Cognitive Behavioural Therapy to Optimize Post-Operative Recovery Pilot (COPE Pilot)

January 27, 2020 updated by: Sheila Sprague, McMaster University

Cognitive Behavioural Therapy to Optimize Post-Operative Recovery: A Randomized Controlled Trial

Psychological factors such as stress, distress, anxiety, depression, and poor coping strategies may be associated with ongoing pain following injuries such as fractures. To study this relationship, patients will undergo cognitive behavioural therapy (CBT) which is designed to modify such thoughts with the goal of reducing ongoing pain and improving quality of life. The goal of this study is to determine if CBT, versus usual care, reduces the prevalence of moderate to severe persistent post-surgical pain (PPSP) over 12-months post-fracture

Study Overview

Detailed Description

The relationship between psychological factors, behaviors, and cognitive processes and the sensation of pain is well documented. Stress, distress, anxiety, depression, catastrophizing, fear-avoidance behaviors, and poor coping strategies appear to have a significant positive relationship with both acute and chronic pain. Evidence suggests that these psychological factors can cause alterations along the spinal and supraspinal pain pathways which influence the perception of pain. Previous studies suggest that patients' beliefs and expectations may be associated with clinical outcomes, including self-reported pain. Previous studies in trauma patients have demonstrated patients' beliefs and expectations regarding their recovery following surgery are associated with functional limitations, lower rates of return to work, and reduced quality of life one year after injury. Furthermore, up to two thirds of patients with operative managed extremity fractures demonstrate unhelpful illness beliefs that increase risks of negative outcomes, including persistent pain. Psychological interventions, such as cognitive behavioural therapy (CBT), that are designed to modify unhelpful beliefs and behaviours have the potential to reduce persistent post-surgical pain and its associated effects among trauma patients.

Our primary objective is to determine if CBT, versus usual care, reduces the prevalence of moderate to severe PPSP over 12 months post-fracture in participants with an open fracture of the appendicular skeleton, or closed fracture of the lower extremity or pelvis. Our secondary objectives are to determine if CBT, versus usual care: 1) increases physical functioning, 2) improves mental functioning, 3) accelerates return to function, 4) reduces pain severity, and 5) reduces pain interference over 12 months post-fracture, and 6) reduces the proportion of participants prescribed opioid class medications (and average dose) at 6 and 12 months post-fracture in patients with an open fracture of the appendicular skeleton or closed fracture of the lower extremity or pelvis. This trial is a multi-centre RCT of 1,000 participants with an open fracture of the appendicular skeleton or closed fracture of the lower extremity or pelvis treated with internal fixation.

Study Type

Interventional

Enrollment (Actual)

83

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

    • New Brunswick
      • Saint John, New Brunswick, Canada, E2L 4L2
        • The Moncton Hospital
    • Nova Scotia
      • Halifax, Nova Scotia, Canada
        • QEII Health Sciences Centre
    • Ontario
      • Hamilton, Ontario, Canada, L8L 2X2
        • Hamilton General Hospital
      • London, Ontario, Canada
        • London Health Sciences Centre
      • Ottawa, Ontario, Canada
        • Ottawa Civic Hospital
      • Thunder Bay, Ontario, Canada
        • Thunder Bay Regional Health Sciences Centre

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (ADULT, OLDER_ADULT)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Adult men or women aged 18 years and older.
  • Presenting to fracture clinic within 2-12 weeks following an acute open fracture of the appendicular skeleton or closed fracture of the lower extremity or pelvis. Patients with multiple fractures may be included.
  • Fracture treated operatively with internal fixation.
  • Willing to participate in CBT
  • Language skills and cognitive ability required to participate in CBT (in the judgement of site research personnel).
  • Consistent online access from a smartphone/internet-enabled device with a minimum operating system able to use the CBT provider application or videoconferencing software applications.
  • Provision of informed consent.

Exclusion Criteria:

  • Fragility fracture.
  • Stress fracture.
  • Fracture of the hand.
  • Fracture of the foot.
  • Concomitant injury which, in the opinion of the attending surgeon, is likely to impair function for as long as or longer than the patient's extremity fracture.
  • Active psychosis.
  • Active suicidality.
  • Active substance use disorder that, in the judgement of the treating surgeon, would interfere in the patient's ability to partake in the CBT and/or the trial.
  • Already participating in, or planning to, start other psychological treatments (including CBT) within the duration of the study (12 months).
  • Anticipated problems, in the judgement of study personnel, with the patient participating in CBT intervention and/or returning for follow-up.
  • Incarceration.
  • Currently enrolled in a study that does not permit co-enrolment in other trials.
  • Previously enrolled in the COPE trial.
  • Other reason to exclude the patient, as approved by the Methods Centre.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: PREVENTION
  • Allocation: RANDOMIZED
  • Interventional Model: PARALLEL
  • Masking: SINGLE

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
EXPERIMENTAL: Intervention - CBT
Participants in this arm will receive cognitive behavioural therapy. Participants will have the choice of completing six real-time telephone or video-delivered CBT sessions with a therapist OR complete online modules with asynchronous feedback with a dedicated therapist in addition to standard of care for their fracture injury.

Participants who are randomized to the CBT intervention will be encouraged to begin CBT immediately following randomization. The CBT intervention will focus on addressing maladaptive beliefs related to pain and recovery as well as teaching skills to enhance coping and management of pain symptoms. The specific focus of CBT sessions will be informed by each individual patient's responses to baseline questionnaires. All other aspects of post-operative care will be at the discretion of participant's surgeon.

Other Name: CBT

NO_INTERVENTION: No intervention- - control
Participants in the control arm of the study will receive standard of care treatment for their fracture(s) but will not receive any Cognitive Behavioral Therapy.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
The prevalence of moderate to severe Persistent Post-Surgical Pain at 12 months' post-fracture
Time Frame: 12 months post-fracture

The primary outcome is PPSP according to the World Health Organization's (WHO) proposed definition.

The WHO's definition requires 4 criteria for the diagnosis of PPSP: 1) Pain that began after surgery or a tissue trauma is experienced; 2) The pain is in an area of preceding surgery or tissue trauma, 3) The pain persisted for at least three months after the initiating event, and 4) The pain is not better explained by an infection, a malignancy, a pre-existing pain condition or any other alternative cause.

12 months post-fracture

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Short Form 36 (SF-36)
Time Frame: 12 months post-fracture
General health related quality of life will be assessed by the SF-36. The SF-36 is an established, reliable and validated health status measure. It is a self-administered, 36-item questionnaire that measures health-related quality of life in 8 domains related to physical, social, mental, and emotional functioning, bodily pain, and general health. Both physical and mental summary scores can be obtained. Each domain is scored separately from 0 (lowest level) to 100 (highest level).
12 months post-fracture
Return to Function questionnaire
Time Frame: 12 months post-fracture
Return to function will be measured by when participants' return to work, household activities, and leisure activities, as well as when they achieve 80% of their pre-injury function. The return to function outcome will be assessed using the Return to Function questionnaire.
12 months post-fracture
BPI-SF
Time Frame: 12 months post-fracture
The Brief Pain Inventory (BPI) assess pain severity and its impact on function
12 months post-fracture
Opioid Use
Time Frame: 12 months post-fracture
Patient-reported use of opioid class medications. To determine if CBT versus usual care reduces the proportion of participants taking opioid class medications at 6 months and 12 months.
12 months post-fracture

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (ACTUAL)

January 9, 2019

Primary Completion (ACTUAL)

August 8, 2019

Study Completion (ACTUAL)

August 8, 2019

Study Registration Dates

First Submitted

September 13, 2018

First Submitted That Met QC Criteria

September 13, 2018

First Posted (ACTUAL)

September 17, 2018

Study Record Updates

Last Update Posted (ACTUAL)

January 29, 2020

Last Update Submitted That Met QC Criteria

January 27, 2020

Last Verified

January 1, 2020

More Information

Terms related to this study

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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