Review of internet-based interventions for pain finds some evidence to support the effectiveness of cognitive and behavioural interventions, but further quality study is needed to assess the effect of peer support and social networking programmes
- Correspondence to David A Williams
Department of Anesthesiology, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby M, Ann Arbor, MI 48106, USA;
Implications for practice and research
■ The internet can deliver some elements of multidisciplinary pain care to patients (and clinical practices) where such services are desired but often unavailable.
■ Cognitive-behavioural therapy (CBT) is a non-pharmacological intervention for pain that appears in this study to have the greatest number of high-quality studies supporting its use over the internet as a means of decreasing pain, improving functional status and decreasing treatment costs.
■ The effects of internet-delivered CBT appear comparable with those of more traditional face-to-face treatment delivery, although none of the studies reviewed made this direct comparison.
Pharmacological pain treatments and interventional pain treatments (ie, injection therapies and surgery) are common approaches to chronic pain management. A large empirical literature supports other non-pharmacological interventions such as CBT, behavioural therapy and exercise modalities. These less costly interventions are less common in routine practice in part due to barriers such as treatment availability, and patient travel burdens. Internet delivery of these evidence-based non-pharmacological pain management approaches can help them become more integrated into routine care.
The systematic review involved a search of randomised controlled trials (RCTs) using internet-based interventions for any types of pain, published between 1990 and 2010. Out of 6724 studies, 17 were selected as meeting predefined selection criteria. Methodological quality was evaluated using both the Jadad Scale and the Yates scale; the latter being specifically designed to evaluate the quality of psychological trials for pain. The selected interventions fell into several categories: (1) CBT, (2) moderated peer support (3) clinical visit preparation and/or follow-up.
Based upon the highest quality studies, the most consistent findings emerging from this review propose that internet-delivered CBT was associated with improvements in pain and physical functioning, and reduction of healthcare costs associated with pain. Internet-delivered CBT for pain had a less robust effect on affective status (eg, anxiety and depression). Limited but positive support was found for internet-delivered peer support programs that also targeted reductions in pain, physical disability and distress; whereas more limited but positive support was offered for social networking programmes to reduce pain in children and adolescents. While holding great potential, there was insufficient evidence to evaluate the use of the internet in supporting traditional clinical practice (eg, clinical visit preparation and follow-up).
A gap has long existed between what we know about chronic pain and how we treat it.1 2 We have known for over 30 years that psychosocial and behavioural factors heavily influence the perception and response to pain. The internet offers the opportunity to more fully integrate known efficacious, non-pharmacological interventions into routine pain care. Of issue is whether traditional face-to-face interventions with known efficacy will translate into a web-based format and retain efficacy. This review provides evidence that they do. In fact, the internet may offer additional unique benefits that include the intervention being available at any time, being accessible from the privacy of ones' home, and the ability to access the content as often as desired and at any pace. A more recent study that was not reviewed in this paper demonstrated internet-delivered CBT to rival or even surpass the effects of pharmacological agents on indices of pain and functional status.3
The internet is filled with pain management programmes that are untested and developed in a less rigorous manner than the RCTs reviewed here. As a warning, it would not be expected that just any programme would bring benefit to patients. As the authors suggest, more research is needed so as to identify those patients most likely to benefit from internet-based interventions. Two types of patients who may be less likely to benefit would be those who are not ready to adopt a self-management perspective and those with severe comorbidities requiring a more intensive approach to care.
Internet-based interventions have the advantage of providing a standardised programme of information, but tailored to the individual patient in a primary care context, either by the doctor or by trained clinical staff. Rather than noticing improvement only at the time of an office or clinic visit, use of the internet permits multi-modal treatment to continue between such visits; thus any improvements can be realised and monitored in real-time to provide greater continuity of care.
Competing interests DW is a consultant for Eli Lilly and Pfizer, Inc.