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      Psychological therapies (Internet‐delivered) for the management of chronic pain in adults

      , , , , , ,

      Cochrane Pain, Palliative and Supportive Care Group

      The Cochrane Database of Systematic Reviews

      John Wiley & Sons, Ltd

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          Abstract

          Background

          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.

          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.

          Related collections

          Most cited references 69

          • Record: found
          • Abstract: found
          • Article: not found

          Internet-administered cognitive behavior therapy for health problems: a systematic review

          Cognitive-behavioral interventions are the most extensively researched form of psychological treatment and are increasingly offered through the Internet. Internet-based interventions may save therapist time, reduce waiting-lists, cut traveling time, and reach populations with health problems who can not easily access other more traditional forms of treatments. We conducted a systematic review of twelve randomized controlled or comparative trials. Studies were identified through systematic searches in major bibliographical databases. Three studies focused on patients suffering from pain, three on headache, and six on other health problems. The effects found for Internet interventions targeting pain were comparable to the effects found for face-to-face treatments, and the same was true for interventions aimed at headache. The other interventions also showed some effects, although effects differed across target conditions. Internet-delivered cognitive-behavioral interventions are a promising addition and complement to existing treatments. The Internet will most likely assume a major role in the future delivery of cognitive-behavioral interventions to patients with health problems.
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            • Record: found
            • Abstract: found
            • Article: not found

            Internet-based chronic disease self-management: a randomized trial.

            The small-group Chronic Disease Self-Management Program (CDSMP) has proven effective in changing health-related behaviors and improving health statuses. An Internet-based CDSMP was developed to reach additional chronic-disease patients. We sought to determine the efficacy of the Internet-based CDSMP. We compared randomized intervention participants with usual-care controls at 1 year. We compared intervention participants with the small-group CDSMP at 1 year. Nine-hundred fifty-eight patients with chronic diseases (heart, lung, or type 2 diabetes) and Internet and e-mail access were randomized to intervention (457) or usual care control (501). Measures included 7 health status variables (pain, shortness of breath, fatigue, illness intrusiveness, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 3 utilization variables (physician visits, emergency room visits, and nights in hospital), and self-efficacy. At 1 year, the intervention group had significant improvements in health statuses compared with usual care control patients. The intervention group had similar results to the small-group CDSMP participants. Change in self-efficacy at 6 months was found to be associated with better health status outcomes at 1 year. The Internet-based CDSMP proved effective in improving health statutes by 1 year and is a viable alternative to the small-group Chronic Disease Self Management Program.
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              • Record: found
              • Abstract: found
              • Article: not found

              The internet-based arthritis self-management program: a one-year randomized trial for patients with arthritis or fibromyalgia.

              To determine the efficacy of an Internet-based Arthritis Self-Management Program (ASMP) as a resource for arthritis patients unable or unwilling to attend small-group ASMPs, which have proven effective in changing health-related behaviors and improving health status measures. Randomized intervention participants were compared with usual care controls at 6 months and 1 year using repeated-measures analyses of variance. Patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia and Internet and e-mail access (n = 855) were randomized to an intervention (n = 433) or usual care control (n = 422) group. Measures included 6 health status variables (pain, fatigue, activity limitation, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 5 utilization variables (physician visits, emergency room visits, chiropractic visits, physical therapist visits, and nights in hospital), and self-efficacy. At 1 year, the intervention group significantly improved in 4 of 6 health status measures and self-efficacy. No significant differences in health behaviors or health care utilization were found. The Internet-based ASMP proved effective in improving health status measures at 1 year and is a viable alternative to the small-group ASMP.
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                Author and article information

                Contributors
                papas@bath.ac.uk , c.eccleston@bath.ac.uk
                Journal
                Cochrane Database Syst Rev
                Cochrane Database Syst Rev
                14651858
                10.1002/14651858
                The Cochrane Database of Systematic Reviews
                John Wiley & Sons, Ltd (Chichester, UK )
                1469-493X
                26 February 2014
                February 2014
                30 September 2019
                : 2014
                : 2
                Affiliations
                University of Bath deptCentre for Pain Research Claverton Down Bath UK
                Pain Research Unit, Churchill Hospital deptCochrane Pain, Palliative and Supportive Care Group Oxford UK
                Palo Alto University deptClinical Psychology Palo Alto USA
                University of Bath deptDepartment of Health Bath UK
                University of Exeter Streatham Campus Exeter UK
                University of Bath deptDepartment of Psychology Claverton Down Bath UK BA2 7AY
                Article
                PMC6685592 PMC6685592 6685592 CD010152.pub2 CD010152
                10.1002/14651858.CD010152.pub2
                6685592
                24574082
                Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
                Categories
                2019 3. Chronic pain
                Chronic non‐cancer pain
                Pain & anaesthesia

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