Given that you’re reading this, I suspect that the thought of an on-line approach to managing pain wouldn’t take a terrible stretch of the imagination. The idea is certainly appealing – after all, there are many, many people with chronic low back pain in the community, and not nearly so many clinicians specialised (or even interested!) in helping people to learn to live well despite their pain. Along with the practicalities of getting the message across to as many people as possible, there is some evidence that people are prepared to reveal more about themselves and their health problems via computer than face-to-face (Williams, Freeman, Bowen, et al. 2000).
In this well-described study, participants were recruited to either receive written material about back pain (the NINDS back pain guide), or to join an on-line eight-session programme based on a cognitive behavioural approach tailored for them and a five month ‘booster’ phase consisting of one session a month.
The participants were recruited in several ways – on-line via ‘professional and patient contacts’ – mainly emails, posting on the American Chronic Pain Association website, and via health professionals registered at PainEDU.org and American Pain Association. Others were recruited via staff recruitment at a pain centre associated with a medical school.
Randomisation was ‘stratified’ so that each group were somewhat equivalent on several variables such as gender, ethnicity, and age – these factors are thought to relate to outcome.
Multiple outcome measures were used, and recorded at intake, one month after intake, three months and six months after intake, and there was a financial incentive for each completed assessment point.
OK, so what did they find?
Overall, the web-based approach did produce some useful or ‘clinically significant’ results. In this case, the IMMPACT groups recommendations for ‘clinically significant’ were adhered to – this is a 10% change in certain variables such as pain intensity, physical impairment and emotional impairment (noting of course that these are all self-reported).
You’ll be wanting to know what these people looked like – well, 95 participants took part in the web-based approach and 104 in the control group. Participants in the website group were excluded from the study on the grounds of things like illness, inability to read, incomplete data and in one instance someone used two names! More women than men participated in the study overall, and the average age was mid-40’s. There were people who had basic schooling, others who had undergraduate degrees and still others with postgraduate degrees. Over half of the participants were working, which is quite different from the people often seen at the clinic in which I work, and interestingly, a majority in both groups were taking opioid medication. More participants than not were recruited online.
Average pain intensity was about 5.6 on a 10 point scale, so these people were not reporting the level of pain intensity often seen at tertiary pain management centres like the one I work in. Disability measures (Oswestry Disability Questionnaire) found total scores of 48 and 46.8 in the control and experimental group respectively. Anxiety and depression measures, using the DASS were 8.4 and 10.15 (anxiety) and 12.36 and 12.59 (depression) at commencement.
Who did best?
Well, this study used the IMMPACT ‘clinical significant’ 10% change as the indication of a ‘good’ outcome – so the changes in score are reported in terms of percentage change from baseline in a summary table. Thankfully the full tables of the measures taken throughout are given but you have to do the calculations yourself to establish percentage change at each data point in time. As an aside, I’m still not sure whether ‘10%’ is actually clinically relevant to the patient – and whether this is accurate across every measure and at every point (is a 10% reduction from 8 ‘worth’ the same as a 10% reduction from 3 on a numeric rating scale?).
The main changes, and the ones that reached the 10% threshold were obtained for ‘current pain’ as measured by the Brief Pain Inventory; DASS depression, anxiety and stress – and were all obtained in the experimental group alone.
Cutting to the chase – what do these results mean?
Well, it does indicate that some of the important psychological outcomes can be influenced by an on-line programme, and that current pain intensity can also be reduced. All of the parameters were moving in the right direction in both groups, and there was certainly a pretty strong indication that the on-line approach was achieving more movement in the right direction than simply giving a bunch of written material.
BUT – here are some of my reservations.
While pain intensity, and mood/anxiety measures changed, none of the functional measures changed. That is, disability associated with chronic low back pain, didn’t change. This means that although the participants felt better in themselves, there’s no indication that this flowed through into being able to do more, or even perceiving that they could do more. This would suggest that there is ‘something missing’ from the mixture, and certainly there is a consistent finding that DOING things (like exercise) – in other words, behavioural change – is an important component of long-term disability reduction.
When the results were analysed in terms of where they were recruited from, on-line recruits differed from those recruited from pain centres in terms of their ‘worst’ pain intensity, ‘average’ pain intensity, and reporting more coping self-statements. Participants from pain centres were more likely to be identified as ‘disabled’ in terms of employment status than those recruited via internet (maybe an economic indicator?). Participants recruited from pain centres were also less likely to make positive changes than those who came from on-line sources. To think then, that it would be possible to replace direct therapist input with an on-line approach for people who have been referred to a pain management centre would be a mistake.
Another major difference between the on-line group and the ‘reading material’ group was therapist input in the form of reminders, and also in the form of structuring the rate at which participants were introduced to aspects of the self management material. I was interested in the use of ‘booster’ sessions as part of follow-up and would have liked more detail on the content.
I could critique the study even more – but on a positive note, I wonder if this sort of approach might be effective for those people who are managing their disability relatively well (remaining at work for example), but who are obtaining things like injections or prn medications during flare-ups. Maybe a programme like this could expand the baseline knowledge of this group of people who are somewhat troubled by their pain and need a boost of confidence.
If a programme like this was supported by face-to-face input maybe through a GP or primary care clinician, who could encourage specific goals to increase activity, do exercise and become less disabled perhaps once a month over a three month period – perhaps it could reduce some of the disability from back pain in our community, and maybe even reduce the number of people who need to be referred to a pain management centre. Worth thinking about huh?!
Chiauzzi E, Pujol LA, Wood M, Bond K, Black R, Yiu E, & Zacharoff K (2010). painACTION-Back Pain: A Self-Management Website for People with Chronic Back Pain. Pain medicine (Malden, Mass.) PMID: 20545873