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

  1. Christopher Eccleston1,*,
  2. Emma Fisher1,
  3. Lorraine Craig2,
  4. Geoffrey B Duggan1,
  5. Benjamin A Rosser3,
  6. Edmund Keogh4

Editorial Group: Cochrane Pain, Palliative and Supportive Care Group

Published Online: 26 FEB 2014

Assessed as up-to-date: 13 NOV 2013

DOI: 10.1002/14651858.CD010152.pub2


How to Cite

Eccleston C, Fisher E, Craig L, Duggan GB, Rosser BA, Keogh E. Psychological therapies (Internet-delivered) for the management of chronic pain in adults. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD010152. DOI: 10.1002/14651858.CD010152.pub2.

Author Information

  1. 1

    University of Bath, Centre for Pain Research, Bath, UK

  2. 2

    University of Bath, Department of Health, Bath, UK

  3. 3

    University of Exeter, Exeter, UK

  4. 4

    University of Bath, Department of Psychology, Bath, UK

*Christopher Eccleston, Centre for Pain Research, University of Bath, Claverton Down, Bath, BA2 7AY, UK. papas@bath.ac.uk. c.eccleston@bath.ac.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 26 FEB 2014

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Description of the condition

Chronic pain is prevalent in both adult and child populations (Breivik 2006; King 2011; Standford 2008), impacting on physical, psychological, and social functioning. Given that chronic pain is a long-term health condition, sustainable solutions to problems of pain, disability, depression, and anxiety are needed. Individuals experiencing chronic pain should be able to access self-management therapies away from expert healthcare centres, and be enabled to sustain self-management over the long-term. There is an opportunity for Internet-delivered therapies to provide methods that support this self-management.

 

Description of the intervention

Inconsistent terminology, including telemedicine, telehealth, ehealth, and Internet-delivered therapy, are commonly used interchangeably. Here, we use the term ‘Internet-delivered therapies’ to encompass technology that uses the worldwide web and facilitates the multifaceted, often psychotherapeutic, approach to modern chronic pain management (Gatchel 2007; Williams 2012). Internet-delivered therapies are only one part of a larger telehealth family of interventions that can assist communication between practitioner and patient, and improve self-management. The potential benefits of telehealth interventions include increased access to healthcare resources, not limited by geographic location or personnel availability, and reduced costs (Jennett 2003). Although remote consultation between the healthcare professional (HCP) and patient may contribute to these benefits, this review is limited to the use of Internet-delivered psychological therapies that use technology as a medium for facilitating traditional therapy delivery. For example, an Internet-based pain management intervention (e.g. Berman 2009) would meet this criterion, whereas an intervention providing traditional therapy by telephone (e.g. Sandgren 2000) would not. Previous research suggests that Internet-delivered treatment in the absence of, or with minimal, HCP involvement may be an effective intervention for chronic pain (Bender 2011; Palermo 2009). Such interventions frequently focus on the reduction of pain intensity and emotional distress, and the encouragement of adaptive behaviour change and skills acquisition. This focus is congruent with policy directives in many countries that advocate self-management and patient empowerment in the treatment of long-term health conditions, such as chronic pain (Bodenheimer 2002; Fu 2003; Jordan 2007; Lewis 2004). The evaluation of the efficacy of standalone Internet-delivered therapy is integral to substantiating whether these types of interventions can facilitate the successful evolution of health care away from the traditional and unsustainable acute model of care. In short, this review assesses whether pain management therapies can be successfully delivered in the home using the Internet as a mode of delivery.

 

How the intervention might work

The use of Internet-delivered therapies for pain-related health care takes a variety of forms, from assessment and education to structured intervention programmes (Keogh 2010). The mechanisms through which Internet-delivered therapies operate vary depending on technology, content, and health condition. The standalone (or minimally facilitated) therapies included in this review are likely to be based on adaptations of established methods of psychological pain management. However, one cannot assume that the impact and function of treatment will be equivalent. The introduction of technology and the reduction, or absence, of human interaction in treatment delivery has the potential to significantly influence the experience of the intervention and, ultimately, the outcome. A function of this review will be to establish, where possible, relations between features of technology, therapy content, and treatment outcome.

 

Why it is important to do this review

This review is designed to complement the review on psychological interventions for chronic pain in adults that excluded psychological or behaviour change therapies delivered over the Internet (Williams 2012). Relevant reviews of similar Internet-based therapies in non-pain conditions include those that focus on a specific targeted behaviour such as smoking cessation (Civljak 2013), or sexual health promotion (Bailey 2010), or those with a focus on a range of relevant behaviours within a lifestyle, such as self-management of type 2 diabetes mellitus (Pal 2013). These reviews have found some evidence for treatment effectiveness but are inconsistent on the economic benefits of telehealth (Black 2011), and there is a lack of analysable data when comparing telehealth interventions with traditional treatment approaches (Bailey 2010; Currell 2000). Furthermore, the quality of telehealth interventions and existing reviews (Martin 2008; Tuntland 2009; Whitten 2007) has been questioned (Black 2011). Evidence supporting the utility of Internet-delivered therapies for chronic pain appears more consistent. For example, Internet-delivered cognitive behavioural therapy (CBT) for chronic pain has produced clinically significant improvements in pain intensity in both adult and child populations (Bender 2011; Palermo 2009; Velleman 2010). At present, there is no systematic evaluation of the broader potential applications of psychological therapies delivered via the Internet. Furthermore, the moderating impact of demographic characteristics, including age, technology employed, and health condition, on treatment outcome within Internet-delivered therapies has yet to be explored within chronic pain (Hardiker 2011; McLean 2010; McLean 2011) .

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

Our objective was to evaluate whether Internet-delivered psychological therapies improve pain symptoms, reduce disability, and improve depression and anxiety in adults with chronic pain. Secondary outcomes included satisfaction with treatment/treatment acceptability and quality of life.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included randomised controlled trial (RCT) comparisons of Internet-delivered therapy for chronic pain compared to an active control, treatment-as-usual, or waiting-list control in this review. Studies had to include 20 or more participants with each condition at each extracted time-point (post-treatment and follow-up). We considered only peer-reviewed publications for inclusion in this review. We included trials if the primary aim was to deliver and evaluate a self-management psychological therapy in adults with chronic non-cancer pain.

 

Types of participants

Adults (aged 18 years or older) who reported non-cancer chronic pain. Studies included participants with headache or migraine (headache conditions) and pain in any body site (e.g. back pain, abdominal pain, musculoskeletal pain, fibromyalgia) (non-headache conditions). Chronic pain was defined as the experience of pain for three months or longer. Mixed-aged samples were included when adult and child data could be separated. We included studies in this review if the sample of participants was predominantly made up of those with chronic pain conditions.

 

Types of interventions

Included studies used an Internet-delivered psychological therapy that was required to be interactive with the user (e.g. respond dynamically based on data input by the user). Technology capable of delivering a psychological treatment programme via the Internet in the absence of, or with limited adjunctive HCP involvement was included. Adjunctive HCP involvement was categorised as involvement that supported a technology-based therapy, but that was not the primary source of treatment. The treatment therapy needed to be designed to promote pain management, by reducing pain experience, disability, and psychological distress, or adaptive behaviour change, or both. Therapies had to be based on an extant psychological model or framework, therefore including credible psychological content. Included studies needed to contain at least one arm using a psychological therapy and at least one comparator arm. Studies categorised as broader telehealth therapies, where technology was used to facilitate traditional communication and treatment between HCP and the individual with chronic pain, but did not deliver the primary psychological therapy itself and did not use the Internet to deliver the therapy (e.g. non-automated email, video conferencing) were excluded. However, these components were permitted to be additional parts to a Internet-delivered psychological therapy.

 

Types of outcome measures

 

Primary outcomes

The primary outcomes were pain, physical disability, depression, and anxiety. For pain outcomes, we extracted data on pain severity where possible. For studies that did not report a pain severity score, we extracted the most relevant outcome (e.g. average pain score). Pain specific measures were preferentially extracted to general measures (e.g. pain-related anxiety rather than a general anxiety measure). Adverse event data were also searched for.

 

Secondary outcomes

Secondary outcomes were quality of life, and treatment acceptability/satisfaction.

 

Search methods for identification of studies

 

Electronic searches

The following databases for RCTs of Internet-delivered interventions for adults with chronic pain were searched (see Appendix 1 for search strategies):

  • Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, Issue 10 of 12 (2013);
  • MEDLINE (OVID ), 1950 to 8/11/13 ;
  • EMBASE (OVID) 1980 to 2013 week 45 ;
  • PsycINFO (OVID) 1806 to Nov week 1, 2013.

 

Searching other resources

We also conducted a search of the reference lists of included papers and relevant review articles to source any studies that did not appear in the electronic searches. We also searched trial registries for trials.

 

Data collection and analysis

 

Selection of studies

Only peer-reviewed studies were eligible for inclusion. Review authors (EF, LC, GBD) reviewed the titles and abstracts of studies identified by the searches to assess eligibility based on the outlined criteria. Full text of studies initially meeting the criteria, or not categorically failing to meet the criteria for final selection, were assessed. Discrepancies between review authors were resolved by discussion; in the event that resolution could not be reached, a third review author (CE) arbitrated. We selected studies for inclusion using the following criteria:

1. must be an RCT published in a peer-reviewed journal;
2. n = > 20 in each arm at extracted time point;
3. therapy must be primarily psychological in at least one arm of the trial;
4. study must have the primary aim of promoting self-management in adults with non-cancer chronic pain;
5. study must use an Internet-delivered therapy as the primary mode of delivery.

 

Data extraction and management

Two review authors (EF, LC) independently extracted data from all included studies. Discrepancies between review authors were resolved by discussion; in the event that resolution could not be reached, a third review author (CE) arbitrated. Quantitative data were entered into Review Manager 5.2 (RevMan 2011). For outcome variables measured on continuous scales the standardised mean differences (SMDs) were calculated from extracted means and standard deviations (SD) collected post-intervention and at follow-up. For dichotomous outcomes, we calculated relative risk ratios (RR) with 95% confidence intervals (CI) using a random-effects model. The number needed to treat to benefit (NNTB) was also calculated:

NNTB = 1/absolute risk reduction (ARR), where ARR = the experimental event rate − the control event rate.

Where the necessary data were not reported, study authors were contacted. In addition to outcome data, participant demographic data were extracted and reported from the included studies.

 

Assessment of risk of bias in included studies

Two review authors assessed risk of bias using the Cochrane method (Higgins 2011), focusing on the evaluation of sequence generation, allocation concealment, blinding (outcome assessors), incomplete data, selective outcome reporting, and assessing other biases. Blinding of participants and personnel was not included in this review, as this category is redundant when reviewing psychological treatments (i.e. it is not possible to blind personnel to delivery of therapy). We categorised the risk of bias for each study as ‘low’, ‘unclear’, or ‘high’. Discrepancies between authors were resolved by discussion; in the event that resolution could not be reached, a third review author arbitrated.

 

Measures of treatment effect

Chronic pain conditions were split into headache and non-headache conditions. Control groups were combined for this review due to the small number of included studies. Each of the four primary outcomes and the two secondary outcomes were extracted and analysed post-treatment and at follow-up. If more than two measures were presented for one outcome, we extracted the most reliable and frequently used measure in the field. Self-report data were preferentially extracted. Post-treatment refers to the time-point first measured after treatment completion. The accepted timeframe for the collection of follow-up data was 3 to 12 months post-intervention. Data outside of this time frame were excluded. In the event of multiple follow-ups within the timeframe we used the latest data collection point. When a trial included more than two arms, we combined the results from the two most similar arms. If it was not appropriate to combine two arms together, (e.g. testing two different psychological therapies versus a control) the control group was split (Higgins 2011). Meta-analyses are presented only when two or more studies could be included for a given outcome. We conducted no sensitivity analyses because of the small number of studies.

 

Assessment of heterogeneity

We assessed heterogeneity by calculating the Chi2and I2 statistics for all outcome variables. We considered values for the I2 statistic above 50% to indicate high levels of heterogeneity, values between 25% and 50% to indicate medium heterogeneity, and those below 25% to indicate low heterogeneity.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Description of studies

See: Characteristics of included studies and Characteristics of excluded studies.

 

Results of the search

The database search of CENTRAL, MEDLINE, EMBASE, and PsycINFO generated a total of 9390 papers (see Figure 1). Fifteen studies met the full inclusion criteria.

 FigureFigure 1. Study flow diagram.

 

Included studies

We categorised the 15 studies on the basis of chronic pain condition: headache conditions (Bromberg 2011; Devineni 2005; Hedborg 2011; Ruehlman 2012; Strom 2000) and non-headache conditions (Berman 2009; Buhrman 2004; Buhrman 2011; Buhrman 2013; Buhrman 2013a; Carpenter 2012; Chiauzzi 2010; Dear 2013; Lorig 2008; Ruehlman 2012; Williams 2010). Ruehlman 2012 considered mixed pain conditions, including headache and back pain and is therefore included in both analyses (headache and non-headache conditions). Of the five studies included within the headache conditions category, three studies included individuals with migraines (Bromberg 2011; Hedborg 2011; Ruehlman 2012), one included individuals with chronic headache (Devineni 2005), and one included individuals with recurrent headache (Strom 2000). In the non-headache conditions category, five studies included individuals with chronic back pain (Buhrman 2004; Buhrman 2011; Carpenter 2012; Chiauzzi 2010; Ruehlman 2012), two included individuals with rheumatoid arthritis, osteoarthritis, or fibromyalgia (Lorig 2008; Williams 2010) and four included individuals with mixed pain conditions (i.e. not headache; Berman 2009; Buhrman 2013; Buhrman 2013a; Dear 2013).

The total number of participants providing data at the end of treatment was 2012 (mean = 134 participants per study, SD = 151, median = 78, interquartile range (IQR) 56 to 144). The total number of participants entering treatment was 2435 (mean = 162 participants per study, SD = 204.68, median = 86, IQR = 62 to 189). Therefore the completion rate for all studies was 82.6%, with the proportion of completers ranging across studies from 75% to 100%. The attrition rate was 17.4% (range 0 to 25%). The mean age of participants entering the studies was 47 years (SD = 7.59 years, range = 37 to 66 years, median = 44.93 years, IQR = 42.50 to 50.46 years). Mean duration of pain was reported in only eight studies (mean = 11.69 years, SD = 5.53 years, range = 9 to 23 years, median = 9.75 years, IQR = 7.46 to 14.50 years). A total of 1989 women were enrolled in the trials compared with 504 men. The average proportion of women per trial was 80%. All studies specified the source of the participants, who were recruited mainly using Internet-based promotion channels (e.g. Internet bulletin boards, established websites, and discussion groups). Fourteen studies used two comparator arms and one had three comparator arms (Hedborg 2011). Of the 14 studies that compared two arms, eight studies used waiting-list controls, three used treatment-as-usual controls, and three used an active control in which participants received educative text-based material or participated in an online discussion forum. The three comparator-armed study used an active control in comparison to two treatments. The first treatment group received a multimodal behaviour treatment and a CD of muscular relaxation. The second treatment group received a hand massage in addition to the Internet-based programme and muscular relaxation CD. The control group received only the CD of muscular relaxation (Hedborg 2011). Studies could not be analysed according to control type due to the small number of included trials.

Fourteen studies evaluated an Internet-delivered psychological therapy of a CBT orientation. One study used an acceptance commitment-based therapy (Buhrman 2013a). The mean duration of therapy was 11 weeks (range 3 to 46 weeks). The primary mode of therapy delivery for all studies was via computer. Two studies offered adjunctive structured telephone support (Buhrman 2004; Buhrman 2011). Two studies used the same pain management therapy, termed painACTION (Bromberg 2011; Chiauzzi 2010). A further four studies were all from the same research group (Buhrman 2004; Buhrman 2011; Buhrman 2013; Buhrman 2013a). Data were available for extraction from all 15 included studies.

We present a summary of the characteristics of therapy and treatment content in Characteristics of included studies.

 

Excluded studies

Forty-nine studies did not meet the inclusion criteria for this study. Fourteen studies did not have chronic non-cancer pain as their primary pain condition (Anderson 2006; Chambers 2006; Cleeland 2011; Everitt 2010; Everitt 2013; Johns 2011; Kroenke 2010; Lorig 2006; Miller 2010; Oerlemans 2011; Premi 1993; Steel 2011; Taieb-Maimon 2012; Weingart 2008). Twelve studies did not use the Internet as their primary mode of treatment delivery (Allen 2008; Childs 2011; Greco 2004; Jennings 2008; Kjeken 2011; Kosterink 2010; Kristjansdottir 2011; Kristjansdottir 2013; Larsman 2010; Naylor 2008; Naylor 2010; Vonk Noordegraaf 2012). Nine studies did not evaluate a self-management psychological intervention (Bieber 2006; Bruce 2005; Fraenkel 2007; Hochlehnert 2006; Huffstutter 2007; Keulers 2007; Macedo 2012; Sandsjo 2010; Sciamanna 2006). Six studies were not randomised control trials (Borckardt 2004; de Bruijn-Kofman 1997; Jacobs 2013; Leboeuf-Yde 2012; Leveille 2007; Spunt 1996). Three studies were excluded because the number of participants in any study arm was less than 20 (Andersson 2002; Brattberg 2006; Brattberg 2007). A further three studies were excluded because the intervention had insufficient psychotherapeutic content; these studies were evaluations of online peer discussion groups (Krein 2010; Leville 2009; Lorig 2002). Finally, two studies used non-inferiority designs (Kleiboer 2009; Russell 2011).

The initial identification of these studies using the search strategy outlined supports the criticism that a diversity of terminology is used to describe pain and therapies. We acknowledge that these judgements were often difficult to make and led to extensive discussions between review authors.

 

Risk of bias in included studies

'Risk of bias’ summaries are shown in Figure 2 and Figure 3. Six 'risk of bias' categories were used: random sequence generation (selection bias), allocation concealment (selection bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and 'free from other bias'. Eight studies described a convincing method of randomisation and were judged to have a low risk of bias; a further six did not provide an adequate description and were judged to be unclear. One study did not describe randomisation and was judged to have a high risk of bias for random sequence generation. Five studies described a convincing method of allocation and had low risk of allocation bias; a further eight studies did not provide an adequate description and we judged them to be unclear. We rated two studies as high risk of allocation bias because group assignment was not concealed from the research assistants. Thirteen studies took assessments online and were therefore judged to have low risk of bias for blinding of outcome assessment. Two studies did not provide an adequate description of outcome assessment and were unclear. No studies were rated as high risk of outcome bias. Seven studies adequately reported attrition and found no significant differences between completers and non-completers; these were judged to have a low risk of bias. Six were rated as unclear risk, mainly due to the non-reporting of differences between completers and non-completers. Two studies had high risk of bias for incomplete data due to statistical differences between completers and non-completers and a data management error that resulted in one outcome measure being unavailable for analysis. Eleven studies reported all outcomes and had a low risk of bias for selective reporting bias. A further four studies were rated to have high risk of selective reporting bias because data could not be extracted. No other sources of bias were found for the 15 studies included in the review. It is noteworthy that almost all outcomes were self-reported assessments, and so there were limited opportunities for influencing participants’ scores. Consequently, most of our judgements of high risk of bias were because of inadequate reporting.

 FigureFigure 2. 'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 3. 'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

 

Effects of interventions

Data were analysed by two categories; headache conditions and non-headache conditions. For both categories, outcomes were analysed post-treatment and at follow-up. Note, no data could be presented for the secondary outcome 'treatment acceptability/satisfaction' due to the lack of studies reporting this outcome quantitatively.

Treatment versus control for headache conditions post-treatment

Two studies with 131 participants were entered into an analysis of the effect of treatment on pain. The overall effect was beneficial for psychological therapies (z = 3.88, p < 0.01, RR 7.28, 95% CI 2.67 to 19.84, I2 = 0%; NNTB = 2.72). Two studies with 241 participants were entered into an analysis of the effects of treatment on disability. The overall effect of psychological therapies was beneficial (z = 4.89, p < 0.01), with a moderate effect size (SMD −0.65, 95% CI −0.91 to −0.39, I2 = 0%) ( Analysis 1.2). Four studies with 617 participants were entered into an analysis of the effects of treatment on depression; there was no clear evidence of benefit for psychological therapies (z = 0.82, p > 0.05, SMD −0.26, 95% CI −0.87 to 0.36, I2 = 92%) ( Analysis 1.3). Three studies with 546 participants were entered into an analysis of the effects of treatment on anxiety. Analyses showed there was no clear evidence of benefit for psychological therapies (z = 1.26, p > 0.05, SMD −0.48, 95% CI −1.22 to 0.27, I2 = 94%) ( Analysis 1.4). Only one study could be entered into an analysis of the effect of psychological therapies on quality of life; hence, no conclusions can be drawn. Only one study reported adverse outcomes (Devineni 2005): the study reported that 11.6% of treatment completers reported worsening of headache symptoms; the distribution between treatment and control groups was not reported.

Treatment versus control for headache conditions at follow-up

No data were available for the analysis of the effects of treatment on pain at follow-up. Only one study could be included for the analysis of the effects of treatment on disability at follow-up; hence, no conclusions can be drawn. Two studies with 425 participants were entered into an analysis of the effects of treatment on depression at follow-up and there was no clear evidence of benefit (z = 0.94, p > 0.05, SMD −1.03, 95% CI −3.18 to 1.12, I2 = 99%) ( Analysis 2.1). Two studies with 425 participants were entered into an analysis of the effects of treatment on anxiety at follow-up; there was no clear evidence of benefit (z = 1.42, p > 0.05, SMD −0.46, 95% CI −1.09 to 0.18, I2 = 88%) ( Analysis 2.2). Quality of life outcomes were not assessed by any study for headache conditions at follow-up.

Treatment versus control for non-headache conditions post-treatment

Eleven studies with 1785 participants were entered into an analysis of the effects of treatment on pain. The overall effect of treatment was beneficial for psychological therapies (z = 3.32, p < 0.01), with a small effect size (SMD −0.37, 95% CI −0.59 to −0.15, I2 = 77%) ( Analysis 3.1; Figure 4). Five studies with 1149 participants were entered into an analysis of the effects of treatment on disability. The overall effect was beneficial for psychological therapies (z = 3.26, p < 0.01), with a moderate effect size (SMD −0.50, 95% CI −0.79 to −0.20, I2= 79%) ( Analysis 3.2; Figure 5). Nine studies with 1013 participants were entered into an analysis of the effects of treatment on depression. The overall effect was beneficial for psychological therapies with a small effect size (z = 2.41, p < 0.05, SMD −0.19, 95% CI −0.35 to −0.04, I2 = 29%) ( Analysis 3.3). Ten studies with 1144 participants were entered into an analysis of the effects of treatment on anxiety. The overall effect for psychological therapies was beneficial, with a small effect size (z = 2.54, p < 0.05, SMD −0.28, 95% CI −0.49 to −0.06, I2 = 66%) ( Analysis 3.4). Three studies with 202 participants were entered into an analysis of the effects of treatment on quality of life. The overall effect did not show a benefit for psychological therapies (z = 1.88, p > 0.05, SMD −0.27, 95% CI −0.54 to 0.01, I2 = 0%) ( Analysis 3.5).

 FigureFigure 4. Forest plot of comparison: 3 Non-headache post treatment, outcome: 3.1 Pain.
 FigureFigure 5. Forest plot of comparison: 3 Non-headache post treatment, outcome: 3.2 Disability.

Treatment versus control for non-headache conditions at follow-up

Four studies with 1202 participants were entered into an analysis of the effects of treatment on pain at follow-up and the overall effect was not beneficial for psychological therapies (z = 1.34, p > 0.05, SMD −0.48, 95% CI −1.18 to 0.22, I2 = 96%) ( Analysis 4.1). Two studies with 850 participants were entered into an analysis of the effects of treatment on disability at follow-up and the overall effect for psychological therapies was beneficial (z = 2.17, p < 0.05), with a small effect size (SMD −0.15, 95% CI −0.28 to −0.01, I2 = 20%) ( Analysis 4.2). Three studies with 551 participants were entered into an analysis of the effects of treatment on depression at follow-up and the overall effect did not show benefit for psychological therapies (z = 0.80, p > 0.05, SMD −0.53, 95% CI −1.84 to 0.78, I2 = 98%) ( Analysis 4.3). Three studies with 551 participants were entered into an analysis of the effects of treatment on anxiety at follow-up. The overall effect was not beneficial for psychological therapies (z = 0.89, p > 0.05, SMD −0.39, 95% CI −1.25 to 0.47, I2 = 95%) ( Analysis 4.4). Quality of life outcomes were not assessed by any study for non-headache conditions at follow-up.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Summary of main results

We investigated the efficacy of psychological therapies for chronic pain management delivered via the Internet, in comparison with active, treatment-as-usual, or waiting-list controls. Fifteen studies met the inclusion criteria for the review and data were available for extraction from all studies. Studies were categorised as headache or non-headache conditions. Eight analyses were conducted for each condition including four primary outcomes of pain, disability, depression, and anxiety. These were assessed at two time points: immediately post-treatment and at follow-up. There were also two secondary outcomes (quality of life and acceptability/satisfaction), which are discussed separately. For headache conditions, pain and disability improved immediately post-treatment. However, these findings should be treated with caution as only two studies could be included in each of the analyses. For non-headache conditions, pain, disability, depression, and anxiety improved immediately post-treatment, and disability also improved at follow-up. However, similar to headache findings, only two studies could be entered into the disability analyses at follow-up, and so this finding should also be interpreted cautiously.

Only one study reported adverse events; 11.6% of the completing participants with headache conditions reported a worsening of headache symptoms (Devineni 2005).

The overall attrition from studies was 17.4% on average (range 0 to 25). Reasons for attrition included health problems and illness, difficulty using a computer or being physically uncomfortable using a computer, and personal problems. For those who stayed in the study, overall compliance rates with treatment requirements (e.g. number of sessions completed) are not known. The planned analyses of secondary outcomes (quality of life and acceptability/satisfaction) were limited because data were sparse. Only one study could be included in the analysis on quality of life in the headache condition so no analysis could be undertaken. No effect was found for the three studies that reported quality of life data immediately post-treatment in the non-headache condition. Internet-delivered psychological therapies are a novel method of treatment delivery, and acceptability and participant satisfaction are important yet neglected variables.

Internet-delivered psychological therapies had an impact on pain, disability, depression, and anxiety for non-headache conditions immediately post-treatment. Findings for the effect on all outcomes for headache conditions are minimal to limited. It should be acknowledged that the small effect sizes and lack of effect for depression and anxiety may be due to the lack of sensitivity to change: the baseline levels of depression and anxiety were low for the participants included in this review. This observation raises the question of the appropriateness of mental health interventions for individuals with chronic pain. In future studies/updates we might require a revised inclusion criterion requiring participants to be sufficiently depressed, anxious, and/or disabled.

In contrast to immediate post-treatment evaluations, few studies included follow-up assessments. Our conclusions regarding the effects of psychological therapies delivered via the Internet on longer-term symptom improvements, particularly with regards to pain, are therefore limited. There was no cut-off for pain severity in the inclusion criteria for this review and participants tended to have moderate pain ratings. It is acknowledged that different findings may have been obtained if studies had included participants with severe pain.

There are some limitations associated with the current set of primary studies included. A high level of heterogeneity was reported for some outcomes, which may have introduced an overestimation of effect. This could be attributed to the following reasons: first, most studies recruit people from the general population who self-select and volunteer to participate. The inclusion of such populations may limit the applicability of findings to clinical populations, and may introduce floor effects on some measures. Second, we combined studies with different comparison arms of treatments as there are not yet sufficient data within the same comparison group. Third, different measures were combined within the same outcome domain. Studies with a standard placebo control are needed. It is also not possible to state whether treatment is more effective than completing an active control (Williams 2012). Some have suggested that individuals in wait-list control groups do not take action to diminish pain-related problems during their waiting period because participants are expectant of future professional support (Cuijpers 2008). In future updates, when data allow, we will seek to compare treatments within their class of comparison treatment (e.g. placebo, treatment-as-usual). Internet-delivered treatment offers the possibility of matching treatment intensity to need, and to shape content to need, but we do not have data from this review that enable us to make any evidence-based comments on these possibilities. Finally, no analysis of adverse effects was possible, and no analysis of treatment expectations, satisfaction, or compliance was possible.

 

Overall completeness and applicability of evidence

Studies in this review were dominated by cognitive behavioural and behavioural treatments. The content of therapies reviewed was fairly homogeneous, with most including cognitive skill building components (e.g. problem solving skills training) as well as applied components (e.g. relaxation training). As found in the review by Williams 2012, which investigated face-to-face psychological therapies in adults with chronic pain (excluding headache), there was an apparent disjunction between the stated aims of treatment, actual treatment content and outcomes measured. Most studies did not include a comprehensive justification of treatment rationale and it was not always clear how the outcomes assessed linked to the intended aims of treatment.

We excluded a number of studies because of the absence of content that could be considered psychological. There are many ways in which the Internet and technology could be used to further the overall goal of independent management of pain. A broader consideration of developments in telehealth and chronic pain would capture work in sensing and assessment, mobile health monitoring, virtual reality including immersive environments, games for pain, and education, to name a few (Keogh 2010). Clearer information is required regarding whether therapies are designed to augment, replace, or improve on face-to-face psychological therapy, and in what way the proposed mechanism of improving self-management is psychological.

 

Agreements and disagreements with other studies or reviews

The findings are consistent with other systematic reviews in this field. Similar effects for have been found for pain outcomes (Bender 2011; Cuijpers 2008; Macea 2010) and activity limitation (Bender 2011). Similar to the findings in this review for non-headache conditions, systematic reviews have found reductions in depression and anxiety scores after CBT was delivered via the Internet (Griffiths 2010; Spek 2007). The types of therapies that met the inclusion criteria varied across reviews. In addition to CBT interventions, Bender 2011 assessed peer-support programmes (e.g. social networking programmes) and clinical visit supports, although they found insufficient evidence for Internet-based clinical support interventions. Cuijpers 2008 considered interventions that consisted of online contact between therapist/moderator and participant, where the Internet facilitated contact, rather than acting as the primary intervention itself. This review, unlike the other three, excluded child studies.

This review can be directly compared to Williams 2012, from which it was partly born. The average age and gender ratio in both reviews were very similar (mean = 48 years, SD = 9 years, women = 71% in Williams 2012, compared with mean = 47 years, SD = 8 years, women = 80% in the current review). Participants were recruited via different methods. Williams 2012 found that most participants were recruited via healthcare settings (e.g. pain rehabilitation clinics, rheumatology clinics, and the community). However, this review found that most participants volunteered after seeing an advert on an Internet forum. The findings of this review also were similar to the face-to-face therapies reviewed by Williams 2012. First, Williams 2012 found that pain, disability, mood (depression), and catastrophising in adults with chronic pain (excluding headache) improved immediately post-treatment. Similarly, this review revealed positive effects for pain, disability, depression, and anxiety post-treatment for individuals with non-headache conditions. However, the results differed at follow-up. Williams 2012 found an effect on mood to be maintained at follow-up. No such effect was found in this review. However, this review found disability to be maintained at follow-up, although the analysis included only two studies and so should be interpreted with caution. There are fewer studies included in this review (N = 15) compared to Williams 2012 (N = 35) and the overall number of participants was also fewer (N = 2012) compared to Williams 2012 (N = 4788).

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

 

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:

  1. Be properly powered to detect meaningful changes in the primary outcomes measured (approximate n = 300);
  2. Use a placebo therapy as the primary comparator;
  3. Make attempts to blind both participants and investigators to treatment selection;
  4. Measure adverse effects, participant satisfaction, adherence to treatment, and reasons for attrition;
  5. Enrol only participants with moderate-to-severe pain, disability, or distress;
  6. 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.

  1. Can therapeutic alliance be achieved with non-human objects/systems, and is it necessary to deliver behaviour change?
  2. Can novel aspects of Internet systems be used therapeutically (e.g. immersion technology, multi-agent connections, remote sensing)?
  3. 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.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

We would like to thank Joanne Abbott for designing and running the search for this review.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
Download statistical data

 
Comparison 1. Headache post treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain2131Risk Ratio (M-H, Random, 95% CI)7.28 [2.67, 19.84]

 2 Disability2241Std. Mean Difference (IV, Random, 95% CI)-0.65 [-0.91, -0.39]

 3 Depression4617Std. Mean Difference (IV, Random, 95% CI)-0.26 [-0.87, 0.36]

 4 Anxiety3546Std. Mean Difference (IV, Random, 95% CI)-0.48 [-1.22, 0.27]

 
Comparison 2. Headache follow-up

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Depression2425Std. Mean Difference (IV, Random, 95% CI)-1.03 [-3.18, 1.12]

 2 Anxiety2425Std. Mean Difference (IV, Random, 95% CI)-0.46 [-1.09, 0.18]

 
Comparison 3. Non-headache post treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain111785Std. Mean Difference (IV, Random, 95% CI)-0.37 [-0.59, -0.15]

 2 Disability51149Std. Mean Difference (IV, Random, 95% CI)-0.50 [-0.79, -0.20]

 3 Depression91013Std. Mean Difference (IV, Random, 95% CI)-0.19 [-0.35, -0.04]

 4 Anxiety101144Std. Mean Difference (IV, Random, 95% CI)-0.28 [-0.49, -0.06]

 5 Quality of life3202Std. Mean Difference (IV, Random, 95% CI)-0.27 [-0.54, 0.01]

 
Comparison 4. Non-headache follow-up

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain41202Std. Mean Difference (IV, Random, 95% CI)-0.48 [-1.18, 0.22]

 2 Disability2850Std. Mean Difference (IV, Fixed, 95% CI)-0.15 [-0.28, -0.01]

 3 Depression3551Std. Mean Difference (IV, Random, 95% CI)-0.53 [-1.84, 0.78]

 4 Anxiety3551Std. Mean Difference (IV, Random, 95% CI)-0.39 [-1.25, 0.47]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Appendix 1. Search strategies

CENTRAL search strategy

#1                  MeSH descriptor: [Telecommunications] explode all trees

#2                  (telemedicine or tele-medicine)

#3                  (telehealth or tele-health)

#4                  (ehealth or e-health)

#5                  (mobile health or mhealth or m-health)

#6                  ICT

#7                  ((inform* or communicat* or interact*) near/6 (computer* or technolog* or software))

#8                  (health* or treat* or therap* or intervention* or assist* or selfmanag* or self-manag*) near/6 (computer* or technolog* or software)

#9                  MeSH descriptor: [Internet] explode all trees

#10            (internet* or world wide web or www or web-based or email or e-mail or online)

#11                (telephone* or phone* or mobile* or cellphone* or apps or text* or SMS or smartphone*)

#12                (virtual reality or augmented reality or VR or AR)

#13                #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12

#14                MeSH descriptor: [Pain] explode all trees

#15                MeSH descriptor: [Pain Measurement] this term only

#16                MeSH descriptor: [Headache Disorders] explode all trees

#17                MeSH descriptor: [Fibromyalgia] this term only

#18                (pain* or headache* or migraine* or fibromyalgia* or neuralgia*)

#19                #14 or #15 or #16 or #17 or #18

#20                #13 and #19

MEDLINE search strategy

1   exp Telecommunications/
2   (telemedicine or tele-medicine).mp.
3   (telehealth or tele-health).mp.
4   (ehealth or e-health).mp.
5   (mobile health or mhealth or m-health).mp.
6   ICT.mp.
7   ((inform* or communicat* or interact*) adj6 (computer* or technolog* or software)).mp.
8   ((health* or treat* or therap* or intervention* or assist* or selfmanag* or self-manag*) adj6 (computer* or technolog* or software)).mp.
9   exp Internet/
10  (internet* or world wide web or www or web-based or email or e-mail or online).mp.
11  (telephone* or phone* or mobile* or cellphone* or apps or text* or SMS or smartphone*).mp.
12  (virtual reality or augmented reality or VR or AR).mp.
13  1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
14  exp Pain/
15  Pain Measurement/
16  exp Headache Disorders/
17  Fibromyalgia/
18  (pain* or headache* or migraine* or fibromyalgia* or neuralgia*).mp
19  14 or 15 or 16 or 17 or 18
20  randomized controlled trial.pt.
21  controlled clinical trial.pt.
22  randomized.ab.
23  placebo.ab.
24  clinical trials as topic.sh.
25  randomly.ab.
26  trial.ti.
27  20 or 21 or 22 or 23 or 24 or 25 or 26
28  13 and 19 and 27

Key:

mp=protocol supplementary concept, rare disease supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier

ab=abstract

ti=title

pt=publication type

sh=subject heading

EMBASE (OVID) search strategy

1     exp Telecommunications/

2     (telemedicine or tele-medicine).tw.

3     (telehealth or tele-health).tw.

4     (ehealth or e-health).tw.

5     (mobile health or mhealth or m-health).tw.

6     ICT.tw.

7     ((inform* or communicat* or interact*) adj6 (computer* or technolog* or software)).tw.

8     ((health* or treat* or therap* or intervention* or assist* or selfmanag* or self-manag*) adj6 (computer* or technolog* or software)).tw.

9     exp Internet/

10     (internet* or world wide web or www or web-based or email or e-mail or online).tw.

11     (telephone* or phone* or mobile* or cellphone* or apps or text* or SMS or smartphone*).tw.

12     (virtual reality or augmented reality or VR or AR).tw.

13     or/1-12

14     exp Pain/

15     Pain Measurement/

16     exp Headache Disorders/

17     Fibromyalgia/

18     (pain* or headache* or migraine* or fibromyalgia* or neuralgia*).tw.

19     or/14-18

20     random$.tw.

21     factorial$.tw.

22     crossover$.tw.

23     cross over$.tw.

24     cross-over$.tw.

25     placebo$.tw.

26     (doubl$ adj blind$).tw.

27     (singl$ adj blind$).tw.

28     assign$.tw.

29     allocat$.tw.

30     volunteer$.tw.

31     crossover procedure/

32     double blind procedure/

33     randomized controlled trial/

34     single blind procedure/

35     or/20-34

36     (animal/ or nonhuman/) not human/

37     35 not 36

38     13 and 19 and 37

 

PsycINFO (OVID) search strategy

1     exp Telecommunications/

2     (telemedicine or tele-medicine).tw.

3     (telehealth or tele-health).tw.

4     (ehealth or e-health).tw.

5     (mobile health or mhealth or m-health).tw.

6     ICT.tw.

7     ((inform* or communicat* or interact*) adj6 (computer* or technolog* or software)).tw.

8     ((health* or treat* or therap* or intervention* or assist* or selfmanag* or self-manag*) adj6 (computer* or technolog* or software)).tw.

9     exp Internet/

10     (internet* or world wide web or www or web-based or email or e-mail or online).tw.

11     (telephone* or phone* or mobile* or cellphone* or apps or text* or SMS or smartphone*).tw.

12     (virtual reality or augmented reality or VR or AR).tw.

13     or/1-12

14     exp Pain/

15     Pain Measurement/

16     exp Headache/

17     Fibromyalgia/

18     (pain* or headache* or migraine* or fibromyalgia* or neuralgia*).tw.

19     or/14-18

20     13 and 19

21     clinical trials/

22     (randomis* or randomiz*).tw.

23     (random$ adj3 (allocat$ or assign$)).tw.

24     ((clinic$ or control$) adj trial$).tw.

25     ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw.

26     (crossover$ or "cross over$").tw.

27     random sampling/

28     Experiment Controls/

29     Placebo/

30     placebo$.tw.

31     exp program evaluation/

32     treatment effectiveness evaluation/

33     ((effectiveness or evaluat$) adj3 (stud$ or research$)).tw.

34     or/21-33

35     20 and 34

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

CE conceived the idea, and led the design and delivery of the review, and contributed to the writing. CE, EF, LC, GBD, BAR and EK contributed to the design and writing of the protocol. CE, GBD, EF and LC selected studies for inclusion. EF and LC extracted data and assessed risk of bias. CE, EF and LC analysed data. EK contributed to writing and oversaw the review process.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Internal sources

  • No sources of support supplied

 

External sources

  • EPSRC, UK.

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

There are no differences between the protocol and the review.

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
Berman 2009 {published data only}
Bromberg 2011 {published data only}
Buhrman 2004 {published data only}
Buhrman 2011 {published data only}
  • Buhrman M, Nilsson-Ihrfeldt E, Jannert M, Strom L, Andersson G. Guided internet-based cognitive behavioural treatment for chronic back pain reduces pain catastrophizing: a randomized controlled trial. Journal of Rehabilitation Medicine 2011;43(6):500-5.
Buhrman 2013 {published data only}
Buhrman 2013a {published data only}
  • Buhrman M, Skoglund A, Husell J, Bergstrom K, Gordh T, Hursti T, et al. Guided internet-delivered acceptance and commitment therapy for chronic pain patients: a randomized controlled trial. Behaviour Research and Therapy 2013;51(6):307-15.
Carpenter 2012 {published data only}
Chiauzzi 2010 {published data only}
Dear 2013 {published data only}
  • Dear BF, Titov N, Perry KN, Jonston L, Wootton BM, Terides MD, et al. The Pain Course: a randomised controlled trial of a clinician-guided internet-delivered cognitive behaviour therapy program for managing chronic pain and emotional well-being. Pain 2013;154(6):942-50.
Devineni 2005 {published data only}
Hedborg 2011 {published data only}
Lorig 2008 {published data only}
Ruehlman 2012 {published data only}
Strom 2000 {published data only}
Williams 2010 {published data only}

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
Allen 2008 {published data only}
  • Allen M, Iezzoni LI, Huang A, Huang L, Leveille SG. Improving patient-clinician communication about chronic conditions: description of an internet-based nurse E-coach intervention. Nursing Research 2008;57(2):107-12.
Anderson 2006 {published data only}
Andersson 2002 {published data only}
Bieber 2006 {published data only}
  • Bieber C, Muller KG, Blumenstiel K, Schneider A, Richter A, Wilke S, et al. Long-term effects of a shared decision-making intervention on physician-patient interaction and outcome in fibromyalgia. A qualitative and quantitative 1 year follow-up of a randomized controlled trial. Patient Education and Counseling 2006;63(3):357-66.
Borckardt 2004 {published data only}
  • Borckardt JJ, Younger J, Winkel J, Nash MR, Shaw D. The computer-assisted cognitive/imagery system for use in the management of pain. Pain Research & Management 2004;9(3):157-62.
Brattberg 2006 {published data only}
Brattberg 2007 {published data only}
  • Brattberg G. Internet-based rehabilitation for individuals with chronic pain and burnout II: a long-term follow-up. International Journal of Rehabilitation Research 2007;30(3):231-4.
Bruce 2005 {published data only}
  • Bruce B, Lorig K, Laurent D, Ritter P. The impact of a moderated e-mail discussion group on use of complementary and alternative therapies in subjects with recurrent back pain. Patient Education and Counseling 2005;58(3):305-11.
Chambers 2006 {published data only}
  • Chambers A, Hennessy E, Powel-Tuck J. Longitudinal trends in quality of life after starting home parenteral nutrition: a randomised controlled study of telemedicine. Clinical Nutrition 2006;25(3):505-14.
Childs 2011 {published data only}
  • Childs JD, Teyhen DS, Van Wyngaarden JJ, Dougherty BF, Ladislas BJ, Helton GL, et al. Predictors of web-based follow-up response in the Prevention Of Low Back Pain In The Military Trial (POLM). BMC Musculoskeletal Disorders 2011;12(1):132.
Cleeland 2011 {published data only}
  • Cleeland CS, Wang XS, Shi Q, Mendoza TR, Wright SL, Berry MD, et al. Automated symptom alerts reduce postoperative symptom severity after cancer surgery: a randomized controlled clinical trial. Journal of Clinical Oncology 2011;29(8):994-1000.
de Bruijn-Kofman 1997 {published data only}
  • de Bruijn-Kofman AT, Van De Wiel H, Groenman NH, Sorbi MJ, Klip E. Effects of a mass media behavioral treatment for chronic headache: a pilot study. Headache 1997;37(7):415–20.
Everitt 2010 {published data only}
  • Everitt HA, Moss-Morris RE, Sibelli A, Tapp L, Coleman NS, Yardley L, et al. Management of irritable bowel syndrome in primary care: feasibility randomised controlled trial of mebeverine, methylcellulose, placebo and a patient self-management cognitive behavioural therapy website. (MIBS trial). BMC Gastroenterology 2010;10(1):136.
Everitt 2013 {published data only}
  • Everitt H, Moss-Morris R, Sibelli A, Tapp L, Coleman N, Yardley L, et al. Management of irritable bowel syndrome in primary care: the results of an exploratory randomised controlled trial of mebeverine, methylcellulose, placebo and a self-management website. BMC Gastroenterology 2013;13(1):68.
Fraenkel 2007 {published data only}
  • Fraenkel L, Rabidou N, Wittink D, Fried T. Improving informed decision-making for patients with knee pain. The Journal of Rheumatology 2007;34(9):1894-8.
Greco 2004 {published data only}
Hochlehnert 2006 {published data only}
  • Hochlehnert A, Richter A, Bludau HB, Bieber C, Blumenstiel K, Mueller K, et al. A computer-based information-tool for chronic pain patients. Computerized information to support the process of shared decision-making. Patient Education and Counseling 2006;61(1):92–8.
Huffstutter 2007 {published data only}
  • Huffstutter J, Craig WD, Schimizzi G, Harshbarger J, Lisse J, Kasle S, et al. A multicenter, randomized, open study to evaluate the impact of an electronic data capture system on the care of patients with rheumatoid arthritis. Current Medical Research and Opinion 2007;23(8):1967–79.
Jacobs 2013 {published data only}
  • Jacobs K, Foley G, Punnett L, Hall V, Gore R, Brownson E, et al. University students' notebook computer use: lessons learned using e-diaries to report musculoskeletal discomfort. Ergonomics 2013;54(2):206–19.
Jennings 2008 {published data only}
  • Jennings MB, Lesczczynski C, Goodwin S. The safety and efficacy of Pain Checker socks in the treatment of mild-to-moderate foot pain: a clinical trial. Journal of the American Podiatric Medical Association 2008;98(4):278-82.
Johns 2011 {published data only}
  • Johns SA, Kroenke K, Theobald DE, Wu J, Tu W. Telecare management of pain and depression in patients with cancer: patient satisfaction and predictors of use. The Journal of Ambulatory Care Management 2011;34(2):126–39.
Keulers 2007 {published data only}
  • Keulers BJ, Welters CFM, Spauwen PHM, Houpt P. Can face-to-face patient education be replaced by computer-based patient education? A randomised trial. Patient Education and Counseling 2007;67(1-2):176–82.
Kjeken 2011 {published data only}
  • Kjeken I, Darre S, Smedslund G, Hagen KB, Nossum R. Effect of assistive technology in hand osteoarthritis: a randomised controlled trial. Annals of the Rheumatic Diseases 2011;70(8):1447–52.
Kleiboer 2009 {published data only}
  • Kleiboer A, Sorbi M, Merelle S, Passchier J, van Doornen L. Utility and preliminary effects of online digital assistance (ODA) for behavioral attack prevention in migraine. Telemedicine Journal and e-Health 2009;15(7):682-90.
Kosterink 2010 {published data only}
  • Kosterink SM, Huis in 't Veld RM, Cagnie B, Hasenbring M, Vollenbroek-Hutten MM. The clinical effectiveness of a myofeedback-based teletreatment service in patients with non-specific neck and shoulder pain: a randomized controlled trial. Journal of Telemedicine and Telecare 2010;16(6):316-21.
Krein 2010 {published data only}
  • Krein S, Metreger T, Kadri R, Hughes M, Kerr EA, Piette JD, et al. Veterans walk to beat back pain: study rationale, design and protocol of a randomized trial of a pedometer-based internet mediated intervention for patients with chronic low back pain.. BMC Musculoskeletal Disorders 2010;11(1):205.
Kristjansdottir 2011 {published data only}
  • Kristjansdottir OB, Fors EA, Eide E, Finset A, Van Dulmen S, Wigers SH, et al. Written online situational feedback via mobile phone to support self-management of chronic widespread pain: a usability study of a Web-based intervention. BMC Musculoskeletal Disorders 2011;12(1):51.
Kristjansdottir 2013 {published data only}
  • Kristjansdottir OB, Fors EA, Eide E, Finset A, Stensrud T, van Dulmen S, et al. A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial. Journal of Medical Internet Research 2013;15(1):e5.
  • Kristjansdottir OB, Fors EA, Eide E, Finset A, Stensrud TL, van Dulmen S, et al. A smartphone-based intervention with diaries and therapist feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain. part 2: 11-month follow-up results of a randomized trial. Journal of Medical Internet Research 2013;15(3):e72.
Kroenke 2010 {published data only}
  • Kroenke K, Theobald D, Wu J, Norton K, Morrison G, Carpenter J, Tu W. Effect of telecare management on pain and depression in patients with cancer: a randomized trial. JAMA 2010;304(2):163-71.
Larsman 2010 {published data only}
  • Larsman P, Hasenbring M, Sandsjo L, Huis in 't Veld RM, Witvrouw E, Kosterink SM, et al. Prognostic factors for the effect of a myofeedback-based teletreatment service. Journal of Telemedicine and Telecare 2010;16(6):336-43.
Leboeuf-Yde 2012 {published data only}
  • Leboeuf-Yde C, Jensen RK, Axen I. Absence of low back pain in patients followed weekly over one year with automated text messages. Chiropractic & Manual Therapies 2012;20(9):1-7.
Leveille 2007 {published data only}
  • Leveille SG, Huang A, Tsai SB, Weingart SN, Iezzoni LI. Screening for chronic conditions using a patient internet portal: recruitment for an internet-based primary care intervention. Journal of General Internal Medicine 2007;23(4):472–5.
Leville 2009 {published data only}
  • Leveille SG, Huang A, Tsai SB, Allen M, Weingart SN, Iezzoni LI. Health coaching via an internet portal for primary care patients with chronic conditions: a randomized controlled trial. Medical Care 2009;47(1):41-7.
Lorig 2002 {published data only}
  • Lorig KR, Laurent DD, Deyo RA, Marnell ME, Minor MA, Ritter PL. Can a Back Pain E-mail Discussion Group improve health status and lower health care costs?: A randomized study. Archives of Internal Medicine 2002;162(7):792-6.
Lorig 2006 {published data only}
Macedo 2012 {published data only}
  • Macedo LG, Maher CG, Latimer J, McAuley JH. Feasibility of using short message service to collect pain outcomes in a low back pain clinical trial. Spine 2012;37(13):1151-1155.
Miller 2010 {published data only}
  • Miller DM, Moore SM, Fox RJ, Atreja A, Fu AZ, Lee JC, et al. Web-based self-management for patients with multiple sclerosis: a practical, randomized trial. Telemedicine Journal and e-Health 2010;17(1):5-13.
Naylor 2008 {published data only}
Naylor 2010 {published data only}
  • Naylor MR, Naud S, Keefe FJ, Helzer JE. Therapeutic Interactive Voice Response (TIVR) to reduce analgesic medication use for chronic pain management. The Journal of Pain 2010;11(12):1410-9.
Oerlemans 2011 {published data only}
  • Oerlemans S, van Cranenburgh O, Herremans PJ, Spreeuwenberg P, van Dulmen S. Intervening on cognitions and behavior in irritable bowel syndrome: a feasibility trial using PDAs. Journal of Psychosomatic Research 2011;70(3):267-77.
Premi 1993 {published data only}
Russell 2011 {published data only}
  • Russell TG, Buttrum P, Wootton R, Jull GA. Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. The Journal of Bone and Joint Surgery 2011;93(2):113-20.
Sandsjo 2010 {published data only}
  • Sandsjo L, Larsman P, Huis in 't Veld RM, Vollenbroek-Hutten MM. Clinical evaluation of a myofeedback-based teletreatment service applied in the workplace: a randomized controlled trial. Journal of Telemedicine and Telecare 2010;16(6):329-35.
Sciamanna 2006 {published data only}
Spunt 1996 {published data only}
Steel 2011 {published data only}
  • Steel J, Geller DA, Tsung A, Marsh JW, Dew MA, Spring M, et al. Randomized controlled trial of a collaborative care intervention to manage cancer-related symptoms: lessons learned. Clinical Trials 2011;8(3):298-310.
Taieb-Maimon 2012 {published data only}
  • Taieb-Maimon M, Cwikel J, Shapira B, Orenstein I. The effectiveness of a training method using self-modeling webcam photos for reducing musculoskeletal risk among office workers using computers. Applied Ergonomics 2012;43(2):376-85.
Vonk Noordegraaf 2012 {published data only}
  • Vonk Noordegraaf A, Huirne JA, Brolmann HA, Emanuel MH, van Kesteren PJ, Kleiverda G, et al. Effectiveness of a multidisciplinary care program on recovery and return to work of patients after gynaecological surgery; design of a randomized controlled trial. BMC Health Services Research 2012;12(1):29.
Weingart 2008 {published data only}
  • Weingart SN, Hamrick HE, Tutkus S, Carbo A, Sands DZ, Tess A, et al. Medication safety messages for patients via the web portal: the MedCheck intervention. International Journal of Medical Informatics 2008;77(3):161-8.

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
Bailey 2010
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Black 2011
Bodenheimer 2002
Breivik 2006
Civljak 2013
Cuijpers 2008
Currell 2000
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Jordan 2007
Keogh 2010
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Lewis 2004
Macea 2010
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Martin 2008
McLean 2010
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Pal 2013
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Williams 2012