18: 308-320
        • Broderick JE
        • Keefe FJ
        • Schneider S
        • Junghaenel DU
        • Bruckenthal P
        • Schwartz JE
        • Kaell AT
        • Caldwell DS
        • McKee D
        • Gould E
        Cognitive behavioral therapy for chronic pain is effective, but for whom?.
        PAIN. 2016; 157: 2115-2123
        • Brown MM
        • Arigo D
        • Wolever RQ
        • Smoski MJ
        • Hall MH
        • Brantley JG
        • Greeson JM
        Do gender, anxiety, or sleep quality predict mindfulness-based stress reduction outcomes?.
        J Health Psychol. 2021; 26: 2656-2662
        • Burgess R
        • Mansell G
        • Bishop A
        • Lewis M
        • Hill J
        Predictors of functional outcome in musculoskeletal healthcare: An umbrella review.
        Eur J Pain. 2020; 24: 51-70
        • Burns JW
        • Jensen MP
        • Thorn B
        • Lillis TA
        • Carmody J
        • Newman AK
        • Keefe F
        Cognitive therapy, mindfulness-based stress reduction, and behavior therapy for the treatment of chronic pain: randomized controlled trial.
        PAIN. 2022; 163: 376-389
        • Burns JW
        • Van Dyke BP
        • Newman AK
        • Morais CA
        • Thorn BE
        Cognitive behavioral therapy (CBT) and pain education for people with chronic pain: Tests of treatment mechanisms.
        J Consult Clin Psychol. 2020; 88: 1008-1018
        • Caudill M
        Managing Pain Before it Manages You.
        Rev. ed. Guilford Press, New York, NY2002
        • Chen Y
        • Campbell P
        • Strauss VY
        • Foster NE
        • Jordan KP
        • Dunn KM
        Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up.
        PAIN. 2018; 159: 252-260
        • Cherkin DC
        • Anderson ML
        • Sherman KJ
        • Balderson BH
        • Cook AJ
        • Hansen KE
        • Turner JA
        Two-year follow-up of a randomized clinical trial of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain.
        JAMA. 2017; 317: 642
        • Cherkin DC
        • Sherman KJ
        • Balderson BH
        • Cook AJ
        • Anderson ML
        • Hawkes RJ
        • Hansen KE
        • Turner JA
        Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial.
        JAMA. 2016; 315: 1240
        • Cherkin DC
        • Sherman KJ
        • Balderson BH
        • Turner JA
        • Cook AJ
        • Stoelb B
        • Herman PM
        • Deyo RA
        • Hawkes RJ
        Comparison of complementary and alternative medicine with conventional mind–body therapies for chronic back pain: Protocol for the Mind–body Approaches to Pain (MAP) randomized controlled trial.
        Trials. 2014; 15: 211
        • Chiesa A
        • Serretti A
        Mindfulness-based interventions for chronic pain: A systematic review of the evidence.
        J Altern Complement Med. 2011; 17: 83-93
        • Costa L d.CM
        • Maher CG
        • McAuley JH
        • Hancock MJ
        • Herbert RD
        • Refshauge KM
        • Henschke N
        Prognosis for patients with chronic low back pain: Inception cohort study.
        BMJ. 2009; 339 (–b3829): b3829
        • Cuijpers P
        • Noma H
        • Karyotaki E
        • Cipriani A
        • Furukawa TA
        Effectiveness and acceptability of cognitive behavior therapy delivery formats in adults with depression: A network meta-analysis.
        JAMA Psychiatry. 2019; 76: 700
        • Day MA
        • Ehde DM
        • Jensen MP
        Psychosocial pain management moderation: The limit, activate, and enhance model.
        J Pain. 2015; 16: 947-960
        • Day MA
        • Thorn BE
        • Ehde DM
        • Burns JW
        • Barnier A
        • Mattingley JB
        • Matthews N
        • Jensen MP
        Moderators of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain: A test of the limit, activate, and enhance model.
        J Pain. 2020; 21: 161-169
        • de Rooij A
        • van der Leeden M
        • Roorda LD
        • Dekker J
        Predictors of outcome of multidisciplinary treatment in chronic widespread pain: An observational study.
        BMC Musculoskelet Disord. 2013; 13: 133
        • Driessen E
        • Hollon SD
        Cognitive behavioral therapy for mood disorders: Efficacy, moderators and mediators.
        Psychiatr Clin North Am. 2010; 33: 537-555
        • Dunn KM
        • Jordan KP
        • Croft PR
        Contributions of prognostic factors for poor outcome in primary care low back pain patients.
        Eur J Pain. 2011; 15: 313-319
        • Ecija C
        • Catala P
        • Lopez-Gomez I
        • Bedmar D
        • Peñacoba C
        What does the psychological flexibility model contribute to the relationship between depression and disability in chronic pain? The role of cognitive fusion and pain acceptance.
        Clin Nurs Res. 2021; : 1-13
        • Ehde DM
        • Dillworth TM
        • Turner JA
        Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research.
        Am Psychol. 2014; 69: 153-166
        • Fish RA
        • Hogan MJ
        • Morrison TG
        • Stewart I
        • McGuire BE
        Willing and able: A closer look at pain willingness and activity engagement on the Chronic Pain Acceptance Questionnaire (CPAQ-8).
        J Pain. 2013; 14: 233-245
        • Fish RA
        • McGuire B
        • Hogan M
        • Morrison TG
        • Stewart I
        Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an internet sample and development and preliminary validation of the CPAQ-8.
        Pain. 2010; 149: 435-443
        • Garland EL
        • Gaylord SA
        • Palsson O
        • Faurot K
        • Douglas Mann J
        • Whitehead WE
        Therapeutic mechanisms of a mindfulness-based treatment for IBS: Effects on visceral sensitivity, catastrophizing, and affective processing of pain sensations.
        J Behav Med. 2012; 35: 591-602
        • Gilpin HR
        • Keyes A
        • Stahl DR
        • Greig R
        • McCracken LM
        Predictors of treatment outcome in contextual cognitive and behavioral therapies for chronic pain: A systematic review.
        J Pain. 2017; 18: 1153-1164
        • Goldberg SB
        • Tucker RP
        • Greene PA
        • Davidson RJ
        • Wampold BE
        • Kearney DJ
        • Simpson TL
        Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis.
        Clin Psychol Rev. 2018; 59: 52-60
        • Gu J
        • Strauss C
        • Bond R
        • Cavanagh K
        How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies.
        Clin Psychol Rev. 2015; 37: 1-12
        • Hayden JA
        • Wilson MN
        • Riley RD
        • Iles R
        • Pincus T
        • Ogilvie R
        Individual recovery expectations and prognosis of outcomes in non-specific low back pain: Prognostic factor review.
        Cochrane Database Syst Rev Issue. 2019; 11 (Art. No.)CD011284
        • Jensen MP
        Psychosocial approaches to pain management: An organizational framework.
        PAIN. 2011; 152: 717-725
        • Jensen MP
        • Karoly P
        Pain-specific beliefs, perceived symptom severity, and adjustment to chronic pain.
        Clin J Pain United States;. 1992; 8: 123-130
      1. Jensen MP, Karoly P: Survey of pain attitudes: professional manual. Lutz, FL: Psychological Assessment Resources; 2008.

        • Jensen MP
        • Romano JM
        • Turner JA
        • Good AB
        • Wald LH
        Patient beliefs predict patient functioning: Further support for a cognitive-behavioural model of chronic pain.
        PAIN. 1999; 81: 95-104
        • Jensen MP
        • Smith DG
        • Ehde DM
        • Robinson LR
        Pain site and the effects of amputation pain: Further clarification of the meaning of mild, moderate, and severe pain.
        PAIN. 2001; 3: 317-322
        • Jensen MP
        • Turner JA
        • Romano JM
        Changes after multidisciplinary pain treatment in patient pain beliefs and coping are associated with concurrent changes in patient functioning.
        PAIN. 2007; 131: 38-47
        • Jensen MP
        • Turner JA
        • Romano JM
        Changes in beliefs, catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment.
        J Consult Clin Psychol. 2001; 69: 655-662
        • Jensen MP
        • Turner JA
        • Romano JM
        • Lawler BK
        Relationship of pain-specific beliefs to chronic pain adjustment.
        PAIN. 1994; 57: 301-309
        • Jones KR
        • Vojir CP
        • Hutt E
        • Fink R
        Determining mild, moderate, and severe pain equivalency across pain-intensity tools in nursing home residents.
        J Rehabil Res Dev. 2007; 44: 305
        • Kabat-Zinn J
        An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results.
        Gen Hosp Psychiatry. 1982; 4: 33-47
        • Kabat-Zinn J
        Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness.
        Random House, New York, NY2005
        • Kabat-Zinn J
        Mindfulness-based interventions in context: past, present, and future.
        Clin Psychol Sci Pract. 2003; 10: 144-156
        • Khoo E-L
        • Small R
        • Cheng W
        • Hatchard T
        • Glynn B
        • Rice DB
        • Skidmore B
        • Kenny S
        • Hutton B
        • Poulin PA
        Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: A systematic review and network meta-analysis.
        Evid Based Ment Health. 2019; 22: 26-35
        • Kraemer H
        • Wilson G
        • Fairburn CG
        • Agras W
        Mediators and moderators of treatment effects in randomized clinical trials.
        Arch Gen Psychiatry. 2002; 59: 877-883
        • Kroenke K
        • Spitzer RL
        • Williams JBW
        The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms.
        Psychosom Med. 2002; 64: 258-266
        • Kroenke K
        • Spitzer RL
        • Williams JBW
        • Löwe B
        The Patient Health Questionnaire somatic, anxiety, and depressive symptom scales: A systematic review.
        Gen Hosp Psychiatry. 2010; 32: 345-359
        • Kroenke K
        • Spitzer RL
        • Williams JBW
        • Monahan PO
        • Löwe B
        Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection.
        Ann Intern Med. 2007; 146: 317
        • Kroenke K
        • Strine TW
        • Spitzer RL
        • Williams JBW
        • Berry JT
        • Mokdad AH
        The PHQ-8 as a measure of current depression in the general population.
        J Affect Disord. 2009; 114: 163-173
        • Lamb SE
        • Hansen Z
        • Lall R
        • Castelnuovo E
        • Withers EJ
        • Nichols V
        • Potter R
        • Underwood MR
        Group cognitive behavioural treatment for low-back pain in primary care: A randomised controlled trial and cost-effectiveness analysis.
        Lancet. 2010; 375: 916-923
        • Litt MD
        • Shafer DM
        • Kreutzer DL
        Brief cognitive-behavioral treatment for TMD pain: Long-term outcomes and moderators of treatment.
        PAIN. 2010; 151: 110-116
        • Mallen CD
        • Peat G
        • Thomas E
        • Dunn KM
        • Croft PR
        Prognostic factors for musculoskeletal pain in primary care: A systematic review.
        Br J Gen Pract. 2007; 57: 655
        • Martinez-Calderon J
        • Jensen MP
        • Morales-Asencio JM
        • Luque-Suarez A
        Pain catastrophizing and function in individuals with chronic musculoskeletal pain: A systematic review and meta-analysis.
        Clin J Pain. 2019; 35: 279-293
        • Martinez-Calderon J
        • Zamora-Campos C
        • Navarro-Ledesma S
        • Luque-Suarez A
        The role of self-efficacy on the prognosis of chronic musculoskeletal pain: A systematic review.
        J Pain. 2018; 19: 10-34
        • Mascaro JS
        • Singh V
        • Wehrmeyer K
        • Scott B
        • Juan J
        • McKenzie-Brown AM
        • Lane OP
        • Haack C
        Randomized, wait-list–controlled pilot study of app-delivered mindfulness for patients reporting chronic pain.
        PAIN Rep. 2021; 6: 1-e924
        • McCracken LM
        • Turk DC
        Behavioral and cognitive–behavioral treatment for chronic pain: Outcome, predictors of outcome, and treatment process.
        Spine. 2002; 27: 2564-2573
        • Miller Jr., RG
        Simultaneous Statistical Inference [Internet].
        Second Edition. Springer-Verlag, New York, NY1981https://doi.org/10.1007/978-1-4613-8122-8
        • Molton IR
        • Terrill AL
        Overview of Persistent Pain in Older Adults.
        Am Psychol. 2014; 69: 197-207
        • Murray CB
        • Patel KV
        • Twiddy H
        • Sturgeon JA
        • Palermo TM
        Age differences in cognitive–affective processes in adults with chronic pain.
        Eur J Pain. 2021; 25: 1041-1052
        • Nicholas MK
        The pain self-efficacy questionnaire: Taking pain into account.
        Eur J Pain. 2007; 11: 153-163
        • Osman A
        • Barrios FX
        • Kopper BA
        • Hauptmann W
        • Jones J
        • O'Neill E
        Factor structure, reliability, and validity of the Pain Catastrophizing Scale.
        J Behav Med. 1997; 20: 589-605
        • Otis JD
        Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach. Therapist Guide.
        Oxford University Press, Oxford, England2007
        • Patrick DL
        • Deyo RA
        • Atlas SJ
        • Singer DE
        • Chapin A
        • Keller RB
        Assessing health-related quality of life in patients with sciatica.
        Spine. 1995; 20: 1899-1909
        • Public Health Service and Health Care Financing Administration
        International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).
        Public Health Service, Washington, DC2011
        • Reiner K
        • Tibi L
        • Lipsitz JD
        Do mindfulness-based interventions reduce pain intensity? A critical review of the literature.
        Pain Med. 2013; 14: 230-242
        • Roland M
        • Morris R
        A study of the natural history of back pain. Part I: Development of a reliable and sensitive measure of disability in low-back pain.
        Spine. 1983; 8: 141-144
        • Shapiro SL
        • Brown KW
        • Thoresen C
        • Plante TG
        The moderation of Mindfulness-based stress reduction effects by trait mindfulness: Results from a randomized controlled trial.
        J Clin Psychol John Wiley & Sons, Ltd;. 2011; 67: 267-277
        • Skelly AC
        • Chou R
        • Dettori JR
        • Turner JA
        • Friedly JL
        • Rundell SD
        • Fu R
        • Brodt ED
        • Wasson N
        • Kantner S
        • Ferguson AJR
        Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update [Internet]. 227. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD, USA2020 (Apr. Report No.: NoAvailable at)
        • Strong J
        • Ashton R
        • Chant D
        The measurement of attitudes towards and beliefs about pain.
        PAIN. 1992; 48: 227-236
      2. Sullivan MJ: The Pain Catastrophizing Scale user manual [Internet]. 2009. Available at:http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/257422/Pain_Catastrophizing_Scale_Manual.pdf

        • Sullivan MJL
        • Bishop SR
        • Pivik J
        The pain catastrophizing scale: Development and validation.
        Psychol Assess. 1995; 7: 524-532
        • Thompson EL
        • Broadbent J
        • Bertino MD
        • Staiger PK
        Do pain-related beliefs influence adherence to multidisciplinary rehabilitation?: A systematic review.
        Clin J Pain. 2016; 32: 164-178
        • Thorn BE
        Cognitive Therapy for Chronic Pain: A Step-by-Step Guide.
        Guilford Press, New York, NY2004
        • Thorn BE
        • Day MA
        • Burns J
        • Kuhajda MC
        • Gaskins SW
        • Sweeney K
        • McConley R
        • Ward CL
        • Cabbil C
        Randomized trial of group cognitive behavioral therapy compared with a pain education control for low-literacy rural people with chronic pain.
        PAIN. 2011; 152: 2710-2720
        • Turk DC
        • Wilson HD
        • Cahana A
        Treatment of chronic non-cancer pain.
        Lancet. 2011; 377: 2226-2235
        • Turk DC
        • Winter F
        The Pain Survival Guide: How to Reclaim Your Life.
        American Psychological Association, Washington, DC2006
        • Turner JA
        Comparison of group progressive-relaxation training and cognitive-behavioral group therapy for chronic low back pain.
        J Consult Clin Psychol. 1982; 50: 757-765
        • Turner JA
        • Anderson ML
        • Balderson BH
        • Cook AJ
        • Sherman KJ
        • Cherkin DC
        Mindfulness-based stress reduction and cognitive behavioral therapy for chronic low back pain: Similar effects on mindfulness, catastrophizing, self-efficacy, and acceptance in a randomized controlled trial.
        PAIN. 2016; 157: 2434-2444
        • Turner JA
        • Clancy S
        Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain.
        J Consult Clin Psychol. 1988; 56: 261-266
        • Turner JA
        • Franklin G
        • Heagerty PJ
        • Wu R
        • Egan K
        • Fulton-Kehoe D
        • Gluck JV
        • Wickizer TM
        The association between pain and disability.
        PAIN. 2004; 112: 307-314
        • Turner JA
        • Holtzman S
        • Mancl L
        Mediators, moderators, and predictors of therapeutic change in cognitive–behavioral therapy for chronic pain.
        PAIN. 2007; 127: 276-286
        • Turner JA
        • Mancl L
        • Aaron LA
        Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial.
        PAIN. 2006; 121: 181-194
      3. Turner JA, Romano JM: Cognitive-behavioral therapy for chronic pain. In: Loeser JD, editor. Bonicas Manag Pain Philadelphia, PA: Lippincott Williams & Wilkins; page 1751–82001.

        • Turner JA
        • Shortreed SM
        • Saunders KW
        • LeResche L
        • Berlin JA
        • Korff MV
        Optimizing prediction of back pain outcomes.
        PAIN. 2013; 154: 1391-1401
        • Turner JA
        • Shortreed SM
        • Saunders KW
        • LeResche L
        • Thielke S
        • Von Korff M
        Does association of opioid use with pain and function differ by fibromyalgia or widespread pain status?.
        PAIN. 2016; 157: 2208-2216
        • Underwood M
        • Mistry D
        • Lall R
        • Lamb S
        Predicting response to a cognitive-behavioral approach to treating low back pain: Secondary analysis of the BeST data set.
        Arthritis Care Res. 2011; 63: 1271-1279
        • van Dis EAM
        • van Veen SC
        • Hagenaars MA
        • Batelaan NM
        • Bockting CLH
        • van den Heuvel RM
        • Cuijpers P
        • Engelhard IM
        Long-term outcomes of cognitive behavioral therapy for anxiety-related disorders: A systematic review and meta-analysis.
        JAMA Psychiatry. 2020; 77: 265
        • Van Dyke BP
        • Newman AK
        • Moraís CA
        • Burns JW
        • Eyer JC
        • Thorn BE
        Heterogeneity of treatment effects in a randomized trial of literacy-adapted group cognitive-ehavioral therapy, pain psychoeducation, and usual medical care for multiply disadvantaged patients with chronic pain.
        J Pain. 2019; 20: 1236-1248
        • Veehof MM
        • Trompetter HR
        • Bohlmeijer ET
        • Schreurs KMG
        Acceptance- and mindfulness-based interventions for the treatment of chronic pain: A meta-analytic review.
        Cogn Behav Ther. 2016; 45: 5-31
        • Vitiello MV
        • McCurry SM
        • Shortreed SM
        • Balderson BH
        • Baker LD
        • Keefe FJ
        • Rybarczyk BD
        • Von Korff M
        Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: The lifestyles randomized controlled trial.
        J Am Geriatr Soc. 2013; 61: 947-956
        • Vlaeyen JWS
        • Morley S
        Cognitive-behavioral treatments for chronic pain: What works for whom?.
        Clin J Pain. 2005; 21: 1-8
        • Wang R
        • Ware JH
        Detecting moderator effects using subgroup analyses.
        Prev Sci. 2013; 14: 111-120
      4. Williams AC de C, Fisher E, Hearn L, Eccleston C: Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev [Internet], 2020: http://doi.wiley.com/10.1002/14651858.CD007407.pub4

        • Zelman DC
        • Hoffman DL
        • Seifeldin R
        • Dukes EM
        Development of a metric for a day of manageable pain control: Derivation of pain severity cut-points for low back pain and osteoarthritis.
        PAIN. 2003; 106: 35-42