Eccleston Christopher, Fisher Emma, Craig Lorraine, Duggan Geoffrey B, Rosser Benjamin A, Keogh Edmund
Centre for Pain Research, University of Bath, Claverton Down, Bath, UK, BA2 7AY.
Cochrane Database Syst Rev. 2014 Feb 26;2014(2):CD010152. doi: 10.1002/14651858.CD010152.pub2.
Chronic pain (i.e. pain lasting longer than three months) is common. Psychological therapies (e.g. cognitive behavioural therapy) can help people to cope with pain, depression and disability that can occur with such pain. Treatments currently are delivered via hospital out-patient consultation (face-to-face) or more recently through the Internet. This review looks at the evidence for psychological therapies delivered via the Internet for adults with chronic pain.
Our objective was to evaluate whether Internet-delivered psychological therapies improve pain symptoms, reduce disability, and improve depression and anxiety for adults with chronic pain. Secondary outcomes included satisfaction with treatment/treatment acceptability and quality of life.
We searched CENTRAL (Cochrane Library), MEDLINE, EMBASE and PsycINFO from inception to November 2013 for randomised controlled trials (RCTs) investigating psychological therapies delivered via the Internet to adults with a chronic pain condition. Potential RCTs were also identified from reference lists of included studies and relevant review articles. In addition, RCTs were also searched for in trial registries.
Peer-reviewed RCTs were identified and read in full for inclusion. We included studies if they used the Internet to deliver the primary therapy, contained sufficient psychotherapeutic content, and promoted self-management of chronic pain. Studies were excluded if the number of participants in any arm of the trial was less than 20 at the point of extraction.
Fifteen studies met the inclusion criteria and data were extracted. Risk of bias assessments were conducted for all included studies. We categorised studies by condition (headache or non-headache conditions). Four primary outcomes; pain symptoms, disability, depression, and anxiety, and two secondary outcomes; satisfaction/acceptability and quality of life were extracted for each study immediately post-treatment and at follow-up (defined as 3 to 12 months post-treatment).
Fifteen studies (N= 2012) were included in analyses. We assessed the risk of bias for included studies as low overall. We identified nine high 'risk of bias' assessments, 22 unclear, and 59 low 'risk of bias' assessments. Most judgements of a high risk of bias were due to inadequate reporting.Analyses revealed seven effects. Participants with headache conditions receiving psychological therapies delivered via the Internet had reduced pain (number needed to treat to benefit = 2.72, risk ratio 7.28, 95% confidence interval (CI) 2.67 to 19.84, p < 0.01) and a moderate effect was found for disability post-treatment (standardised mean difference (SMD) ‒0.65, 95% CI ‒0.91 to ‒0.39, p < 0.01). However, only two studies could be entered into each analysis; hence, findings should be interpreted with caution. There was no clear evidence that psychological therapies improved depression or anxiety post-treatment (SMD -0.26, 95% CI -0.87 to 0.36, p > 0.05; SMD -0.48, 95% CI -1.22 to 0.27, p > 0.05), respectively. In participants with non-headache conditions, psychological therapies improved pain post-treatment (p < 0.01) with a small effect size (SMD -0.37, 95% CI -0.59 to -0.15), disability post-treatment (p < 0.01) with a moderate effect size (SMD -0.50, 95% CI -0.79 to -0.20), and disability at follow-up (p < 0.05) with a small effect size (SMD -0.15, 95% CI -0.28 to -0.01). However, the follow-up analysis included only two studies and should be interpreted with caution. A small effect was found for depression and anxiety post-treatment (SMD -0.19, 95% CI -0.35 to -0.04, p < 0.05; SMD -0.28, 95% CI -0.49 to -0.06, p < 0.01), respectively. No clear evidence of benefit was found for other follow-up analyses. Analyses of adverse effects were not possible.No data were presented on satisfaction/acceptability. Only one study could be included in an analysis of the effect of psychological therapies on quality of life in participants with headache conditions; hence, no analysis could be undertaken. Three studies presented quality of life data for participants with non-headache conditions; however, no clear evidence of benefit was found (SMD -0.27, 95% CI -0.54 to 0.01, p > 0.05).
AUTHORS' CONCLUSIONS: There is insufficient evidence to make conclusions regarding the efficacy of psychological therapies delivered via the Internet in participants with headache conditions. Psychological therapies reduced pain and disability post-treatment; however, no clear evidence of benefit was found for depression and anxiety. For participants with non-headache conditions, psychological therapies delivered via the Internet reduced pain, disability, depression, and anxiety post-treatment. The positive effects on disability were maintained at follow-up. These effects are promising, but considerable uncertainty remains around the estimates of effect. These results come from a small number of trials, with mostly wait-list controls, no reports of adverse events, and non-clinical recruitment methods. Due to the novel method of delivery, the satisfaction and acceptability of these therapies should be explored in this population. These results are similar to those of reviews of traditional face-to-face therapies for chronic pain.
慢性疼痛（即持续时间超过三个月的疼痛）很常见。心理疗法（如认知行为疗法）可以帮助人们应对此类疼痛可能伴随的疼痛、抑郁和残疾问题。目前的治疗方式是通过医院门诊咨询（面对面），或者最近通过互联网进行。本综述旨在探讨通过互联网为慢性疼痛成人患者提供心理疗法的证据。
我们的目的是评估通过互联网提供的心理疗法是否能改善慢性疼痛成人患者的疼痛症状、减轻残疾程度、改善抑郁和焦虑状况。次要结果包括对治疗的满意度/治疗可接受性以及生活质量。
我们检索了Cochrane图书馆的CENTRAL、MEDLINE、EMBASE和PsycINFO数据库，检索时间从建库至2013年11月，以查找调查通过互联网为慢性疼痛成人患者提供心理疗法的随机对照试验（RCT）。还从纳入研究的参考文献列表和相关综述文章中识别潜在的RCT。此外，还在试验注册库中搜索RCT。
识别并全文阅读经同行评审的RCT以纳入研究。如果研究使用互联网提供主要治疗方法、包含足够心理治疗内容并促进慢性疼痛的自我管理，我们就将其纳入。如果试验任何一组在提取数据时参与者人数少于20，则排除该研究。
15项研究符合纳入标准并提取了数据。对所有纳入研究进行了偏倚风险评估。我们根据病情（头痛或非头痛病情）对研究进行分类。提取了四项主要结果：疼痛症状、残疾程度、抑郁和焦虑，以及两项次要结果：治疗后立即和随访时（定义为治疗后3至12个月）每项研究的满意度/可接受性和生活质量。
15项研究（N = 2012）纳入分析。我们评估纳入研究的总体偏倚风险较低。我们识别出9项高“偏倚风险”评估、22项不明确评估和59项低“偏倚风险”评估。大多数高偏倚风险判断是由于报告不充分。分析显示有七种效应。接受通过互联网提供心理疗法的头痛患者疼痛减轻（治疗获益所需人数 = 2.72，风险比7.28，95%置信区间（CI）2.67至19.84，p < 0.01），治疗后残疾程度有中等效应（标准化均数差（SMD）‒0.65，95% CI ‒0.91至‒0.
