is this my best side

e-Therapy: online CBT programmes for people with chronic pain


There are many problems with helping people access timely and appropriate chronic pain management programmes. In the US, comprehensive multi or inter-disciplinary programmes have been decreasingly funded compared with single discipline approaches. In New Zealand, the chance of being accepted into a Pain Management Centre in some cities is 1:10 if you’re not covered by ACC. Finding, resourcing and keeping clinicians in this specialist area is challenging.

So…many people have looked for alternative ways to deliver this vital and effective management approach, and with increasing use of the interwebs and smartphone apps for health information, it’s not surprising there have been some attempts to develop online pain management programmes, usually following a broadly cognitive behavioural approach.

How well do they work?

Good question. And one that needs to be answered before rushing out to set them up.  The first caveat, though, needs to be a reminder that when we look at comparing online programmes with face-to-face, we may not be comparing apples with apples. Here are the differences I’ve identified:

  • Group process in face-to-face approaches is different from online versions. This is because so much of our communication relies on visual feedback, and even with video/web cams we’re not getting the rich information we rely on in face-to-face discussions.
  • Many online programmes don’t use group approaches at all. Treatment can be carried out individually, and even in face-to-face approaches, treatments can be conducted with individual people rather than in groups. I personally think this is only more useful than group approaches for the small number of people who find it hard to be in a group: distractible, angry, dominant people, and those who don’t speak the language or can’t hear what’s going on. There’s a lot to be said for being able to watch other people and learn vicariously from them. But online programmes typically don’t have the capacity for group discussions in real time, except perhaps for moderated chat rooms.
  • Behaviour change is less likely with online approaches. The group process directly influences what people do, and without that face-to-face contact, it’s much easier for people to talk the talk while not walking the walk. Even if the behaviour change only occurs during the face-to-face sessions, that’s more than nothing at all!

Just as face-to-face cognitive behaviourally-based pain management programmes differ in content, form and duration, so do online versions. This makes comparing the approaches challenging. We also need to remember that most of the research showing that pain management programmes are effective do so when comparing the programme against a waiting list, or a non-treatment or placebo control. When the comparison is between a pain management programme and another active treatment, the results are less stunning. We should also remember that the outcomes being measured are important: is it pain reduction (not so likely, but possible)? Is it increased function (likely)? Reduced distress (probable)? Increased confidence (generally yes, at least for a while)?

To the studies:

I’m going to draw from three recent studies published by the same group, all three studies vary slightly in their scope, and were conducted in Sweden. Participants were recruited from the University-based Pain Centre, and had received a medical examination but no multidisciplinary treatment.  Participants were screened over the phone, and randomly allocated to one of two groups. In the first study, the two groups were the control group which was an online discussion group, with the second group an online ACT-based programme consisting of seven sections (Buhrman, Skoglund, Husell, Bergstrom, Gordh, Hursti et al, 2013).

The second study was an online “refresher” programme for people who had previously attended the Uppsala University chronic pain programme. Participants were invited if they had completed their programme 1 – 5 years before, had been recently screened medically, and were interviewed/screened to ensure their eligibility.  Participants were also randomised into two groups: the control group as above, and the treatment group which had eight sessions incorporating action planning, exercise, applied relaxation, cognitive restructuring, mindfulness and sleep and stress (Buhrman, Fredriksson, Edstrom, Shafiei, Tarnquvist, Ljotsson et al, 2013).

The final study by this group has yet to be published, and is a similar programme to that in the second one, and again the research design was as above. Participants in this study were those with depression and anxiety, and treatment was tailored to directly address these problems, drawing from the content above, but tailored to meet the individual needs as assessed in the screening interview (Buhrman, Syk, Burvall, Hartig, Gordh, & Andersson, in press).

What happened?

For all three programmes, outcomes showed improvement in the areas we want to see (reduced distress, anxiety, depression, increased activity engagement and willingness). This was maintained for six – twelve months. All well and good, the programmes are useful.

The questions that arise for me are whether some of the steps required for a research project might influence programme usefulness – and even participation. The authors of the in press article acknowledge this, finding that they did not provide telephone support for this last group, and therefore had more drop-outs. But of course this could happen if participants don’t think they’re getting any new information, so we’re not sure if this is important. But there is information suggesting that personal phone contact, the interview process and follow-ups by clinicians form an important part of helping people maintain interest and engagement in a programme. Could this be a potential barrier to “real world” success for internet-based programmes?

Other issues have been identified in other studies of self-management, such as the need for GP’s to actively endorse these programmes, giving authoritative sanction for them so people participating are encouraged to use them. Where this isn’t carried out the programmes don’t seem to have as much uptake.

There’s also the “I’m in a research study” effect. Simply by being in a research project people can be more enthusiastic about participating, and completing all those questionnaires. There’s the emailed reminders, the “specialness” of having your opinion valued, the enthusiasm of the researchers themselves.

What do I conclude?

By comparison with pain-related apps for smart phones (Lalloo, Jibb, Rivera, Agarwal & Stinson, in press), internet-based cognitive behaviourally-based programmes for chronic pain are broad in scope, usually based on some theoretical position, and some have been scientifically studied. In fact, Lalloo and colleagues point out that many apps don’t have health professional input, and haven’t been tested for effectiveness. While apps may offer some support for self-management, they are probably not your best choice for e-therapy.

CBT-based programmes, on the other hand, seem to have some effectiveness at least on some parameters, and within the constraints of a research format.

I’d like to see a programme developed for people in the community without requiring medical assessment, and based on a model of how people move from “Limbo Land” where pain doesn’t make any sense, through to “Living well with chronic pain” where a range of ways of getting on with life are used in a flexible and persistent way. I’d love to see this kind of programme operating without obstacles to getting involved like being screened, or medically assessed, and where participants can choose the elements that interest them. People with pain might just choose what they’re ready for more effectively than if a professional gets in on the act – what do you think?

 

Buhrman, Monica, Skoglund, Astrid, Husell, Josefin, Bergström, Kristina, Gordh, Torsten, Hursti, Timo, . . . Andersson, Gerhard. (2013). Guided internet-delivered acceptance and commitment therapy for chronic pain patients: A randomized controlled trial. Behaviour Research and Therapy, 51(6), 307-315. doi: http://dx.doi.org/10.1016/j.brat.2013.02.010

Buhrman, M., Fredriksson, A., Edström, G., Shafiei, D., Tärnqvist, C., Ljótsson, B., . . . Andersson, G. (2013). Guided Internet-delivered cognitive behavioural therapy for chronic pain patients who have residual symptoms after rehabilitation treatment: Randomized controlled trial. European Journal of Pain, 17(5), 753-765. doi: 10.1002/j.1532-2149.2012.00244.x

Buhrman, Monica PhD, Syk, Martin, Burvall, Olle, Hartig, Terry, Gordh, Torsten, & Andersson, Gerhard. Individualized Guided Internet-delivered Cognitive Behaviour Therapy for Chronic Pain Patients with Comorbid Depression and Anxiety: A Randomized Controlled Trial. Clinical Journal of Pain. in press

Lalloo, Chitra, Jibb, Lindsay A. , Rivera, Jordan , Agarwal, Arnav , & Stinson, Jennifer N. . “There’s a Pain App for That”: Review of Patient-Targeted Smartphone Applications for Pain Management. Clinical Journal of Pain. in press

7 comments

  1. Bronnie, may I answer your question with a resounding YES. We are in fact in the process of offering such a programme. Watch this space!

  2. Thank you for bringing up this topic. It is one that gets discussed within my pain service both in the context to support clients that are unable to access our service (out of funding area & rural communities) and for clients that have completed a pain management programme, but require some form of on-going support with consistency, maintenance and implementation of learned pain management skills into their own daily lives.

    I agree that pain management within a group process is almost always more effective than 1:1 based therapy. The ‘Magic’ that happens within a group process would most likely be lost in an online based approach. That said more and more people are getting used to using social media and other online communities to maintain and build their sense of connectedness. Our detentions of groups and forma of interaction have shifted (and will continue to shift) dramatically.
    I think e-learning will have to become an integral part of our approach and individual e-programmes would be a great resource. I would love to see this be taken further though… to me a successful e-based pain management approach would allow for clients to both complete elements of e-learning at their own pace as well as allow for interaction with other participants through sharing or idea’s resources and experiences. I’ve seen some great projects of on-line e-Art Therapy where participants actually have a joint start date and go through a process as a group; sharing their art and insights as they grow and learn. This type of approach would require a professional for monitoring and wouldn’t suit everyone, but it could potentially bridge the divide between face to face group interaction and singular individual online learning.

    I wholeheartedly agree that the threshold for such programmes should be low and barriers should be minimal. I would love to hear more from people who are currently developing these type of interventions…

    1. hmmm don’t know what happened there… it should have said: ‘Our definitions of groups and forms of interaction have shifted (and will continue to shift) dramatically’.

      1. The interweb’s a weird and wonderful thing…! I have definitely found the research into PMPs using qualitative methodologies ALL show how important learning from other people in the same situation really is. A forum, or some sort of discussion element, or Q & A approach might go some way towards bringing this in. I’ve also participated in online teaching using Adobe Connect, and done a CBT programme using the same approach, and this did help – but at least part of pain management involves observing other people as part of the learning, so it wouldn’t completely replace face to face stuff.
        In the context of the work I’m doing for Pain BC, the people who might use the material are not as severely disabled or distressed as those seen in tertiary pain management services, and I do think there’s a real need for tertiary services to exist. I just wish there was a way to capture the less distressed/disabled people earlier, and make accessing CBT approaches much less formidible than it is currently.

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