Key messages
• Online cognitive behavioural therapy represents the most common remotely-delivered psychological therapy. It may improve pain and disability in individuals experiencing chronic pain.
• It is largely unclear whether remotely-delivered psychological therapies improve quality of life or cause harmful effects due to limited evidence, of often limited quality.
• We need more and better studies to investigate remotely-delivered psychological therapies. Future studies should explore a broader range of technologies and therapies, and focus on possible unwanted effects.
Why consider remotely-delivered psychological therapies for chronic pain?
Chronic pain is pain that lasts three months or longer. It is a common experience that can significantly impact on a person’s everyday life and well-being. Psychological therapies have been found to improve mood and pain-related disability. The most common psychological approach for chronic pain is cognitive behavioural therapy (CBT), which focuses on the interrelationship between thoughts, feelings, and actions, to support symptom management.
Unfortunately, gaining access to psychological therapies may be difficult. There are limited numbers of qualified healthcare professionals providing these services, and some people may find it physically difficult to attend clinics. Technologies (such as mobile phones, computers, and the Internet) may offer new ways of delivering psychological therapies directly to people within their everyday environment and without a healthcare professional being present. This approach (known as remote delivery) has the potential to help more people access therapy.
What did we want to find out?
We wanted to find out if remotely-delivered psychological therapies:
• improve pain, disability, and quality of life (i.e. well-being across life as a whole);
• cause any unintended harmful effects.
What did we do?
We searched for studies that compared remotely-delivered psychological therapies with usual care or non-psychological treatments (such as education about pain). We looked at study results at the end of treatment and up to one year after.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 32 studies that included 4924 people with a range of chronic pain conditions, such as back pain, osteoarthritis, fibromyalgia, and rheumatoid arthritis. Average ages ranged from 24 to 67 years. Where those taking part were followed up after treatment ended, this follow-up was between 3 and 12 months later; we did not include results collected after 12 months. Studies included in the review were carried out across 11 countries, with over half attributable to Sweden (9), the USA (6), and Australia (5). All studies were funded by government grants or charities, bar one study that did not state its funding source.
Studies investigated treatments based on the psychological therapies of CBT (25 studies) and acceptance and commitment therapy (ACT; 7 studies). One of the CBT studies included an additional group who received a positive psychology intervention. All therapies were delivered online, except one study using a smartphone app.
Main results
Our results only speak to therapy delivered by the Internet due to the lack of alternative forms of remote delivery in the studies.
• Compared to usual treatment (i.e. the standard support typically available), online CBT probably reduces pain and may reduce disability slightly. It is unclear whether online CBT improves quality of life or has unintended harmful effects.
• Compared to non-psychological treatments for pain (e.g. education, online discussion boards), online CBT also probably reduces pain slightly. However, it probably makes little to no difference to quality of life, may make little or no difference to disability, and it is unclear whether it has unintended harmful effects.
• The benefits of online CBT compared to usual treatment are probably no longer present at 3 to 12 months after treatment ends. We do not know if this finding is also the case when compared to a non-psychological treatment because the effects are unclear.
It is unclear whether other psychological therapies (such as ACT) lead to improvements because, overall, we are very uncertain of the available results.
What are the limitations of the evidence?
We have moderate confidence that pain is reduced by online CBT by the end of treatment, but this improvement is not present 3 to 12 months later. In addition, we have moderate confidence in our finding of no benefits of online CBT for disability and quality of life at follow-up. However, we have little to very little confidence in our findings for ACT.
Three main factors reduced our confidence in the evidence. First, some of the studies were very small or there were not enough studies to be certain about their results. Second, where there were small numbers of studies for an outcome, the evidence did not cover a range of pain conditions, so we cannot assume that those findings would be the same across all types of chronic pain. Finally, the results were sometimes inconsistent across studies.
How up to date is this evidence?
The evidence is up to date to 29 June 2022.