Can treatment over the Internet help chronic pain?

The Internet offers a means of delivering therapies to people in their homes to help them manage chronic pain and a new Cochrane review has explored the evidence on how well these work. Current evidence suggests that psychological treatments delivered in this way may help adults with non-headache pain, reducing pain, disability, depression and anxiety, but more research is needed before we can be confident about these results.

Using the Internet to deliver therapies has obvious benefits, including its reach free from geographical constraints, convenience and low costs. People living with chronic pain, lasting longer than three months, are in it for the long haul and should be able to access support to help them manage their condition away from expert healthcare centres. A new review from the Cochrane Pain, Palliative and Supportive Care Group has just been published, which explored whether pain management therapies can be successfully delivered via the Internet to reduce pain and disabilty and improve anxiety and depression in adults with non-cancer chronic pain. The reviewers were also interested in whether people liked the programmes and whether they improved their quality of life. They found 15 randomized controlled trials (RCTs) with just over 2000 adults and compared those having internet-delivered therapies with those on waiting lists.

The researchers found:

• People with headache conditions had less pain and disability after treatment; it wasn't clear if they were less depressed or anxious
• People with non-headache conditions had less pain, disability, depression and anxiety after treatment and the positive effects on disability were maintained at follow-up
• It's not known whether the therapies improve quality of life in people with headache pain; three RCTs reported on this for people with non-headache pain and did not find an improvement
• No studies reported on adverse effects of treatment

Overall, the studies were judged to be at low risk of bias, but the results come from a small number of trials. Only two RCTs were included in the analysis of pain and disability in people with headache conditions and there's just not enough evidence to be able to draw conclusions about the treatment for this patient group with any confidence. We don't know whether people liked the treatments. There were other weaknesses we should consider too, as one of the review authors, Dr Emma Fisher from the University of Bath's Centre for Pain Research, explains below. I asked her to talk about their findings:

"We really enjoyed reading the trials and seeing the innovative ways that psychological treatments can be delivered via the Internet. Technology is becoming increasingly important and dominates much of how we retrieve information and communicate. However, only a small number of trials were included in this review so we are cautious of our findings. Further, of the 15 included trials, four of them were carried out by the same author group. Another issue that stuck out for me in particular was the recruitment methods used which I believe may have had an impact on the results. Many of the trials asked participants to self-select (i.e. they were recruited via adverts or in the community, rather than being recruited through a clinic or hospital).

Despite these limitations, I think the review delivers an important message – evidence to date shows that psychological treatments can be beneficial and reduce pain and disability post-treatment for adults with chronic pain, and in adults with non-headache pain it has a beneficial effect for anxiety and depression. We need more trials (from varied author groups) to raise our confidence in the estimate of outcomes. The benefits of receiving therapy via the internet is clear; it can reach more people, in more places, and is flexible. However, this is likely to be beneficial for certain populations and more research is needed to determine which group of chronic pain adults would benefit most."

This review complements an earlier one on psychological therapies for adults with chronic, non-headache pain delivered in other ways. This review found that, compared with no treatment, cognitive behavioural therapy (CBT) resulted in some small improvements, more for disability, mood and catastrophic thinking than for pain, with some lasting effects six months later. The evidence for behaviour therapy is weaker and more sparse; it showed few and only short-lived benefits. It's not known which type of treatment might be best for which person.

There is growing support for the effectiveness of psychological therapies, and particularly CBT, for the management of chronic pain and its delivery via the Internet shows promise. Clearly there is more work to be done to increase our understanding of the usefulness of these therapies and means of delivery. The above review (Williams 2012) includes a thoughtful discussion of the challenges for the research community in this area.