Controlled trial of Internet-based treatment with telephone support for chronic back pain

Chronic health conditions and internet behavioral interventions: a review of factors to enhance user engagement

The objective of this study was to review the evidence about what factors influence user engagement in Internet-based behavioral interventions for chronic illness. We conducted a systematic review of the recent published literature. Searches of MEDLINE (using Ovid and PubMed), The Cochrane Library, and PsycINFO, from January 2000 to December 2008, were completed. Additional articles were identified from searching the bibliographies of retrieved articles. We identified studies of interactive health communication interventions delivered via the Internet that, apart from delivering health information, had another component such as interactive tools to manage illness, decision support for treatment, or social support. We restricted the age range to adulthood. The search identified 186 abstracts; 46 articles were reviewed. We used a qualitative approach called "positive deviance" to study those interventions that have succeeded in engaging users where most have failed. Some ways to improve user engagement in Internet interventions suggested by our review include addressing health concerns that are important and relevant to an individual patient or consumer and an individualized approach, such as personally tailored advice and feedback. Interventions that are part of larger health management programs that include clinicians appear to be especially promising.

Chronic health conditions and internet behavioral interventions: a review of factors to enhance user engagement

The objective of this study was to review the evidence about what factors influence user engagement in Internet-based behavioral interventions for chronic illness. We conducted a systematic review of the recent published literature. Searches of MEDLINE (using Ovid and PubMed), The Cochrane Library, and PsycINFO, from January 2000 to December 2008, were completed. Additional articles were identified from searching the bibliographies of retrieved articles. We identified studies of interactive health communication interventions delivered via the Internet that, apart from delivering health information, had another component such as interactive tools to manage illness, decision support for treatment, or social support. We restricted the age range to adulthood. The search identified 186 abstracts; 46 articles were reviewed. We used a qualitative approach called "positive deviance" to study those interventions that have succeeded in engaging users where most have failed. Some ways to improve user engagement in Internet interventions suggested by our review include addressing health concerns that are important and relevant to an individual patient or consumer and an individualized approach, such as personally tailored advice and feedback. Interventions that are part of larger health management programs that include clinicians appear to be especially promising.

An exploration of chronic pain patients' perceptions of home telerehabilitation services

OBJECTIVES

To explore patients' perceptions regarding prospective telerehabilitation services and the factors that facilitate or impede patients' intentions to use these services.

DESIGN

Using semi-structured interviews, patients reflected on the pros and cons of various scenarios of prospective telerehabilitation services. Patients' arguments were first arranged according to the Unified Theory of Acceptance and Use of Technology (UTAUT). Next, using inductive analysis, the data for each UTAUT component were analysed and arranged into subthemes.

SETTING AND PARTICIPANTS

Twenty-five chronic pain patients were selected from a rehabilitation centre in the Netherlands.

RESULTS

Overall, participants considered telerehabilitation helpful as a complementary or follow-up treatment, rather than an autonomous treatment. Arguments mainly related to the UTAUT constructs of 'performance expectancy' and 'facilitating conditions'. Patients valued the benefits such as reduced transportation barriers, flexible exercise hours and the possibility to better integrate skills into daily life. However, many patients feared a loss of treatment motivation and expressed concerns about both reduced fellow sufferer contact and reduced face-to-face therapist contact. Few arguments related to 'social norms' and 'effort expectancy'.

CONCLUSIONS

The effect of telerehabilitation on healthcare strongly depends on patients' willingness to use. Our study showed that chronic pain patients valued the benefits of telerehabilitation but hesitate to use it as an autonomous treatment. Therefore, future initiatives should maintain traditional care to some degree and focus on patients' attitudes as well. Either by giving information to increase patients' confidence in telerehabilitation or by addressing reported drawbacks into the future design of these services. Further quantitative studies are needed to explore patients' intentions to use telerehabilitation.

A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain

Low back pain (LBP) is a common and disabling disorder in western society. The management of LBP comprises a range of different intervention strategies including surgery, drug therapy, and non-medical interventions. The objective of the present study is to determine the effectiveness of physical and rehabilitation interventions (i.e. exercise therapy, back school, transcutaneous electrical nerve stimulation (TENS), low level laser therapy, education, massage, behavioural treatment, traction, multidisciplinary treatment, lumbar supports, and heat/cold therapy) for chronic LBP. The primary search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to 22 December 2008. Existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria. The search strategy outlined by the Cochrane Back Review Groups (CBRG) was followed. The following were included for selection criteria: (1) randomized controlled trials, (2) adult (≥ 18 years) population with chronic (≥ 12 weeks) non-specific LBP, and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery, or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias, and outcomes at short, intermediate, and long-term follow-up. The GRADE approach was used to determine the quality of evidence. In total 83 randomized controlled trials met the inclusion criteria: exercise therapy (n = 37), back school (n = 5), TENS (n = 6), low level laser therapy (n = 3), behavioural treatment (n = 21), patient education (n = 1), traction (n = 1), and multidisciplinary treatment (n = 6). Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. Behavioural treatment was found to be effective in reducing pain intensity at short-term follow-up compared to no treatment/waiting list controls. Finally, multidisciplinary treatment was found to reduce pain intensity and disability at short-term follow-up compared to no treatment/waiting list controls. Overall, the level of evidence was low. Evidence from randomized controlled trials demonstrates that there is low quality evidence for the effectiveness of exercise therapy compared to usual care, there is low evidence for the effectiveness of behavioural therapy compared to no treatment and there is moderate evidence for the effectiveness of a multidisciplinary treatment compared to no treatment and other active treatments at reducing pain at short-term in the treatment of chronic low back pain. Based on the heterogeneity of the populations, interventions, and comparison groups, we conclude that there are insufficient data to draw firm conclusion on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP.

Psychological treatment of chronic pain

Psychological treatment has emerged as a common component of a multidimensional and interdisciplinary plan of pain care for many persons with persistent pain. Treatments are informed by a biopsychosocial model of pain and a long history of psychological research that has identified the central role of behavioral, cognitive, and emotional factors that are believed to contribute to the perpetuation, if not the development, of chronic pain and pain-related disability and emotional distress. Empirically supported self-regulatory, behavioral, cognitive-behavioral, and acceptance and commitment interventions are reviewed, and current and future interventions are highlighted. Important issues related to individual differences and disparities in the experience of pain and pain treatment are discussed. In particular, race and ethnicity are considered, and special considerations for the management of pain in children and older adults are discussed.

An Internet-based self-help treatment for fear of public speaking: a controlled trial

This study offers data about the efficacy of "Talk to Me," an Internet-based telepsychology program for the treatment of fear of public speaking that includes the most active components in cognitive-behavior therapy (CBT) for social phobia (exposure and cognitive therapies). One hundred twenty-seven participants with social phobia were randomly assigned to three experimental conditions: (a) an Internet-based self-administered program; (b) the same program applied by a therapist; (c) a waiting-list control group. Results showed that both treatment conditions were equally efficacious. In addition, Talk to Me and the same treatment applied by a therapist were more efficacious than the waiting-list condition. Treatment gains were maintained at 1-year follow-up. The results from this study support the utility of Internet-delivered CBT programs in order to reach a higher number of people who could benefit from CBT. Internet-delivered CBT programs could also play a valuable role in the dissemination of CBT.

Internet-enhanced management of fibromyalgia: a randomized controlled trial

Both pharmacological and non-pharmacological interventions have demonstrated efficacy in the management of fibromyalgia (FM). Non-pharmacological interventions however are far less likely to be used in clinical settings, in part due to limited access. This manuscript presents the findings of a randomized controlled trail of an Internet-based exercise and behavioral self-management program for FM designed for use in the context of a routine clinical care. 118 individuals with FM were randomly assigned to either (a) standard care or (b) standard care plus access to a Web-Enhanced Behavioral Self-Management program (WEB-SM) grounded in cognitive and behavioral pain management principles. Individuals were assessed at baseline and again at 6 months for primary endpoints: reduction of pain and an improvement in physical functioning. Secondary outcomes included fatigue, sleep, anxiety and depressive symptoms, and a patient global impression of improvement. Individuals assigned to the WEB-SM condition reported significantly greater improvement in pain, physical functioning, and overall global improvement. Exercise and relaxation techniques were the most commonly used skills throughout the 6 month period. A no-contact, Internet-based, self-management intervention demonstrated efficacy on key outcomes for FM. While not everyone is expected to benefit from this approach, this study demonstrated that non-pharmacological interventions can be efficiently integrated into routine clinical practice with positive outcomes.

Web-based treatment for infertility-related psychological distress

Infertility has been associated with stigma and negative psychosocial functioning. However, only a small proportion of this population actually receives care. Fertility patients predominantly use the Internet for information gathering, social support, and assistance with decision-making; yet, available web resources are unreliable sources of mental health care. Web-based alternatives also have the potential to assist with intervention access difficulties and may be of significant lower cost. This study evaluated the efficacy of a web-based approach to providing a cognitive behavioral intervention with 31 infertile women seeking medical reproductive technologies. Following randomized assignment, participants using the web-based intervention were compared with those in a wait-list control condition on general and infertility-related psychological stress measures. Results were mixed regarding intervention efficacy. Significant declines in general stress were evidenced in the experimental group compared with a wait-list control group. However, website access did not result in statistically significant improvements on a measure of infertility-specific stress. These findings add to the literature on psychological interventions for women experiencing fertility problems. Moreover, despite the widespread use of the Internet by this population, the present study is one of the first to investigate the usefulness of the Internet to attenuate stress in this population. Preliminary results suggest general stress may be significantly reduced in infertile women using an online cognitive behavioral approach.

The efficacy of Web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis

Our objective was to conduct a systematic review and meta-analysis to quantify the efficacy of web-based cognitive behavioral interventions for the treatment of patients with chronic pain. MEDLINE and other databases were searched as data sources. Reference lists were examined for other relevant articles. We included 11 studies that evaluated the effects of web-based interventions on chronic pain using specific scales of pain. The pooled effect size (standardized mean difference between intervention versus waiting-list group means) from a random effects model was .285 (95% confidence interval: .145-.424), favoring the web-based intervention compared with the waiting-list group, although the effect was small. In addition, these results were not driven by any particular study, as shown by sensitivity analysis. Results from funnel plot argue against publication bias. Finally, the average dropout rate was 26.6%. In our meta-analysis, we demonstrate a small effect of web-based interventions, when using pain scale as the main outcome. Despite the minor effects and high dropout rates, the decreased costs and minor risk of adverse effects compared with pharmacological treatments support additional studies in chronic pain patients using web-based interventions. Further studies will be important to confirm the effects and determine the best responders to this intervention.

PERSPECTIVE

Our findings suggest that web-based interventions for chronic pain result in small pain reductions in the intervention group compared with waiting-list control groups. These results advance the field of web-based cognitive behavioral interventions as a potential therapeutic tool for chronic pain and can potentially help clinicians and patients with chronic pain by decreasing treatment costs and side effects.

painACTION-back pain: a self-management website for people with chronic back pain

OBJECTIVE

To determine whether an interactive self-management Website for people with chronic back pain would significantly improve emotional management, coping, self-efficacy to manage pain, pain levels, and physical functioning compared with standard text-based materials.

DESIGN

The study utilized a pretest-posttest randomized controlled design comparing Website (painACTION-Back Pain) and control (text-based material) conditions at baseline and at 1-, 3, and 6-month follow-ups.

PARTICIPANTS

Two hundred and nine people with chronic back pain were recruited through dissemination of study information online and at a pain treatment clinic. The 6-month follow-up rates for the Website and control groups were 73% and 84%, respectively.

MEASUREMENTS

Measures were based on the recommendations of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials and included measures of pain intensity, physical functioning, emotional functioning, coping, self-efficacy, fear-avoidance, perceived improvement with treatment, self-efficacy, and catastrophizing.

RESULTS

Compared with controls, painACTION-Back Pain participants reported significantly: 1) lower stress; 2) increased coping self-statements; and 3) greater use of social support. Comparisons between groups suggested clinically significant differences in current pain intensity, depression, anxiety, stress, and global ratings of improvement. Among participants recruited online, those using the Website reported significantly: 1) lower "worst" pain; 2) lower "average" pain; and 3) increased coping self-statements, compared with controls. Participants recruited through the pain clinic evidenced no such differences.

CONCLUSIONS

An online self-management program for people with chronic back pain can lead to improvements in stress, coping, and social support, and produce clinically significant differences in pain, depression, anxiety, and global rates of improvement.

Self-management of chronic low back pain: an exploration of the impact of a patient-centered website

OBJECTIVE

This paper examines from a qualitative approach the role of a patient-centered website - named "Oneself" - on patients' chronic low back pain self-management attitudes and behaviors in the Italian part of Switzerland.

METHODS

In-depth interviews have been conducted with a purposive and convenient sample of 18 chronic low back pain sufferers who had used Oneself during 6 months. Data collection and analysis were driven by grounded theory.

RESULTS

Reported positive effects of the use of Oneself on self-management attitudes and behaviors include self-comprehension, improvement of argumentative abilities, orientation, development of self-confidence and maintenance of a high level of attention. In some cases, participants affirm to have experienced negative effects such as confusion and discouragement. The individual's previous awareness of cLBP and level of self-management plays a main role in the way people use the website and in its impact. Based on this criterium, a typology of four patterns of use is drawn.

CONCLUSION

Patient-centered websites are useful for enhancing self-management of chronic low back pain. However, individuals take advantage of this means differently, based on their stage of advancement in the self-management process.

PRACTICE IMPLICATIONS

Information and supports provided online should be tailored according to people's stage of advancement.

Computer-mediated patient education: opportunities and challenges for supporting women with ovarian cancer

A majority of women with ovarian cancer will face recurrent disease despite receiving aggressive chemotherapy at the time of diagnosis. Given the complex medical and psychosocial needs of women with ovarian cancer and the time constraints within busy clinical settings, providing women with the necessary education related to their disease and treatments can be challenging. The advent of computers and web-based technologies has created new opportunities for educating cancer patients and supporting them to better cope with their disease. This article reviews prior studies of computer-based patient education interventions to identify key intervention components and other factors associated with improved patient outcomes. Opportunities for using computer-based technologies to support women with ovarian cancer are discussed and WRITE Symptoms (a Written Representational Intervention To Ease Symptoms), a web-based, symptom management intervention for women with recurrent ovarian cancer, is introduced.

A three-group study, internet-based, face-to-face based and standard- management after acute whiplash associated disorders (WAD) - choosing the most efficient and cost-effective treatment: study protocol of a randomized controlled trial

Background

The management of Whiplash Associated Disorders is one of the most complicated challenges with high expenses for the health care system and society. There are still no general guidelines or scientific documentation to unequivocally support any single treatment for acute care following whiplash injury.

The main purpose of this study is to try a new behavioural medicine intervention strategy at acute phase aimed to reduce the number of patients who have persistent problems after the whiplash injury. The goal is also to identify which of three different interventions that is most cost-effective for patients with Whiplash Associated Disorders. In this study we are controlling for two factors. First, the effect of behavioural medicine approach is compared with standard care. Second, the manner in which the behavioural medicine treatment is administered, Internet or face-to-face, is evaluated in it's effectiveness and cost-effectiveness.

Methods/Design

The study is a randomized, prospective, experimental three-group study with analyses of cost-effectiveness up to two-years follow-up. Internet – based programme and face-to-face group treatment programme are compared to standard-treatment only. Patient follow-ups take place three, six, twelve and 24 months, that is, short-term as well as long-term effects are evaluated. Patients will be enrolled via the emergency ward during the first week after the accident.

Discussion

This new self-help management will concentrate to those psychosocial factors that are shown to be predictive in long-term problems in Whiplash Associated Disorders, i.e. the importance of self-efficacy, fear of movement, and the significance of catastrophizing as a coping strategy for restoring and sustaining activities of daily life. Within the framework of this project, we will develop, broaden and evaluate current physical therapy treatment methods for acute Whiplash Associated Disorders. The project will contribute to the creation of a cost-effective behavioural medicine approach to management of acute Whiplash Associated Disorders. The results of this study will answer an important question; on what extent and how should these patients be treated at acute stage and how much does the best management cost.

Trial registration number

Current Controlled Trials ISRCTN61531337

Logging on for better sleep: RCT of the effectiveness of online treatment for insomnia

STUDY OBJECTIVES

Despite effective cognitive behavioral treatments for chronic insomnia, such treatments are underutilized. This study evaluated the impact of a 5-week, online treatment for insomnia.

DESIGN

This was a randomized controlled trial with online treatment and waiting list control conditions.

PARTICIPANTS

Participants were 118 adults with chronic insomnia.

SETTING

Participants received online treatment from their homes.

INTERVENTION

Online treatment consisted of psychoeducation, sleep hygiene, and stimulus control instruction, sleep restriction treatment, relaxation training, cognitive therapy, and help with medication tapering.

MEASUREMENT AND RESULTS

From pre- to post-treatment, there was a 33% attrition rate, and attrition was related to referral status (i.e., dropouts were more likely to have been referred for treatment rather than recruited from the community). Using a mixed model analysis of variance procedure (ANOVA), results showed that online treatment produced statistically significant improvements in the primary end points of sleep quality, insomnia severity, and daytime fatigue. Online treatment also produced significant changes in process variables of pre-sleep cognitive arousal and dysfunctional beliefs about sleep.

CONCLUSIONS

Implications of these findings are that identification of who most benefits from online treatment is a worthy area of future study.

An evaluation of Web-based education as an alternative to group lectures for diabetes self-management

This study evaluated the efficacy of Web-based diabetes self-management education for newly diagnosed patients with type II diabetes as an alternative to group lectures. Using a non-equivalent control group, pretest-post-test design, the participants in the Web group (n = 15) took part in a Web-based diabetes self-management program, while those in the lecture group (n = 16) attended 3 h of group lectures provided by health-care professionals specializing in diabetes care. The outcome variables were measured at the baseline (T0), and 6 weeks (T1) and 3 months (T2) after the interventions. The glycosylated hemoglobin (HbA1c) percentage and diabetes care knowledge in the Web group improved significantly from T0 to T1, while the diabetes care behavior improved significantly from T0 to T1 and from T1 to T2. The diabetes care knowledge and diabetes care behavior in the lecture group improved significantly from T0 to T1, but the HbA1c percentage did not change significantly between any times. These results show the potential of the Web-based program as an alternative to group lectures for diabetes self-management education.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. No comprehensive systematic review has been published since 1999.

OBJECTIVES

To evaluate the effectiveness of psychological therapies on pain, disability, and mood.

SEARCH STRATEGY

Randomised controlled trials (RCTs) of psychological therapy were identified by searching MEDLINE, EMBASE and Psychlit and CENTRAL from the beginning of each abstracting service until January 2008. A further search was undertaken from January 2008 to August 2008. Additional studies were identified from the reference lists of retrieved papers and from discussion with investigators.

SELECTION CRITERIA

Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. Studies were excluded if the pain was primarily headache, or was associated with a malignant disease. Studies were also excluded if the number of patients in any treatment arm was less than 10.

DATA COLLECTION AND ANALYSIS

Fifty-two studies were examined with a quality rating scale specifically designed for use with these studies. Data were extracted from 40 studies (4781 participants) by two authors. Two main classes of treatment (Cognitive Behavioural Therapy (CBT) and Behaviour Therapy (BT)), were compared with two control conditions (Treatment as Usual (TAU) and Active control (AC)), at two assessment points (immediately following treatment and six months following treatment), giving eight comparisons. For each comparison, treatment effectiveness was assessed on three outcomes: pain, disability, and mood giving a total of 24 analyses.

MAIN RESULTS

Overall there is an absence of evidence for BT, except for pain immediately following treatment compared with TAU. CBT has some small positive effects for pain, disability and mood. At present there is insufficient data on quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

AUTHORS' CONCLUSIONS

CBT and BT have weak effects in improving pain. CBT and BT have minimal effects on disability associated with chronic pain. CBT and BT are effective in altering mood outcomes, and there is some evidence that these changes are maintained at six months.

Using the Internet to provide cognitive behaviour therapy

A new treatment form has emerged that merges cognitive behaviour therapy with the Internet. By delivering treatment components, mainly in the form of texts presented via web pages, and provide ongoing support using e-mail promising outcomes can be achieved. The literature on this novel form of treatment has grown rapidly over recent years with several controlled trials in the field of anxiety disorders, mood disorders and behavioural medicine. For some of the conditions for which Internet-delivered CBT has been tested, independent replications have shown large effect sizes, for example in the treatment of social anxiety disorder. In some studies, Internet-delivered treatment can achieve similar outcomes as in face-to-face CBT, but the literature thus far is restricted mainly to efficacy trials. This article provides a brief summary of the evidence, comments on the role of the therapist and for which patient and therapist this is suitable. Areas of future research and exploration are identified.

[New information and communication technologies in the treatment of chronic pain]

OBJECTIVE

To review the literature for evidence of the effectiveness of chronic pain treatments that apply new information and communication technologies, namely, the Internet and computer-assisted treatments.

METHODS

We carried out a systematic search of the literature indexed on MEDLINE and PsycInfo.

RESULTS

Eight articles were selected. In 5, the new technologies were used to implement treatments online while in the other 3 studies technology was used to create forums for patient discussion.

CONCLUSIONS

In general the results of the studies reviewed demonstrate that treatments based on new technologies are effective and efficient and that patients hold positive attitudes toward them. However, reviewed results were not always consistent, probably because of differences in how the studies were designed.

Systematic review of back schools, brief education, and fear-avoidance training for chronic low back pain

BACKGROUND

Seven previous systematic reviews (SRs) have evaluated back schools, and one has evaluated brief education, with the latest SR including studies until November 2004. The effectiveness of fear-avoidance training has not been assessed.

PURPOSE

To assess the effectiveness of back schools, brief education, and fear-avoidance training for chronic low back pain (CLBP).

STUDY DESIGN

A SR.

METHODS

We searched the MEDLINE database of randomized controlled trials (RCT) until August 2006 for relevant trials reported in English. Assessment of effectiveness was based on pain, disability, and sick leave. RCTs that reported back schools, or brief education as the main intervention, were included. For fear-avoidance training, evaluation of domain-specific outcome was required. Two reviewers independently reviewed the studies.

RESULTS

Eight RCTs including 1,002 patients evaluated back schools, three studies were of high quality. We found conflicting evidence for back schools compared with waiting list, placebo, usual care, and exercises, and a cognitive behavioral back school. Twelve trials including 3,583 patients evaluated brief education. Seven trials, six of high quality, evaluated brief education in the clinical setting. We found strong evidence of effectiveness on sick leave and short-term disability compared with usual care. We found conflicting or limited evidence for back book or Internet discussion (five trials, two of high quality) compared with waiting list, no intervention, massage, yoga, or exercises. Three RCTs of high quality, including 364 patients, evaluated fear-avoidance training. We found moderate evidence that there is no difference between rehabilitation including fear-avoidance training and spinal fusion.

CONCLUSIONS

Consistent recommendations are given for brief education in the clinical setting, and fear-avoidance training should be considered as an alternative to spinal fusion, and back schools may be considered in the occupational setting. The discordance between reviews can be attributed differences in inclusion criteria and application of evidence rules.

Internet-administered cognitive behavior therapy for health problems: a systematic review

Cognitive-behavioral interventions are the most extensively researched form of psychological treatment and are increasingly offered through the Internet. Internet-based interventions may save therapist time, reduce waiting-lists, cut traveling time, and reach populations with health problems who can not easily access other more traditional forms of treatments. We conducted a systematic review of twelve randomized controlled or comparative trials. Studies were identified through systematic searches in major bibliographical databases. Three studies focused on patients suffering from pain, three on headache, and six on other health problems. The effects found for Internet interventions targeting pain were comparable to the effects found for face-to-face treatments, and the same was true for interventions aimed at headache. The other interventions also showed some effects, although effects differed across target conditions. Internet-delivered cognitive-behavioral interventions are a promising addition and complement to existing treatments. The Internet will most likely assume a major role in the future delivery of cognitive-behavioral interventions to patients with health problems.

Internet based HIV prevention research targeting rural MSM: feasibility, acceptability, and preliminary efficacy

Internet delivered primary prevention interventions for HIV risk reduction present significant challenges. Changing lifestyle behaviors, such as beginning to use condoms, is difficult and men seeking dates on line may want to avoid thinking about HIV risk which may lead to low initiation and high dropout rates. Many Internet delivered HIV risk reduction programs have mimicked face-to-face outreach programs, failing to take advantage of the Internet's capabilities or did not conduct evaluation. This study focuses on examining the feasibility, acceptability, and efficacy of an Internet delivered HIV risk reduction program for rural men who have sex with men (MSM). The program included online recruiting, three intervention modules, each with two sessions, online questionnaires. The intervention was developed based on iterative research and the Information-Motivation-Behavioral skills model. Participants (N = 475) were randomly assigned to one of six module orders and data were collected automatically at pre-test and after each module. Data supports the feasibility and acceptability of the program as demonstrated by good retention and rapid program completion. Knowledge, self-efficacy, outcome expectancies and motivation increase in a dose response fashion. Post-intervention behavior changes included reduced anal sex and significant increases in condom use. Limitations include a short follow-up period, a predominantly young white rural sample, and the lack of an attention control. Overall the results of the study provide support for the efficacy of Internet-based interventions to reduce risk of HIV infection. Results also support traditional research methods to evaluate HIV prevention programs delivered exclusively through the Internet.

Chronic pain and praying to a higher power: useful or useless?

In the present study a Swedish sample of 118 persons with chronic pain completed online tests on two occasions in association with treatment trials. A three item subscale measuring praying as a coping strategy was derived from the Coping Strategies Questionnaire (CSQ), but adapted to refer to "a higher power" instead of "God". Measures of pain and anxiety/depression were also included. Results revealed significant associations between praying and pain interference and impairment. Praying was also associated with anxiety and depression scores. Results also showed that prayer predicted depression scores at follow-up, and that follow-up prayer was predicted by pain interference at first measurement occasion. Overall, if prayer had any relation with the other variables it was in the negative direction of more distress being associated with more praying both concurrently and prospectively.

Developing a rehabilitation model of breast cancer patients through literature review and hospital rehabilitation programs

PURPOSE

This study aimed to develop a rehabilitation model of breast cancer patients through review of literature and available online hospital rehabilitation programs.

METHODS

Electronic searches of the literature related to rehabilitation programs of breast cancer patients in Cumulative Index to Nursing & Allied Health Literature, PubMed Clinical Queries, and Academic Search were carried out. In addition, hospital websites were reviewed for their rehabilitation programs, which in turn were reviewed and analyzed regarding their contents.

RESULTS

The four dimensions, 12 categories, and concepts related to rehabilitation of breast cancer patients were uncovered. The four dimensions were concerns and problems, types of rehabilitation, activities, and quality of life. The 12 categories consisted of 2 categories in concerns and problems, 4 categories in types of rehabilitation, 4 categories in activities, and 2 categories in quality of life. A rehabilitation model for breast cancer patients was constructed that was grounded in the four dimensions, 12 categories, and concepts.

CONCLUSION

Rehabilitation of breast cancer patients deserves special attention to achieve optimal quality of life. Health care professionals need to be educated about rehabilitation as an effective intervention.

Evidence-informed management of chronic low back pain with back schools, brief education, and fear-avoidance training

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Internet methods for delivering behavioral and health-related interventions (eHealth)

Emerging communications technologies allow us to potentially reach more individuals with effective health-related advice and information at a very low cost. As we begin a new era of "personalized medicine," advances in consumer health informatics will parallel and eventually merge with those being made in bioinformatics (e.g., genomic information), medical informatics (e.g., electronic medical records), and public health informatics (e.g., disease surveillance). This article discusses access, use, quality, and types of eHealth programming with a focus on the Internet as the initial instantiation of this programming. Also discussed are criteria relevant to the dissemination of eHealth programming in real-world settings. Finally, possible directions for future eHealth research are presented.

Internet-based rehabilitation for individuals with chronic pain and burnout: a randomized trial

This study investigates utilization of the Internet in the rehabilitation of people on long-term sick leave with chronic pain and/or burnout. Fifty-five people were randomly assigned to two groups: a treatment group (n = 27) that participated in a rehabilitation course over the Internet and a waiting list group (n = 28). The goals were to improve participants' health and increase quality of life, and, for those who were not on permanent disability pensions, to increase work capacity, if possible. A 20-week program, based on 19 films on different themes, was supplemented with written material and a Socratic dialogue over the Internet. Upon completion of the rehabilitation course, statistically significant improvements were observed in the treatment group in comparison to the waiting list group, for variables such as depression, pain, vitality, social function, performance problems involving work or other activities due to physical illness and the presence of stress symptoms. Thirteen of 23 individuals (57%) also increased their work capacity. The number needed to treat regarding recovering from anxiety and depression was 2. For increased work capacity, the number needed to treat was 3. Rehabilitation of people on long-term sick leave carried out over the Internet is a good complement to other rehabilitation programs.

Directions for the International Society for Research on Internet Interventions (ISRII)

In 2004, the International Society for Research on Internet Interventions (ISRII) was formed to encourage eHealth researchers to collaborate in their efforts to further the science behind developing, testing, and disseminating Web-based treatment programs. The group held its second meeting (April 2006) to clarify the Society's direction and identify key issues that need addressing in the field. These issues are identified and examined in the current paper. Given the success of using the Internet to treat a range of medical and mental health problems, and the growing need for better dissemination of health care, Internet interventions will almost certainly play a prominent role in global health. ISRII plans to provide the necessary venue to ensure the science driving this field is strong, enabling researchers to conduct the highest quality research and permitting meaningful conclusions from completed studies.

Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: a randomized, controlled trial

We evaluated the short- and long-term efficacy of a brief cognitive-behavioral therapy (CBT) for chronic temporomandibular disorder (TMD) pain in a randomized controlled trial. TMD clinic patients were assigned randomly to four sessions of either CBT (n=79) or an education/attention control condition (n=79). Participants completed outcome (pain, activity interference, jaw function, and depression) and process (pain beliefs, catastrophizing, and coping) measures before randomization, and 3 (post-treatment), 6, and 12 months later. As compared with the control group, the CBT group showed significantly greater improvement across the follow-ups on each outcome, belief, and catastrophizing measure (intent-to-treat analyses). The CBT group also showed a greater increase in use of relaxation techniques to cope with pain, but not in use of other coping strategies assessed. On the primary outcome measure, activity interference, the proportion of patients who reported no interference at 12 months was nearly three times higher in the CBT group (35%) than in the control group (13%) (P=0.004). In addition, more CBT than control group patients had clinically meaningful improvement in pain intensity (50% versus 29% showed > or =50% decrease, P=0.01), masticatory jaw function (P<0.001), and depression (P=0.016) at 12 months (intent-to-treat analyses). The two groups improved equivalently on a measure of TMD knowledge. A brief CBT intervention improves one-year clinical outcomes of TMD clinic patients and these effects appear to result from specific ingredients of the CBT.

Cognitive-Behavioral self-help for chronic pain

Cognitive behavioral self-help is a potentially cost-saving method of delivering evidence-based treatment to a wide range of chronic pain patients. This article provides a rationale for self-help and focuses on the effectiveness of self-help in the management of chronic pain, which typically includes some degree of lay leader or professional facilitation. The evidence for these treatments is generally positive (e.g., reductions in pain and pain-related disability) across such illnesses as arthritis, back pain, headache, and temporomandibular joint disorders. When implementing self-help, professionals need to consider individual differences in suitability for using a self-management treatment and evaluate the outcome in the context of a stepped care approach. This article uses three case examples to illustrate the use of cognitive behavioral self-help delivered in the care of scleroderma patients.

Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: A randomized controlled trial

Sixty-four individuals with social phobia (social anxiety disorder) were assigned to a multimodal cognitive-behavioral treatment package or to a waiting list control group. Treatment consisted of a 9-week, Internet-delivered, self-help program that was combined with 2 group exposure sessions in real life and minimal therapist contact via e-mail. Results were analyzed on an intention-to-treat basis, including all randomized participants. From pre- to posttest, treated participants in contrast to controls showed significant improvement on most measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). The overall within- and between-groups effect sizes were Cohen's d = 0.87 and 0.70, respectively. Treatment gains were maintained at 1-year follow-up. The results from this study support the continued use and development of Internet-distributed, self-help programs for people diagnosed with social phobia.

Prevention of work disability due to musculoskeletal disorders: the challenge of implementing evidence

BACKGROUND

The process of returning disabled workers to work presents numerous challenges. In spite of the growing evidence regarding work disability prevention, little uptake of this evidence has been observed. One reason for limited dissemination of evidence is the complexity of the problem, as it is subject to multiple legal, administrative, social, political, and cultural challenges.

PURPOSE AND METHODS

A literature review and collection of experts' opinion is presented, on the current evidence for work disability prevention, and barriers to evidence implementation. Recommendations are presented for enhancing implementation of research results.

CONCLUSION

The current evidence regarding work disability prevention shows that some clinical interventions (advice to return to modified work and graded activity programs) and some non-clinical interventions (at a service and policy/community level but not at a practice level) are effective in reducing work absenteeism. Implementation of evidence in work disability is a major challenge because intervention recommendations are often imprecise and not yet practical for immediate use, many barriers exist, and many stakeholders are involved. Future studies should involve all relevant stakeholders and aim at developing new strategies that are effective, efficient, and have a potential for successful implementation. These studies should be based upon a clearer conceptualization of the broader context and inter-relationships that determine return to work outcomes.