Psychological therapies (Internet‐delivered) for the management of chronic pain in adults Edited (no change to conclusions)
Chronic pain (i.e. pain lasting longer than three months) is common. Psychological therapies (e.g. cognitive behavioural therapy) can help people to cope with pain, depression and disability that can occur with such pain. Treatments currently are delivered via hospital out‐patient consultation (face‐to‐face) or more recently through the Internet. This review looks at the evidence for psychological therapies delivered via the Internet for adults with chronic pain.Objectives
Our objective was to evaluate whether Internet‐delivered psychological therapies improve pain symptoms, reduce disability, and improve depression and anxiety for adults with chronic pain. Secondary outcomes included satisfaction with treatment/treatment acceptability and quality of life.Search methods
We searched CENTRAL (Cochrane Library), MEDLINE, EMBASE and PsycINFO from inception to November 2013 for randomised controlled trials (RCTs) investigating psychological therapies delivered via the Internet to adults with a chronic pain condition. Potential RCTs were also identified from reference lists of included studies and relevant review articles. In addition, RCTs were also searched for in trial registries.Selection criteria
Peer‐reviewed RCTs were identified and read in full for inclusion. We included studies if they used the Internet to deliver the primary therapy, contained sufficient psychotherapeutic content, and promoted self‐management of chronic pain. Studies were excluded if the number of participants in any arm of the trial was less than 20 at the point of extraction.Data collection and analysis
Fifteen studies met the inclusion criteria and data were extracted. Risk of bias assessments were conducted for all included studies. We categorised studies by condition (headache or non‐headache conditions). Four primary outcomes; pain symptoms, disability, depression, and anxiety, and two secondary outcomes; satisfaction/acceptability and quality of life were extracted for each study immediately post‐treatment and at follow‐up (defined as 3 to 12 months post‐treatment).Main results
Fifteen studies (N= 2012) were included in analyses. We assessed the risk of bias for included studies as low overall. We identified nine high 'risk of bias' assessments, 22 unclear, and 59 low 'risk of bias' assessments. Most judgements of a high risk of bias were due to inadequate reporting.
Analyses revealed seven effects. Participants with headache conditions receiving psychological therapies delivered via the Internet had reduced pain (number needed to treat to benefit = 2.72, risk ratio 7.28, 95% confidence interval (CI) 2.67 to 19.84, p < 0.01) and a moderate effect was found for disability post‐treatment (standardised mean difference (SMD) ‒0.65, 95% CI ‒0.91 to ‒0.39, p < 0.01). However, only two studies could be entered into each analysis; hence, findings should be interpreted with caution. There was no clear evidence that psychological therapies improved depression or anxiety post‐treatment (SMD −0.26, 95% CI −0.87 to 0.36, p > 0.05; SMD −0.48, 95% CI −1.22 to 0.27, p > 0.05), respectively. In participants with non‐headache conditions, psychological therapies improved pain post‐treatment (p < 0.01) with a small effect size (SMD −0.37, 95% CI −0.59 to −0.15), disability post‐treatment (p < 0.01) with a moderate effect size (SMD −0.50, 95% CI −0.79 to −0.20), and disability at follow‐up (p < 0.05) with a small effect size (SMD −0.15, 95% CI −0.28 to −0.01). However, the follow‐up analysis included only two studies and should be interpreted with caution. A small effect was found for depression and anxiety post‐treatment (SMD −0.19, 95% CI −0.35 to −0.04, p < 0.05; SMD −0.28, 95% CI −0.49 to −0.06, p < 0.01), respectively. No clear evidence of benefit was found for other follow‐up analyses. Analyses of adverse effects were not possible.
No data were presented on satisfaction/acceptability. Only one study could be included in an analysis of the effect of psychological therapies on quality of life in participants with headache conditions; hence, no analysis could be undertaken. Three studies presented quality of life data for participants with non‐headache conditions; however, no clear evidence of benefit was found (SMD −0.27, 95% CI −0.54 to 0.01, p > 0.05).Authors' conclusions
There is insufficient evidence to make conclusions regarding the efficacy of psychological therapies delivered via the Internet in participants with headache conditions. Psychological therapies reduced pain and disability post‐treatment; however, no clear evidence of benefit was found for depression and anxiety. For participants with non‐headache conditions, psychological therapies delivered via the Internet reduced pain, disability, depression, and anxiety post‐treatment. The positive effects on disability were maintained at follow‐up. These effects are promising, but considerable uncertainty remains around the estimates of effect. These results come from a small number of trials, with mostly wait‐list controls, no reports of adverse events, and non‐clinical recruitment methods. Due to the novel method of delivery, the satisfaction and acceptability of these therapies should be explored in this population. These results are similar to those of reviews of traditional face‐to‐face therapies for chronic pain.
Christopher Eccleston, Emma Fisher, Lorraine Craig, Geoffrey B Duggan, Benjamin A Rosser, Edmund Keogh
Plain language summary
Psychological therapies delivered via the Internet for adults with longstanding distressing pain and disability
Chronic pain (i.e. pain lasting longer than three months) is common. Psychological therapies (e.g. cognitive behavioural therapy) can help people to cope with pain, depression and disability that can occur with such pain. Treatments currently are delivered via hospital out‐patient consultation (face‐to‐face) or more recently through the Internet. This review looks at the evidence for psychological therapies delivered via the Internet for adults with chronic pain.
Four databases were searched up to November 2013. We found 15 trials that met our inclusion criteria. Four trials included individuals with headache pain, 10 trials included individuals with non‐headache pain, and one trial included individuals with both headache and non‐headache pain. We looked at data about pain, disability, depression, and anxiety immediately after the end of treatment and between 3 to 12 months follow‐up. We also looked at how satisfied people were with the treatments, and its effects on their quality of life.
We found that for people with headache pain, pain symptoms and disability scores improved immediately following the end of treatment. However, only two trials could be entered into each of these analyses and so findings should be treated with caution. For people with non‐headache pain, pain, disability, depression, and anxiety improved immediately after the end of treatment. Disability was also improved at follow‐up. Only one study recorded quality of life scores in individuals with headache pain, so we were unable to analyse the results. Three studies presented quality of life scores for individuals with non‐headache pain immediately following treatment. We did not find that quality of life improved after receiving the therapy. No data could be analysed on treatment satisfaction/acceptability.
We conclude that these findings are promising for psychological treatments delivered via the Internet for the management of chronic pain in adults, but more trials are needed to determine the efficacy of such therapies.
Christopher Eccleston, Emma Fisher, Lorraine Craig, Geoffrey B Duggan, Benjamin A Rosser, Edmund Keogh
Implications for practice
Internet‐delivered cognitive behavioural therapy (CBT) for the management of chronic pain in adults may be effective for the short‐term management of pain, disability, depression, and anxiety in individuals with chronic non‐headache pain conditions, but there is currently limited evidence for their effectiveness for headache pain and disability, and no evidence for their effectiveness on depression and anxiety in individuals with chronic headache conditions. On average, participants entering trials of Internet‐delivered treatment are mildly disabled and distressed. No conclusions can be made for treatments other than CBT. We do not know if these treatments are associated with adverse events and we do not know how satisfied participants are with these treatments.
Implications for research
Delivering cognitive and behaviour change therapies via the Internet without an expert health professional managing real‐time delivery is possible. However, the exact content of therapy, the characteristics of the treatment method, and the methods by which individuals are selected for such therapy are not known. In essence we do not know what can work for whom and in what context. This research is at a very early stage of development and the studies reviewed here can usefully be considered immature. Two areas of research are needed.
First, the most effective method of face‐to‐face treatment identified in Williams 2012 should be adapted for delivery via the Internet using the most effective method of evaluation: the placebo‐controlled RCT. Future RCTs should have the following critical features:
- Be properly powered to detect meaningful changes in the primary outcomes measured (approximate n = 300);
- Use a placebo therapy as the primary comparator;
- Make attempts to blind both participants and investigators to treatment selection;
- Measure adverse effects, participant satisfaction, adherence to treatment, and reasons for attrition;
- Enrol only participants with moderate‐to‐severe pain, disability, or distress;
- Select domains and outcome measurement tools commensurate with IMMPACT guidance (Dworkin 2005).
Second, further pre‐evaluation studies are needed to examine critical aspects of Internet delivery of therapeutic communication, such as, but not limited to the following.
- Can therapeutic alliance be achieved with non‐human objects/systems, and is it necessary to deliver behaviour change?
- Can novel aspects of Internet systems be used therapeutically (e.g. immersion technology, multi‐agent connections, remote sensing)?
- Can Internet treatments augment traditional real‐time human interaction and can limited human interaction (e.g. skills practice review or telephone support) augment Internet‐delivered therapies?
Research is needed in both fundamental aspects of Internet communication: persuasion and therapy. However, whilst this research develops, we believe there is a case for efficacy studies on the current most promising treatments for adults with chronic pain.Get full text at The Cochrane Library
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