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

  1. Christopher Eccleston1,*,
  2. Emma Fisher2,
  3. Lorraine Craig3,
  4. Geoffrey B Duggan1,
  5. Benjamin A Rosser4,
  6. Edmund Keogh5

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

    Seattle Children’s Research Institute, Child Health, Behaviour, and Development, Seattle, USA

  3. 3

    University of Bath, Department of Health, Bath, UK

  4. 4

    University of Exeter, Exeter, UK

  5. 5

    University of Bath, Department of Psychology, Bath, UK

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

Publication History

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

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Characteristics of included studies [ordered by study ID]
Berman 2009

MethodsRCT; 2 arms; assessed pre-treatment and post-treatment (at 6 weeks)


ParticipantsEnd of treatment n = 78

Start of treatment n = 89

Sex = 68 F, 10 M

Mean age = 65.8 years (SD not given)

Source = community-based settings (e.g. community centres)

Diagnosis = most common causes of pain cited by participants were: arthritis, spinal stenosis or degenerative disc problems, previous injuries or surgery, and sciatica. Full descriptions not given

Mean years of pain = not given


Interventions''Online mind-body self care intervention'' - ''Cognitive-behavioural model with problem solving approach.... The self-care modules included a selection on mind-body exercises in each of the following areas: (1) abdominal breathing, (2) relaxation, (3) writing about positive experiences, (4) writing about difficult experiences, (5) creative visual expression, and (6) positive thinking''


OutcomesPrimary pain outcome: Brief Pain Inventory-Short Form (BPI)

Primary disability outcome: none

Primary depression outcome: Centre for Epidemiological Studies Short Depression Scale (CES-D)

Primary anxiety outcome: State-Trait Anxiety Inventory (STAI Y-6)

1. Pain Self-efficacy Questionnaire

2. Awareness of response to pain, using a computed total score for the five relevant items on the Pain Awareness Questionnaire (PAQ)

3. Confidence with pain management (two items on PAQ)

4. Satisfaction survey

5. Self care (one question in the satisfaction survey)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskParticipants were randomly assigned to either the intervention or comparison group via a simple coin toss

Allocation concealment (selection bias)High riskGroup assignment was not concealed, participants assigned to the intervention group received orientation to the website by research assistants

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Low riskFewer than 10% missing data with the exception of CES-D, for which instructions were followed. Attrition was adequately explained and missing data appeared to have been imputed using appropriate methods

Selective reporting (reporting bias)Low riskPublished report includes data for all expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Bromberg 2011

MethodsRCT; 2 arms; assessed pretreatment, post-treatment (at 4 weeks) and at follow-up (at 3 and 6 months)


ParticipantsEnd of treatment n =144

Start of treatment n = 189

Sex = 165 F, 20 M

Mean age = 42.62 (SD 11.5) years

Source = recruited through several methods: (1) website postings, (2) electronic newsletter announcements, (3) 22 neurology practices that distributed informational flyers to people with chronic pain and (4) postings to social networking/community sites

Diagnosis = migraine

Mean years of pain = not given


Interventions''painACTION, Internet based self-management tool'' - ''The intervention incorporates cognitive behavior therapy and self-management principles to teach people with migraine “how to” apply practical self-management skills, techniques, and strategies to motivate and support participant engagement in active pain self-management behaviours. Tasks included completing self assessments, taking lessons using interactive tools and using a pain tracker''


OutcomesPrimary pain outcome: none

Primary disability outcome: Migraine Disability Assessment Questionnaire

Primary depression outcome: Depression Anxiety Stress Scale (DASS-21)

Primary anxiety outcome: DASS-21

1. Daily Headache Record

2. Chronic Pain Coping Inventory-42 (CPCI-42)

3. Headache Management Self-Efficacy Scale

4. Pain Catastrophizing Scale (PCS)

5. Headache-Specific Locus of Control

6. Patient Global Impression of Change (PGIC)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table used for group assignment

Allocation concealment (selection bias)Unclear riskStudy staff created a randomisation table that contained 8 blocks. It is not clear whether study staff were blinded

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
High riskThe study was originally powered for two primary outcomes; however, because of a data management error one outcome measure was not available for analysis. Attrition was fully described; however, there were statistical differences between completers and non-completers

Selective reporting (reporting bias)High riskOne expected outcome (Daily Headache Record) was not available due to a data management error, therefore all expected outcomes are not included

Other biasLow riskStudy appears to be free of other sources of bias

Buhrman 2004

MethodsRCT; 2 arms; assessed pretreatment, post-treatment (at 6 weeks) and at follow-up (at 3 months)


ParticipantsEnd of treatment n = 51

Start of treatment n = 51

Sex = 21 F, 35 M

Mean age = 44.6 (SD 10.4) years

Source = newspaper articles in national and regional papers as well as through a webpage for health

Diagnosis = chronic back pain

Mean years of pain = 10.1 (SD 9.2) years


Interventions''Internet based pain management programme with telephone support'' - ''Treatment model delivered was derived primarily from a cognitive-behavioural model of chronic pain... and included psychological components (e.g. dealing with unhelpful thoughts and beliefs, changing focus) as well as stretching and physical exercises.... Telephone contact was with a therapist once a week to review homework, answer questions and maintain motivation''


OutcomesPrimary pain outcome: Multidimensional Pain Inventory (MPI)

Primary disability outcome: none

Primary depression outcome: Hospital Anxiety and Depression Scale (HADS)

Primary anxiety outcome: HADS

1. Coping Strategies Questionnaire

2. Pain and Impairment Relationship Scale (PAIRS)

3. Pain Diary

4. Treatment credibility - 5 items on an adapted 10-point scale

5. Satisfaction with treatment format


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskSubjects were randomised using dice, where even numbers meant treatment and odd numbers meant control condition

Allocation concealment (selection bias)Unclear riskInsufficient information regarding allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Low riskReport n = 5 dropped out, reason for attrition is not documented. Differences between completers and non-completers reported

Selective reporting (reporting bias)Low riskPublished report includes data for all expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Buhrman 2011

MethodsRCT; 2 arms; assessed pretreatment, post-treatment (at 12 weeks)


ParticipantsEnd of treatment n = 50

Start of treatment n = 54

Sex = 37 F, 17 M

Mean age = 43.2 (SD 9.8) years

Source = newspaper articles in national and regional papers, as well as recruitment through a webpage

Diagnosis = chronic back pain

Mean years of pain = 12.1 (SD 8.5) years


Interventions''Guided Internet-based cognitive behavioural treatment'' - ''Self help management programme administered via the Internet... based on CBT. The participants were instructed to test and practice different coping strategies e.g. relaxation, cognitive skills, stress management as well as physical exercise techniques... The text was divided into 8 modules. Participants were prompted to submit weekly reports on treatment progress. Treatment group had one structured telephone conversation with a therapist and access to a computer technician via email."


OutcomesPrimary pain outcome: MPI

Primary disability outcome: none

Primary depression outcome: HADS

Primary anxiety outcome: HADS

1. Coping Strategies Questionnaire

2. PAIRS

3. Quality of life inventory


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomisation was made by an independent person through a webpage with a randomisation program. Method used unclear

Allocation concealment (selection bias)Low riskRandomisation was made by an independent person through a webpage with a randomisation program. Third-party involvement therefore meets the criteria for concealment

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Low risk"Data were analysed using the intention-to-treat principle with all available data regardless of completion of the actual treatment. Participants lost to follow-up were first not replaced using last observation carried forward, as this assumes stability from pre-treatment. Given the few drop-outs, the authors regarded this as a defensible procedure instead of modelling the lost observations (n = 5) using bootstrap methodology or mixed models approaches. All analyses were repeated with the 5 missing cases replaced by their baseline data. This did not affect the outcome"

Selective reporting (reporting bias)Low riskPublished report includes data for all expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Buhrman 2013

MethodsRCT; 2 arms; assessed pretreatment, post-treatment, and at 6 months.


ParticipantsEnd of treatment n = 56

Start of treatment n = 72

Sex = 52 F, 20 M

Mean age = 40.1 (SD 8.94) years

Source = former attendants at a pain centre

Diagnosis = back, neck, shoulder, and generalised pain

Mean years of pain = 6.2 (SD 2.07) years


InterventionsEight treatment modules of the Internet programme, CBT-based. Included relaxation, physical exercise plan, balance when planning activities, cognitive restructuring, mindfulness, stress management, sleep hygiene

Control group participated in an online discussion forum with weekly discussion topics presented


OutcomesPrimary pain outcome: MPI

Primary disability outcome: none

Primary depression outcome: HADS

Primary anxiety outcome: HADS

1. Coping Strategies Questionnaire

2. PAIRS

3. Quality of life inventory

4. Chronic Pain Acceptance Questionnaire


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"Randomization was made by an independent person using a true random number service"

Allocation concealment (selection bias)Low risk"Randomization was made by an independent person using a true random number service"

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Low riskAttrition fully reported, no statistical differences between completers and non-completers

Selective reporting (reporting bias)Low riskPublished report includes data for all expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Buhrman 2013a

MethodsRCT; 2 arms; assessed pretreatment, post-treatment, and at 6 months.


ParticipantsEnd of treatment n = 61

Start of treatment n = 76

Sex = 45 F, 31 M

Mean age = 49.1 (SD 10.34) years

Source = attendants at a pain centre

Diagnosis = back, neck, shoulder, hips/legs/feet, and generalised pain

Mean years of pain = 15.3 (SD 11.65) years


InterventionsSeven treatment sections ACT-based. MP3 files could be played on MP3 player or computer. Treatment involved learning and practising mindfulness exercises

Control group participated in an online discussion forum with weekly discussion topics presented


OutcomesPrimary pain outcome: MPI

Primary disability outcome: none

Primary depression outcome: HADS

Primary anxiety outcome: HADS

1. Coping Strategies Questionnaire

2. PAIRS

3. Quality of life inventory

4. Chronic Pain Acceptance Questionnaire


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"76 patients remained and were randomized to either the treatment or to the control group.... Using a true random number service"

Allocation concealment (selection bias)Low risk"Randomization was made by an independent person using a true random number service"

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAttrition reported in flow diagram. Differences between dropouts and completers not reported. Intension-to-treat analyses carried out.

Selective reporting (reporting bias)Low riskPublished report includes data for all expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Carpenter 2012

MethodsRCT; 2 arms; assessed pretreatment, post-treatment (at 3 weeks) and at follow-up (at 6 weeks)


ParticipantsEnd of treatment n = 131

Start of treatment n = 141

Sex = 117 F, 24 M

Mean age = 42.5 (SD 10.3) years

Source = Internet bulletin boards and advertisements in mainstream and alternative newspapers

Diagnosis = chronic lower back pain

Mean years of pain = 8.6 (SD 7.8) years


Interventions''Online self-help intervention (Wellness Workbook)'' - online interactive CBT intervention. It uses a mind/body treatment rational, including content on: pain education, CBT techniques (including cognitive restructuring), stress management, relaxation, mindfulness and values-based behavioural activation.


OutcomesPrimary pain outcome: Pain Assessment Questionnaire (pain rating of average pain)

Primary disability outcome: Roland-Morris Disability

Primary depression outcome: none

Primary anxiety outcome: PCS

1. Survey of Pain Attitudes

2. Arthritis Self Efficacy Scale

3. The Fear Avoidance Beliefs Questionnaire (FABQ)

4. The Negative Mood Regulation Scale

5. Demographics and Pain Assessment Questionnaire


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomised using a random number table

Allocation concealment (selection bias)Unclear riskInsufficient information regarding allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThere was differential attrition between the two groups with higher dropout in the wait-list condition. Compared with completers, non-completers were significantly more likely to be men, older in age and have lower average pain

Selective reporting (reporting bias)High riskPain ratings not described as an outcome measure in the methods, and not reported at 6-week follow-up. The report includes all data for the other expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Chiauzzi 2010

MethodsRCT; 2 arms; assessed pretreatment, post-treatment (at 4 weeks) and at follow-up (at 3 and 6 months)


ParticipantsEnd of treatment n = 186

Start of treatment n = 209

Sex = 134 F, 64 M

Mean age = 46.14 (SD 11.99) years

Source = "online dissemination through professional and patient contacts, and staff recruiting at a pain centre"

Diagnosis = chronic back pain

Mean years of pain = not given


Interventions''painACTION, Internet based self-management tool'' - painACTION-Back Pain is a website based on CBT and self-management principles. The intervention includes components on: 1) collaborative decision making with health professionals; 2) CBT to improve self-efficacy, manage thoughts and mood, set clinical goals, work on problem-solving life situations, and prevent pain relapses; (3) motivational enhancement through tailored feedback; and (4) wellness activities to enhance good sleep, nutrition, stress management, and exercise practices.


OutcomesPrimary pain outcome: BPI

Primary disability outcome: Oswestry Disability Questionnaire

Primary depression outcome: DASS-21

Primary anxiety outcome: DASS-21

1. PGIC

2. CPCI-42

3. PCS

4. Pain Self-Efficacy Questionnaire

5. FABQ


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskParticipants were randomised using an adaptive or “stratified” randomisation that ensures group equivalence on preselected variables that may relate to outcome across conditions. Gender, race/ethnicity, and age bracket (18 to 40, 41 to 60, 60 years and over) were included in the randomisation algorithm. No method described

Allocation concealment (selection bias)Unclear riskInsufficient information regarding allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo description given

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAttrition reported. Differences between completers and non-completers not reported

Selective reporting (reporting bias)Low riskThe report includes all data for expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Dear 2013

MethodsRCT; 2 arms; assessed pretreatment, post-treatment and at 3 months


ParticipantsEnd of treatment n = 62

Start of treatment n = 60

Sex = 27 F, 4 M

Mean age = 47 (SD 13) years

Source = advertisements about the trial were placed in newsletters and on websites operated by non-governmental institutions that offer information and services to people with chronic pain, including beyondblue, Chronic Pain Australia, Australian Pain Management Association, and Arthritis Australia.

Diagnosis = mixed body pain sites

Mean years of pain = 7.36 (SD 8.10) years


Interventions"The Pain Course" based on principles of CBT. Modules include sleep hygiene, problem-solving, assertiveness, managing attention, and core beliefs. 8 weeks in length. Wait-list control


OutcomesPrimary pain outcome: Wisconsin Brief Pain Questionnaire

Primary disability outcome: Roland-Morris Disability Questionnaire

Primary depression outcome: Patient Health Questionnaire 9-Item

Primary anxiety outcome: Generalized Anxiety Disorder 7-Item

1. Pain Self-efficacy questionnaire

2. TAMPA Scale of Kinesiophobia

3. Pain Responses Self-Statements


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNo method described

Allocation concealment (selection bias)High riskNo method described

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAttrition reported, differences between completers and non-completers not described

Selective reporting (reporting bias)Low riskThe report includes all data for expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Devineni 2005

MethodsRCT; 2 arms; assessed pretreatment, post-treatment (at 4 weeks) and at follow-up (at 2 months)


ParticipantsEnd of treatment n = 86

Start of treatment n =86

Sex = 108 F, 31 M

Mean age = 42.3 (SD 11.9) years

Source = common Internet-based promotion channels

Diagnosis = chronic headache

Mean years of pain = not given


Interventions''Internet-delivered behavioural regimen'' - Behavioural regimen composed of: progressive muscle relaxation, limited biofeedback with autogenic training and stress management.


OutcomesPrimary pain outcome: Headache Symptom Questionnaire

Primary disability outcome: Headache Disability Inventory (HDI)

Primary depression outcome: CES-D

Primary anxiety outcome: STAI


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskReports that participants were randomly assigned to either immediate treatment or symptom monitoring control; however, randomisation method is not specified

Allocation concealment (selection bias)Unclear riskInsufficient information regarding allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Low riskSubject flow through phases of the project is detailed along with dropout predictors. Although attrition rate is high, this is acknowledged and discussed

Selective reporting (reporting bias)High riskFollow-up data is not fully reported. Post-treatment data are fully reported

Other biasLow riskStudy appears to be free of other sources of bias

Hedborg 2011

MethodsRCT; 3 arms; pretreatment, 8 months (experimental and control), 11 months (experimental only)


ParticipantsEnd of treatment n = 76

Start of treatment n = 83

Sex = 58 F, 25 M

Mean age = 47.73 (SD not given) years

Source = participants were recruited after being approached during a previous descriptive study on migraine

Diagnosis = migraine

Mean years of pain = 23.2 years (SD not given)


Interventions''Internet-based multimodal behavior treatment (MBT) with hand massage'' - ''The MBT program was intended to increase participants' awareness of essential factors in everyday life that might have an impact on their migraine. This training program consisted of the following topics: stress physiology, physical activity, diet, thought patterns, handling of emotions, and attitudes (toward oneself and others)''


OutcomesPrimary pain outcome: none

Primary disability outcome: none

Primary depression outcome: Montgomery-Asberg Depression Rating Scale

Primary anxiety outcome: none

1) PQS23 - An instrument developed at the Department of Environmental Stress Disorders (CEOS), Uppsala University

2) Assessment of opinions about MBT and hand massage interventions


NotesOutcome measures at 8 months are used as there are no post-treatment measures for the control group


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"A sequence of random numbers was generated in Statistical Package for the Social Sciences 18.0 (SPSS) software, stratified by gender in order to obtain an equal distribution of women and men in the groups. Based on magnitude, these numbers were arranged into three equal-sized groups, which translated into the three study groups. The number sequence thus translated into a unique sequence of group affiliation which corresponded to the chronological order of inclusion"

Allocation concealment (selection bias)Low riskThe randomisation procedure was performed by an independent researcher, thus the process was blinded to the investigators

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Low riskAttrition fully reported, no statistical differences between completers and non-completers

Selective reporting (reporting bias)Low riskReported all data for expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Lorig 2008

MethodsRCT; 2 arms; assessed pretreatment, post-treatment (at 6 months) and at follow-up (at 12 months)


ParticipantsEnd of treatment n = 641

Start of treatment n = 855

Sex = 781 F, 74 M

Mean age = 52.35 (SD 11.55) years

Source = established websites, online newsletters and discussion groups

Diagnosis = rheumatoid arthritis, osteoarthritis or fibromyalgia

Mean years of pain = not given


Interventions''Internet-based Arthritis Self-Management Program (ASMP)'' - ''ASMP consists of password protected, interactive, Web-based instruction (The Learning Center); Web-based bulletin board discussion (The Discussion Center); tools that the participants can use individually, such as exercise logs, medication diaries, and tailored exercise programmes. The Learning Center content includes design of individualized exercise programmes; use of cognitive symptom management such as relaxation, visualization, distraction, and self-talk; methods for managing negative emotions such as anger, fear, and depression; an overview of medications; aspects of physician–patient communication; healthy eating; fatigue management; action planning; feedback; and methods for solving arthritis related problems''


OutcomesPrimary pain outcome: Health indicator - Pain (0-10)

Primary disability outcome: Health indicator - Disability (0-3)

Primary depression outcome: none

Primary anxiety outcome: none

1. Six health-related quality of life indicators (Health distress, Self reported global health, Disability, Activity limitation, Fatigue, Pain)

2. Four health-related behaviours (stretching and strengthening exercises, aerobic exercise, use of cognitive symptom techniques and use of techniques to improve communication with healthcare providers)

3. Five utilisation measures (self-reported outpatient visits to physicians, emergency room visits, nights in the hospital, chiropractic visits and physical therapy visits)

4. Arthritis Self-Efficacy Scale


NotesIntervention duration was 6 weeks, post-treatment outcome measures assessed at 6 months


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskReports that participants were randomised to either the intervention group or to a control group; however, does not give any information about randomisation method

Allocation concealment (selection bias)Unclear riskInsufficient information regarding allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
High riskAttrition fully reported, statistical differences between completers and non-completers

Selective reporting (reporting bias)Low riskPublished report includes data for all expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Ruehlman 2012

MethodsRCT; 2 arms; assessed pretreatment, post-treatment (at 7 weeks) and at follow-up (at 14 weeks)


ParticipantsEnd of treatment n = 241

Start of treatment n = 305

Sex = 195 F, 110 M

Mean age = not given

Source = established websites, e-mails to website members and newsletters

Diagnosis = "The most common diagnoses were migraine headaches (65.5%) and back injury (60.5%). Tension headaches, fibromyalgia, osteoarthritis, face or jaw pain, and premenstrual pain were somewhat less common, with 20–40% of the participants reporting these".

Mean years of pain = Not given; however, 89.5% of participants reported having pain for more than 2 years


Interventions''The Chronic Pain Management Program (CPMP)'' - ''CPMP leverages technical capabilities with program content and functionality derived from cognitive behavior therapy, interpersonal, and self-management approaches to address the adaptive burdens of chronic pain in adults. A custom learning plan is created for each user after the online completion of the Profile of Chronic Pain (PCP). The PCP includes online activities (e.g. interactive exercises) and off-line activities (e.g. lifestyle activities such as exercise)''


OutcomesPrimary pain outcome: Profile of Chronic Pain (PCP): Screen

Primary disability outcome: none

Primary depression outcome: CES-D

Primary anxiety outcome: DASS-21

1. Test of pain knowledge that assessed the role of thought, emotion, social responses to pain and behaviour to the pain experience

2. PCP: Extended Assessment

3. Functional limitations in 10 areas of daily living (social life, sex, sleep, recreation, chores, work, self-care, parenting, routine physical activities and exercise)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskReports participants were randomised; however, randomisation method is not specified

Allocation concealment (selection bias)Unclear riskInsufficient information regarding allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Low riskChi2 tests indicated that the probability of missing data differed across the 2 conditions, with the experimental group having the higher missing data rate. Authors used full information maximum likelihood estimation to deal with missing data

Selective reporting (reporting bias)Low riskPublished report includes data for all expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

Strom 2000

MethodsRCT; 2 arms; assessed pretreatment and post-treatment (at 6 weeks)


ParticipantsEnd of treatment n = 45

Start of treatment n = 45

Sex = 69 F, 33 M

Mean age = 36.7 years (SD not given)

Source = participants were recruited by means of newspaper articles in national and regional papers and notes in Internet magazines

Diagnosis = recurrent headache

Mean years of pain = not given


Interventions''Self help treatment, applied relaxation and problem solving'' - ''The relaxation program was largely derived from the method of applied relaxation... and autogenic training.... The instructions were adjusted to suit the self help format. Participants were presented with different methods aimed to be useful in the identification of problems, coping with problems in general, and coping with headache-related problems...''


OutcomesPrimary pain outcome: Headache Index

Primary disability outcome: HDI

Primary depression outcome: BDI

Primary anxiety outcome: none

1. Number of headache days per week

2. Peak intensity of headache

3. Multidimensional Locus of Pain Control Questionnaire (MLPC)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskReport that participants were randomised into either treatment or waiting-list condition; however, randomisation method is not specified

Allocation concealment (selection bias)Unclear riskInsufficient information regarding allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Unclear riskSome questionnaires taken online, other questionnaires filled out on paper. No description given if outcome assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAcknowledges that the dropout rate was proportionately large (56%); however, there is insufficient reporting of attrition reasons. Dropouts tended to be younger and had a headache for a shorter duration

Selective reporting (reporting bias)High riskResults of the MLPC questionnaire are not reported

Other biasLow riskStudy appears to be free of other sources of bias

Williams 2010

MethodsRCT; 2 arms; assessed pretreatment and post-treatment (at 6 months)


ParticipantsEnd of treatment n = 106

Start of treatment n = 118

Sex = 112 F, 6 M

Mean age = 50.46 (SD 11.45) years

Source = conducted at the Avera Research Institute; participants were referred to the study by their primary or specialist care physician, who received recruitment materials through their local provider network

Diagnosis = fibromyalgia

Mean years of pain = 9.4 (SD 6.46) years


Interventions''Internet based exercise and behavioural self-management'' - ''The website entitled ‘‘Living Well with Fibromyalgia (FM) contained 13 modules segregated into three broad segments: (a) educational lectures providing background knowledge about FM as a disease state, (b) education, behavioral, and cognitive skills designed to help with symptom management, and (c) behavioral and cognitive skills designed to facilitate adaptive life style changes for managing FM. Each of the 13 modules featured a video lecture on the topic by a clinician experienced in applying the selected topic with respect to FM, written summaries of the video lecture for reading or downloading, homework and self-monitoring forms for applying the behavioral strategies described in the video lecture, and supplemental educational materials unique to each topic (e.g., audio relaxation exercises and readings)''


OutcomesPrimary pain outcome: BPI

Primary disability outcome: The Short Form-36 Physical Functioning Scale

Primary depression outcome: CES-D

Primary anxiety outcome: Stait-Trait Personality Inventory

1. Multidimensional Fatigue Inventory

2. PGIC

3. Mini-International Neuropsychiatric Interview

4.Client Satisfaction Questionnaire


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskParticipants were randomly assigned to a treatment condition in a 1:1 ratio. A computerised randomisation program assisted in the development of the allocation sequence for the study

Allocation concealment (selection bias)Low riskAllocation concealment was utilised to prevent selection bias and group assignment was given to both the participant and selected study staff only after completion of the baseline assessments

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments taken online

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAttrition reported. Differences between completers and non-completers not reported

Selective reporting (reporting bias)Low riskPublished report includes data for all expected outcomes

Other biasLow riskStudy appears to be free of other sources of bias

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Allen 2008Does not use the Internet as primary mode of delivering treatment

Anderson 2006Not chronic non-cancer pain

Andersson 2002Inadequate n: number of participants in any study arm was less than 20

Bieber 2006Does not evaluate a self-management psychological intervention

Borckardt 2004Not a randomised control trial

Brattberg 2006Inadequate n: number of participants in any study arm was less than 20

Brattberg 2007Inadequate n: number of participants in any study arm was less than 20

Bruce 2005Does not evaluate a self-management psychological intervention

Chambers 2006Not chronic non-cancer pain

Childs 2011Does not use the Internet as primary mode of delivering treatment

Cleeland 2011Not chronic non-cancer pain

de Bruijn-Kofman 1997Not a randomised control trial

Everitt 2010Not chronic non-cancer pain

Everitt 2013Not chronic non-cancer pain

Fraenkel 2007Does not evaluate a self-management psychological intervention

Greco 2004Does not use the Internet as primary mode of delivering treatment

Hochlehnert 2006Does not evaluate a self-management psychological intervention

Huffstutter 2007Does not evaluate a self-management psychological intervention

Jacobs 2013Not a randomised control trial

Jennings 2008Does not use the Internet as primary mode of delivering treatment

Johns 2011Not chronic non-cancer pain

Keulers 2007Does not evaluate a self-management psychological intervention

Kjeken 2011Does not use the Internet as primary mode of delivering treatment

Kleiboer 2009Used a non-inferiority hypothesis

Kosterink 2010Does not use the Internet as primary mode of delivering treatment

Krein 2010Intervention has insufficient psychotherapeutic content

Kristjansdottir 2011Does not use the Internet as primary mode of delivering treatment

Kristjansdottir 2013Does not use the Internet as primary mode of delivering treatment

Kroenke 2010Not chronic non-cancer pain

Larsman 2010Does not use the Internet as primary mode of delivering treatment

Leboeuf-Yde 2012Not a randomised control trial

Leveille 2007Not a randomised control trial

Leville 2009Intervention has insufficient psychotherapeutic content

Lorig 2002Intervention has insufficient psychotherapeutic content

Lorig 2006Not chronic non-cancer pain

Macedo 2012Does not evaluate a self-management psychological intervention

Miller 2010Not chronic non-cancer pain

Naylor 2008Does not use the Internet as primary mode of delivering treatment

Naylor 2010Does not use the Internet as primary mode of delivering treatment

Oerlemans 2011Not chronic non-cancer pain

Premi 1993Not chronic non-cancer pain

Russell 2011Used a non-inferiority hypothesis

Sandsjo 2010Does not evaluate a self-management psychological intervention

Sciamanna 2006Does not evaluate a self-management psychological intervention

Spunt 1996Not a randomised control trial

Steel 2011Not chronic non-cancer pain

Taieb-Maimon 2012Not chronic non-cancer pain

Vonk Noordegraaf 2012Does not use the Internet as primary mode of delivering treatment

Weingart 2008Not chronic non-cancer pain

 
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]