Data Support Online Therapies for Chronic Pain : Cognitive-behavioral therapy in a Web-based format improves patients' quality of life.
Teens Taking Charge
Another CBT-based site for young people, “Teens Taking Charge: Managing Arthritis Online” focuses specifically on those with juvenile idiopathic arthritis and their parents.
In a 12-week nonblinded, randomized controlled trial done at four centers in Canada, 46 adolescents aged 12-18 with JIA plus one parent each were randomized to the Internet intervention or control arm (J. Rheumatol. 2010;37:1944-52).
The CBT-based self-management modules, written specifically for teens, provide education about arthritis and symptom management, and also address areas such as relaxation, medications, distraction, and managing thoughts. A journal page allows the teen to track progress. Two modules for parents focus on arthritis impact and “letting go.” Multimedia components include more than 300 pages of content, including Flash animation, video, forums for teens and parents, surveys, and weekly quizzes. The online “coach” has a BA degree in psychology.
At posttreatment, the intervention group had significantly better knowledge and lower average weekly pain intensity.
painAction
This interactive self-management Web site for people with chronic back pain was evaluated in a pretest-posttest controlled trial in which 209 patients were randomized to either the site (
The site was based on CBT and self-management principles, including collaborative decision making, goal setting, problem solving, relapse prevention, nutrition, stress management, and exercise. As with many of the other sites, this one included interactive tools, personalized assessments, and a library of articles.
At 6 months, clinically significant changes were seen in pain, depression, anxiety, and global ratings of improvement among those randomized to the site, which is supported by Endo Pharmaceuticals Inc. and King Pharmaceuticals Inc.
Living Well With Fibromyalgia
From Dr. Williams' group at the University of Michigan, this Internet-based exercise and behavioral self-management program for fibromyalgia was designed for use in the context of clinical care. A total of 118 patients were randomized to the program plus standard care, or standard care alone (Pain 2010;151:694-702).
Among the site's features are CBT modules including educational material about fibromyalgia and its treatment; symptom management with modalities including medications, exercise, sleep, and relaxation; and lifestyle changes including goal setting, problem solving, and graded activation.
Multimedia tools include video lectures by professionals, downloadable worksheets, self-monitoring forms, and audio recordings of exercises (
At 6 months, overall improvement was seen in 57% with the Web program vs. 21% with standard care alone.
The proportion experiencing 30% pain improvement or greater (pain responders) was 29% vs. 8% with standard care alone, and functional improvement, defined as an improvement of 0.5 standard deviations, was seen in 31% vs. 6%. All differences were statistically significant, and the number needed to treat for both outcomes was 5, better than the typical 7-19 seen in pharmaceutical trials, Dr. Williams noted.
In a recent meta-analysis of 11 studies of Web-based interventions for chronic pain that used pain scale scores as the main outcome, the standardized mean difference between intervention and waiting-list group means was 0.285, favoring the Web interventions but with a small effect size (J. Pain 2010;11:917-29).
“Broader adoption of this method of delivering care for pain needs to be moved to the next level in terms of both infrastructure and practitioner consensus,” Dr. Williams said in an interview.
“Hopes of expanding Internet-based behavioral treatment for pain would need to contain content reflecting a broader consensus of experts from the various disciplines associated with pain management,” he said.
“Currently there is great interest in developing such resources both in the public and private sectors.
“This appears to be a valuable approach to supplying individuals with an aspect of effective pain management that is often missing.”
Dr. Williams is a consultant for Eli Lilly & Co., Forest Pharmaceuticals, and Bristol-Myers Squibb.
