Internet-based treatment of headache: does telephone contact add anything?

Digital clinics for diagnosing and treating migraine

PURPOSE OF REVIEW

Several innovative digital technologies have begun to be applied to diagnosing and treating migraine. We reviewed the potential benefits and opportunities from delivering migraine care through comprehensive digital clinics.

RECENT FINDINGS

There are increasing applications of digitization to migraine diagnosis and management, including e-diaries, and patient self-management, especially after the COVID-19 pandemic. Digital care delivery appears to better engage chronic migraine sufferers who may struggle to present to physical clinics.

SUMMARY

Digital clinics appear to be a promising treatment modality for patients with chronic migraine. They potentially minimize travel time, shorten waiting periods, improve usability, and increase access to neurologists. Additionally, they have the potential to provide care at a much lower cost than traditional physical clinics. However, the current state of evidence mostly draws on case-reports, suggesting a need for future randomized trials comparing digital interventions with standard care pathways.

Implementing a digital solution for patients with migraine-Developing a methodology for comparing digitally delivered treatment with conventional treatment: A study protocol

Migraine is one of the most frequent and expensive neurological disease in the world. Non-pharmacological and digitally administered treatment options have long been used in the treatment of chronic pain and mental illness. Digital solutions increase the patients' possibilities of receiving evidence-based treatment even when conventional treatment options are limited. The main goal of the study is to assess the efficacy of interdisciplinary digital interventions compared to conventional treatment. The maximum number of participants in this multi-centre, open-label, prospective, randomized study is 600, divided into eight treatment groups. The participants will take part in either a conventional or a digital intervention, performing various tests and interdisciplinary tasks. The primary outcome is expected to be a reduction in the number of headache days. We also undertake to measure various other headache-related burdens as a secondary outcome. The sample size, digital interventions not conducted via video calls, the lack of human connection, limited intervention program, and the conducting of studies only in digitally sophisticated countries are all significant limitations. However, we believe that digitally mediated treatment options are at least as effective as traditional treatment options while also allowing for a significantly higher patient throughput. The future of chronic disease treatment is remote monitoring and high-quality digitally mediated interventions.The study is approved by the Ethics Committee of the University of Tartu for Human Research (Permission No. 315T-17, 10.08.2020) and is registered at ClinicalTrials.gov: NTC05458817 (14.07.2022).

Scheduled Support Versus Support on Demand in Internet-Delivered Cognitive Behavioral Therapy for Social Anxiety Disorder: Randomized Controlled Trial

Objectives

Clinician-supported internet-delivered cognitive behavioral therapy (ICBT) can be an effective treatment option when treating social anxiety disorder (SAD). Unguided ICBT is often found to be less effective. One possible solution to reduce the costs of clinician support is to provide support on demand. In this format of guidance, participants have the option to contact their clinician if needed. In a few studies, this mode of support has been compared favorably to scheduled support.

Method

Participants in a previously reported controlled trial on SAD who had been in a waitlist control group were randomly allocated to ICBT with either on-demand guidance or scheduled weekly therapist guidance. A total of 99 participants were included. Data were collected weekly on the primary outcome measure, the Liebowitz Social Anxiety Scale self-report (LSAS-SR), and at pre- and post-treatment for secondary measures. Data were analyzed in accordance with the intention-to-treat principle using mixed-effects models.

Results

Both groups improved significantly during the treatment according to the LSAS-SR ratings. The groups did not differ in their estimated change during the treatment period, with a between-group effect of d = 0.02, 95% CI [-0.37, 0.43]. Both groups experienced similar improvement also on the secondary outcome measures, with small between-group effect sizes on all outcomes.

Conclusions

The findings indicate that support on demand can be an effective way of providing guidance in ICBT for SAD, although more research on this topic is needed. A limitation of the study is that it was conducted in 2009, and the findings were in the file drawer. Subsequent published studies support our initial findings, but more research is needed.

Ecological momentary assessment and applied relaxation: Results of a randomized indicated preventive trial in individuals at increased risk for mental disorders

Applied Relaxation (AR) is an established behavioral mental health intervention, but its efficacy in real life contexts remains unclear. Using randomized controlled trial data, we examined whether AR can effectively reduce mental health problems in daily life. A sample of 277 adults with increased psychopathological symptoms but without 12-month DSM-5 mental disorders at study entry was randomly assigned to an intervention group receiving AR training (n = 139) and an assessment-only control group (n = 138). Ecological momentary assessments were used to assess psychological outcomes in daily life over a period of seven days at baseline, post, and 12-month follow-up, respectively. Multilevel analyses indicated that all psychopathological symptoms decreased more in the intervention group than in the control group from baseline to post (range β = -0.31 for DASS-depression to β = -0.06 for PROMIS-anger). However, from post to follow-up, psychopathological symptoms decreased more in the control group than in the intervention group, so that only the intervention effects for PROMIS-depression (β = -0.10) and PROMIS-anger (β = -0.09) remained until follow-up. Moreover, positive affect (β = 0.19), internal control beliefs (β = 0.15), favorable coping (β = 0.60), and unfavorable coping (β = -0.41) improved more in the intervention group than in the control group, and these effects were mostly maintained in the long term. Some effects were stronger among women, older individuals, and individuals with higher initial symptoms. These findings suggest that AR can effectively reduce mental health problems in daily life. Trial registration. The trial has been registered at ClinicalTrials.gov (NCT03311529).

Effectiveness of eHealth therapeutic education interventions in the management of fibromyalgia: protocol for a systematic review and meta-analysis

INTRODUCTION

Non-pharmacological approaches have shown promising results in improving symptoms and quality of life of patients with fibromyalgia. However, these approaches may not be easily accessible or feasible for everyone. eHealth interventions may offer a more convenient and cost-effective approach to reach a wider range of patients with fibromyalgia and improve their outcomes. As eHealth tools become more prevalent in clinical practice, it is crucial to understand their effectiveness, limitations and how they can be integrated into standard care to optimise clinical outcomes. This systematic review aims to evaluate the effectiveness of eHealth therapeutic education interventions in managing fibromyalgia.

METHODS AND ANALYSIS

Randomised controlled trials including eHealth therapeutic education interventions for individuals ≥18 years old with fibromyalgia, published in English or Spanish, will be retrieved by searching the databases PubMed, CINAHL Plus, EMBASE, Scopus, ISI Web of Science, PsycINFO and the Cochrane Central Register of Controlled Trials. Covidence software will be used for the selection of studies and data extraction. The risk of bias and the certainty of evidence will be assessed using the Cochrane Risk of Bias Assessment tool. We plan to perform a meta-analysis contingent on the number of studies retrieved and the interstudy heterogeneity, which will be explored with I2 statistics.

ETHICS AND DISSEMINATION

This protocol and the subsequent systematic review will not collect individual-level data and do not require approval by an ethical committee. We intend to disseminate the study results via peer-reviewed scientific journals and relevant (inter)national conferences.

PROSPERO REGISTRATION NUMBER

CRD42022343373.

Efficacy of computer- and/or internet-based cognitive-behavioral guided self-management for depression in adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Depression is a worldwide disease. CBT-based self-help treatment allows patients with mild to moderate depression symptoms to improve their depression or to bridge the waiting- or pandemic period until they receive further clinical treatment.

OBJECTIVE

This systematic review and meta-analysis aims to explore the efficacy, acceptability and improvement in quality of life of computer-delivered and/or internet-based CBT self-help interventions with minimal guidance (up to 10 min) for depression. The second aim was to compare the effectiveness of reducing depression symptoms at post-treatment of treatment by the type of minimal guidance: (1) e-mail, (2) telephone calls, (3) e-mail and telephone together, or (4) face-to-face.

METHODS

The Cochrane depression, anxiety, and neurosis review group's specialized register electronic searches, grey literature, reference lists and correspondence were used to search for published and unpublished RCTs that reported efficacy of computer- and/or internet-based CBT self-help treatments for depression with minimal guidance up to 10 min per week. Methodological quality of included studies was evaluated with Cochrane Collaboration tools for assessing risk of bias. The meta-analysis was accomplished using the RevMen software.

RESULTS

In total, 2809 study abstracts were checked for eligibility. Out of these, 19 studies (21 samples) with a total of 3226 participants were included. The results showed that concerning efficacy, the treatment group is superior to the control group with a medium to large effect size of 0.65. Also, treatment groups with combined guidance by e-mail and telephone calls together had greater effects (SMD -0.76) than groups with other types of minimal guidance (guided by e-mail SMD -0.63; guided face to-face SMD - 0.66; guided by telephone calls SMD -0.49). Findings showed also, that iCBT with minimal guidance had small but statistically significant effect size of 0.28 in improving quality of life. Moreover, there were higher drop-out rates in the treatment condition (RR 1.36) than in the control groups.

CONCLUSIONS

The results of this meta-analysis support the efficacy of computer- and/or internet-based CBT self-help programs with minimal weekly guidance up to only 10 min for improving depression symptoms at post-treatment for adults. In addition, the results are pointing towards two practical implications. Firstly, depressed persons can use self-help treatment with minimal guidance at home to improve their symptoms or to bridge the waiting time - or pandemic period - before they receive professional face-to-face treatment. Secondly, it can help clinicians to make the decision about using CBT-based self-help treatments for patients that do not need urgent professional treatment, or to combine it with face-to-face therapy.

Guided internet-based cognitive-behavioral therapy for patients with chronic pain: A meta-analytic review

BACKGROUND

Chronic pain has a large individual and societal burden. Previous reviews have shown that internet-based cognitive-behavioral therapy (iCBT) can support patients' pain coping. However, factors related to participant experience of iCBT and effective and safe iCBT delivery for chronic pain have not recently been summarized.

OBJECTIVE

The aim of this review was to give an overview of the efficacy of guided iCBT for chronic pain on psychological, physical, and impact on daily life outcomes, including factors that inform optimal delivery.

METHODS

Cochrane, Emcare, Web of Science, PubMed, PsycINFO, and Embase were systematically searched from inception to 11 February 2022. Randomized controlled trials on guided iCBTs for adults with chronic pain were included with a broad range of outcomes.

RESULTS

The search yielded 7406 studies of which 33 studies were included totaling 5133 participants. ICBT was more effective than passive control conditions for psychological (ES = 0.34-0.47), physical (ES = 0.26-0.29), and impact outcomes (ES = 0.38-0.41). ICBT was more effective than active control conditions for distress (ES = 0.40), pain acceptance (ES = 0.15), and pain interference after outlier removal (ES = 0.30). Longer treatments were associated with larger effects for anxiety and quality of life than shorter treatments. Mode of therapist contact (synchronous, asynchronous or a mix of both) was not related to differences in effect sizes in most outcomes. However, studies with mixed and synchronous contact modes had higher effects on pain self-efficacy than studies with asynchronous contact modes. Treatment satisfaction was high and adverse events were minor. Dropout was related to time, health, technical issues, and lack of computer skills.

CONCLUSIONS

Guided iCBT is an effective and potentially safe treatment for chronic pain. Future research should more consistently report on iCBT safety and detail the effectiveness of individual treatment components to optimize iCBT in clinical practice.

Internet-Delivered Cognitive Behavioral Therapy for Insomnia Comorbid With Chronic Pain: Randomized Controlled Trial

Background

Patients with chronic pain often experience insomnia symptoms. Pain initiates, maintains, and exacerbates insomnia symptoms, and vice versa, indicating a complex situation with an additional burden for these patients. Hence, the evaluation of insomnia-related interventions for patients with chronic pain is important.

Objective

This randomized controlled trial examined the effectiveness of internet-based cognitive behavioral therapy for insomnia (ICBT-i) for reducing insomnia severity and other sleep- and pain-related parameters in patients with chronic pain. Participants were recruited from the Swedish Quality Registry for Pain Rehabilitation.

Methods

We included 54 patients (mean age 49.3, SD 12.3 years) who were randomly assigned to the ICBT-i condition and 24 to an active control condition (applied relaxation). Both treatment conditions were delivered via the internet. The Insomnia Severity Index (ISI), a sleep diary, and a battery of anxiety, depression, and pain-related parameter measurements were assessed at baseline, after treatment, and at a 6-month follow-up (only ISI, anxiety, depression, and pain-related parameters). For the ISI and sleep diary, we also recorded weekly measurements during the 5-week treatment. Negative effects were also monitored and reported.

Results

Results showed a significant immediate interaction effect (time by treatment) on the ISI and other sleep parameters, namely, sleep efficiency, sleep onset latency, early morning awakenings, and wake time after sleep onset. Participants in the applied relaxation group reported no significant immediate improvements, but both groups exhibited a time effect for anxiety and depression at the 6-month follow-up. No significant improvements on pain-related parameters were found. At the 6-month follow-up, both the ICBT-i and applied relaxation groups had similar sleep parameters. For both treatment arms, increased stress was the most frequently reported negative effect.

Conclusions

In patients with chronic pain, brief ICBT-i leads to a more rapid decline in insomnia symptoms than does applied relaxation. As these results are unique, further research is needed to investigate the effect of ICBT-i on a larger sample size of people with chronic pain. Using both treatments might lead to an even better outcome in patients with comorbid insomnia and chronic pain.

Trial Registration

ClinicalTrials.gov NCT03425942; https://clinicaltrials.gov/ct2/show/NCT03425942

A Biofeedback App for Migraine: Development and Usability Study

Background

Biofeedback is effective in treating migraines. It is believed to have a beneficial effect on autonomous nervous system activity and render individuals resilient to stressors that may trigger a migraine. However, widespread use of biofeedback is hampered by the need for a trained therapist and specialized equipment. Emerging digital health technology, including smartphones and wearables (mHealth), enables new ways of administering biofeedback. Currently, mHealth interventions for migraine appear feasible, but development processes and usability testing remain insufficient.

Objective

The objective of this study was to evaluate and improve the feasibility and usability of an mHealth biofeedback treatment app for adults with migraine.

Methods

In a prospective development and usability study, 18 adults with migraine completed a 4-week testing period of self-administered therapist-independent biofeedback treatment consisting of a smartphone app connected to wearable sensors (Cerebri, Nordic Brain Tech AS). The app included biofeedback training, instructions for self-delivery, and a headache diary. Two wearable sensors were used to measure surface electromyographic voltage at the trapezius muscle and peripheral skin temperature and heart rate at the right second fingertip. Participants were instructed to complete a daily headache diary entry and biofeedback session of 10 minutes duration. The testing period was preceded by a preusability expectation interview and succeeded by a postusability experience interview. In addition, an evaluation questionnaire was completed at weeks 2 and 4. Adherence was calculated as the proportion of 10-minute sessions completed within the first 28 days of treatment. Usability and feasibility were analyzed and summarized quantitatively and qualitatively.

Results

A total of 391 biofeedback sessions were completed with a median of 25 (IQR 17-28) per participant. The mean adherence rate was 0.76 (SD 0.26). The evaluation questionnaire revealed that functionality and design had the highest scores, whereas engagement and biofeedback were lower. Qualitative preexpectation analysis revealed that participants expected to become better familiar with physical signals and gain more understanding of their migraine attacks and noted that the app should be simple and understandable. Postusability analysis indicated that participants had an overall positive user experience with some suggestions for improvement regarding the design of the wearables and app content. The intervention was safe and tolerable. One case of prespecified adverse events was recorded in which a patient developed a skin rash from the sticky surface electromyography electrodes.

Conclusions

The app underwent a rigorous development process that indicated an overall positive user experience, good usability, and high adherence rate. This study highlights the value of usability testing in the development of mHealth apps.

Demanding and effective: participants' experiences of internet-delivered prolonged exposure provided within two months after exposure to trauma

Background: The use of remotely delivered early intervention after trauma may prevent and/or reduce symptoms of post-traumatic stress. Our research group evaluated a novel three-week therapist-guided internet-delivered intervention based on prolonged exposure (Condensed Internet-Delivered Prolonged Exposure; CIPE) in a pilot trial. The results indicated that the intervention was feasible, acceptable and reduced symptoms of post-traumatic stress at post-intervention compared to a waiting-list condition. Exposure to traumatic memories can be emotionally demanding and there is a need for detailed investigation of participants' experiences in receiving this type of intervention remotely. Objective: Investigate participants' experiences of receiving CIPE early after trauma. Method: In this study, qualitative thematic analysis was used and semi-structured interviews with 11 participants six months after intervention completion were conducted. All interviews were audio-recorded and transcribed verbatim. Results: One overarching theme labelled as 'demanding and effective' was identified. Participants expressed that treatment effects could only be achieved by putting in a lot of effort and by being emotionally close to the trauma memory during exposure exercises. Participants reported CIPE to be a highly credible- and educative intervention that motivated them to fully engage in exposure exercises. The most distressing parts of the intervention was perceived as tolerable and important to do to heal psychologically after trauma. For many participants, the possibility to engage in the intervention whenever and where it suited them was helpful, although some participants described it as challenging to find a balance between their own responsibility and when to expect therapist support. The internet-based format was perceived as a safe forum for self-disclosure that helped some participants overcome avoidance due to shame during imaginal exposure. Conclusion: CIPE was considered demanding, yet effective by the interviewed participants. The most distressing parts of the intervention was perceived to be the most important and were tolerable and feasible to provide online.

Effectiveness of Hands-Off Therapy in the Management of Primary Headache: A Systematic Review and Meta-Analysis

A number of hands-off therapies have been widely reported and are used in the management of headache. This systematic review and meta-analysis aimed to assess evidence supporting these therapies on selected headache outcomes. A systematic literature search for randomized clinical trials reporting on the effects of hands-off therapies for headache was performed in two electronic databases; PubMed and Web of Science (PROSPERO: CRD42018093559). Risk of bias was assessed using the Cochrane risk of bias tool. Meta-analysis was performed using Review Manager v5.4. Thirty-five studies, including 3,403 patients with migraine, tension-type or chronic headaches were included in the review. Methodological quality of the studies ranged from poor to good. Result-synthesis revealed moderate evidence for aerobic exercises, relaxation training and pain education for reducing pain intensity and disability. Other hands-off interventions were either weak or limited in evidence. Meta-analysis of 22 studies indicated that the effect of hands-off therapies significantly differed from one another for pain intensity, disability and quality of life (p < 0.05). Relaxation training, aerobic and active/stretching exercises had significant effect on pain intensity and disability (p < 0.05). To conclude, few hands-off therapies were effective on selected headache outcomes. Evidence to support other hands-off therapies is limited by paucity of studies.

A Pilot Randomized Controlled Trial of Acceptance and Commitment Therapy Guided Self-Help for Overweight and Obese Adults High in Weight Self-Stigma

Weight self-stigma, in which individuals internalize stigmatizing messages about weight, is a prevalent problem that contributes to poor quality of life and health. This pilot randomized controlled trial evaluated acceptance and commitment therapy (ACT) guided self-help using The Diet Trap for 55 overweight/obese adults high in weight self-stigma. Participants were randomized to the ACT self-help book plus phone coaching (GSH-P; n = 17), self-help book plus email prompts only (GSH-E; n = 20), or a waitlist condition (n = 18), with online self-report assessments at baseline and posttreatment (8 weeks later). Participants reported high satisfaction ratings and engagement with the ACT self-help book, with no differences between GSH-P and GSH-E. Both GSH-P and GSH-E improved weight self-stigma relative to waitlist with large effect sizes. There were mixed findings for health outcomes. The GSH-P condition improved more on healthy eating behaviors and general physical activity, but neither ACT condition improved more than waitlist on self-reported body mass index, emotional eating, and a second measure of physical activity. Results suggest an ACT self-help book with email prompts can reduce weight self-stigma and potentially improve some health behavior outcomes. Phone coaching may provide additional benefits for generalizing ACT to diet and physical activity.

Scheduled Telephone Support for Internet Cognitive Behavioral Therapy for Depression in Patients at Risk for Dropout: Pragmatic Randomized Controlled Trial

Background

Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient.

Objective

This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression.

Methods

Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a ≥14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)–measured depressive symptoms and time spent in treatment.

Results

Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ.

Conclusions

Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice.

Trial Registration

International Standard Randomised Controlled Trial Number (ISRCTN) 55123131; http://www.isrctn.com/ISRCTN55123131.

An Online Pain Education Program for Working Adults: Pilot Randomized Controlled Trial

Background

Pain is a common public health concern, and the pain situation among the general population is serious in mainland China. Working adults commonly experience pain because of long sitting times, a lack of free time, and exercise. A lack of pain-related knowledge is also a significant factor. Educational and therapeutic programs delivered online were used more often in Western countries, and accessible programs in China are limited, especially for pain management. Therefore, we carried out an online pain education program for working adults to self-manage pain. The program was delivered through WeChat, a popular and secure social media with a large population base in China.

Objective

This study aimed to (1) provide pain-related knowledge and self-relief strategies, (2) help participants reduce pain and improve pain-related emotional well-being, and (3) explore participants’ learning performance and the acceptability of the online pain education program.

Methods

This was a randomized controlled trial. Chinese adults aged between 16 and 60 years with full-time employment, with pain in the past 6 months, and without any mental illness were recruited using snowball sampling through the internet and were randomly allocated to an experimental group and a control group in 1:1 ratio after the baseline assessment. The 4-week educational program that included basic knowledge of pain, pharmacological and nonpharmacological treatments, and related resources was provided only to the experimental group. Outcomes of pain, depression, anxiety, stress, and pain self-efficacy were measured at baseline (T0), posttreatment (T1), and 1-month follow-up (T2). Participants’ acceptability and satisfaction were explored after completing the educational program.

Results

In total, 95 eligible participants joined in the program: 47 in the experimental group and 48 in the control group. Neck and shoulder, head, and back were most commonly reported pain sites with high pain scores. Pain intensity and interference of the experimental group were significantly reduced after the educational program. Depression, anxiety, and stress clinically improved and pain self-efficacy improved after the educational program. The difference in depression, anxiety, stress, and pain self-efficacy within a group or between groups was not statistically significant; however, clinical improvements were demonstrated. A significant correlation between dosage of the intervention and pain intensity and depression was demonstrated. After completing the educational program, more than half of the participants showed acceptance of and satisfaction with the program, and they were willing to recommend the program to others.

Conclusions

Our findings highlight the significant potential of this online education program in the treatment of pain.

Trial Registration

ClinicalTrials.gov NCT03952910; https://clinicaltrials.gov/ct2/show/NCT03952910

A randomized trial of telemedicine for migraine management

Objective

To determine whether synchronous video-based telemedicine visits with specialists are feasible and to evaluate clinical effectiveness, patient perceptions, and other benefits of telemedicine visits for follow-up migraine care in a tertiary headache center.

Design

A one-year, randomized clinical trial.

Results

Fifty patients were screened and 45 entered the study (43 women, two men). Out of 96 scheduled visits, 89 were successfully conducted using telemedicine. Eighteen patients (out of 22) in the telemedicine cohort and 12 patients (out of 23) in the in-office cohort completed the study. In this small study, clinical outcomes, namely improvement in MIDAS, number of headache days, and average severity at 12 months for participants in the telemedicine group, were not different from those in the in-office group. Convenience was rated higher and visit times were shorter in the telemedicine group.

Conclusions

In this cohort of patients with severe migraine-related disability, telemedicine was a feasible mode of treatment and an effective alternative to in-office visits for follow-up migraine care. Physician productivity could be higher with telemedicine, and patients may get better access because of its convenience.

Trial Registration

This study is listed on ClinicalTrials.gov (NCT01706003).

Pain situations among working adults and the educational needs identified: an exploratory survey via WeChat

OBJECTIVES

The aim of this study is to 1) investigate the pain situation among working adults in China; 2) explore the self-initiate pain reliving strategies applied by working adults; and 3) collect people's interests and suggestions to the topics of the online pain education program.

METHODS

This is an exploratory survey through WeChat. The study was conducted from May 2018 to December 2018. Participants were recruited following the snowball sampling. In total of 664 people were recruited and 502 satisfied the criteria. SPSS was used for data analysis. Descriptive statistical analysis were used to present the utilization of pain treatments and suggested topics. Chi-square test, independent multiple logistic regression and Spearman's correlation were used to analysis the data.

RESULTS

The overall incidence of pain among the participants is 45% and higher among female (63%) than male (37%). Neck (68.72%, 4.10 ± 2.31), shoulder (62.56%, 3.78 ± 2.41) and head (49.34%, 4.23 ± 2.52) are reported as the most common and severe pain sites. Working is affected by pain and the results show that there is a negative correlation between pain intensity and work (rs = - 0.194) among the working population. Non-pharmacological treatments (55.77%) were chosen more by pain suffers. Totally 63.39% of participants show interests in the online pain education program and physical and psychological impact of pain is the most suggested topic (22.51%).

CONCLUSION

The pain prevalence is high among working adults in China. Impact of pain on work is a significant problem for the working adults. It is important to identify people at risk and deliver timely intervention to reduce pain. People showed their willingness in joining the online program. Therefore, future online pain education program can be developed.

An Evaluation of the Effectiveness of the Modalities Used to Deliver Electronic Health Interventions for Chronic Pain: Systematic Review With Network Meta-Analysis

BACKGROUND

Electronic health (eHealth) is the use of information and communication technology in the context of health care and health research. Recently, there has been a rise in the number of eHealth modalities and the frequency with which they are used to deliver technology-assisted self-management interventions for people living with chronic pain. However, there has been little or no research directly comparing these eHealth modalities.

OBJECTIVE

The aim of this systematic review with a network meta-analysis (NMA) is to compare the effectiveness of eHealth modalities in the context of chronic pain.

METHODS

Randomized controlled trials (N>20 per arm) that investigated interventions for adults with chronic pain, delivered via an eHealth modality, were included. Included studies were categorized into their primary node of delivery. Data were extracted on the primary outcome, pain interference, and secondary outcomes, pain severity, psychological distress, and health-related quality of life. Pairwise meta-analyses were undertaken where possible, and an NMA was conducted to generate indirect comparisons and rankings of modalities for reducing pain interference.

RESULTS

The search returned 18,470 studies with 18,349 being excluded (duplicates=2310; title and abstract=16,039). Of the remaining papers, 30 studies with 5394 randomized participants were included in the review. Rankings tentatively indicated that modern eHealth modalities are the most effective, with a 43% chance that mobile apps delivered the most effective interventions, followed by a 34% chance that interventions delivered via virtual reality were the most effective.

CONCLUSIONS

This systematic review with an NMA generated comparisons between eHealth modalities previously not compared to determine which delivered the most effective interventions for the reduction of pain interference in chronic pain patients. There are limitations with this review, in particular, the underrepresented nature of some eHealth modalities included in the analysis. However, in the event that the review is regularly updated, a clear ranking of eHealth modalities for the reduction of pain interference will emerge.

Adherence to Behavioral Therapy for Migraine: Knowledge to Date, Mechanisms for Assessing Adherence, and Methods for Improving Adherence

PURPOSE OF REVIEW

In other disease states, adherence to behavioral therapies has gained attention, with a greater amount of studies discussing, defining, and optimizing adherence. For example, a meta-analysis formally discussed adherence in 25 studies of CBT for 11 different disorders, with only 6 of the 25 omitting addressing or defining adherence. Many studies have discussed the use of text messages, graph-based adherence rates, and email/telephone reminders to improve adherence. This paper examined the available literature regarding adherence to behavioral therapy for migraine as well as adherence to similar therapies in other disease states. The goal of this research is to apply lessons learned from adherence to behavioral therapy for other diseases in better understanding how we can improve adherence to behavioral therapy for migraine.

RECENT FINDINGS

Treatment for migraine typically includes both pharmacologic and non-pharmacologic therapies, including progressive muscle relaxation (PMR), cognitive behavioral therapy (CBT), and biofeedback. Behavioral therapies have been shown to significantly reduce headache frequency and intensity, but high attrition rates and suboptimal adherence can undermine their efficacy. Traditionally, adherence to behavioral therapy has been defined by self-report, including paper headache diaries and assignments. In person attendance has also been employed as a method of defining and monitoring adherence. With the advent of personal electronics, measurements of adherence have shifted to include electronic-based methods such as computer-based programs and mobile-based therapies. Furthermore, some studies have taken advantage of electronic methods such as email reminders, push notifications, and other mobile-based reminders to optimize adherence. The JITA-I, a novel method of engaging individual patient adherence, has also been suggested as a possible method to improve adherence by tailoring engagement with a mobile health app-based on patient input. These novel methods may be utilized in behavioral therapy for migraine for further optimizing adherence. Few intervention studies to date have addressed the optimal ways to impact adherence to migraine behavioral therapy. Further research is required regarding adherence with behavioral therapies, specifically via mobile health interventions to better understand how to define and improve adherence via this novel forum. Once we are able to understand optimal methods of tracking adherence, we will be better equipped to understand the role of adherence in shaping outcomes for behavioral therapy in migraine.

The effectiveness of various computer-based interventions for patients with chronic pain or functional somatic syndromes: A systematic review and meta-analysis

Computer-based interventions target improvement of physical and emotional functioning in patients with chronic pain and functional somatic syndromes. However, it is unclear to what extent which interventions work and for whom. This systematic review and meta-analysis (registered at PROSPERO, 2016: CRD42016050839) assesses efficacy relative to passive and active control conditions, and explores patient and intervention factors. Controlled studies were identified from MEDLINE, EMBASE, PsychInfo, Web of Science, and Cochrane Library. Pooled standardized mean differences by comparison type, and somatic symptom, health-related quality of life, functional interference, catastrophizing, and depression outcomes were calculated at post-treatment and at 6 or more months follow-up. Risk of bias was assessed. Sub-group analyses were performed by patient and intervention characteristics when heterogeneous outcomes were observed. Maximally, 30 out of 46 eligible studies and 3,387 participants were included per meta-analysis. Mostly, internet-based cognitive behavioral therapies were identified. Significantly higher patient reported outcomes were found in comparisons with passive control groups (standardized mean differences ranged between -.41 and -.18), but not in comparisons with active control groups (SMD = -.26 - -.14). For some outcomes, significant heterogeneity related to patient and intervention characteristics. To conclude, there is a minority of good quality evidence for small positive average effects of computer-based (cognitive) behavior change interventions, similar to traditional modes. These effects may be sustainable. Indications were found as of which interventions work better or more consistently across outcomes for which patients. Future process analyses are recommended in the aim of better understanding individual chances of clinically relevant outcomes.

Mindfulness for female outpatients with chronic primary headaches: an internet-based bibliotherapy

Our aim was to investigate effectiveness of mindfulness by bibliotherapy on disability, distress, perceived pain and mindfulness in women with tension headaches and migraines. Primary headaches have been of great interest to mental health researchers because of the high prevalence, as well as significant disability and distress in the affected people. Despite the promising results of in-person treatment and some limitations that such interventions may cause, patients may be encountered with problems when using health care services. The present study is a quasi-experimental randomized design with pre-test, post-test, and control group. The study population consisted of 1396 women with migraine headache referring to headache clinic of Baqiyatallah Hospital in Tehran. Of these, 30 patients (including tboh experimental and control group) were selected by objective sampling method and were randomly assigned to the two groups. The experimental group, in addition to medical treatment as usual, was treated for a period of 8 sessions by Mindfulness-based Stress Reduction Internet-based Bibliotherapy, but the control group used only the medical treatment. The sample had no attritions. Data were collected by the four scales of (DASS-21), Migraine Disability Assessment Test (MIDAS), McGill's Short Form Questionnaire (MPQ-SF), and Mindfulness Inventory (MAAS). We used covariance analysis to analyze the findings in the measured scales. MBSR-IBB treatment had no significant effect on pain sensory dimension (P <0.44), despite improvement of mindfulness (P <0.0001). In contrast, the greatest effect was on the level of disability (P <0.0001). We observed also a significant improvement in distress (P <0.0001). In conclusion, in spite of the presence of headaches, the mindfulness improved the quality of life and reduced the level of mental distress. In addition, using the Internet-based bibliotherapy method, these services can be used with easier access, lower cost, and more flexibility.

Tailored Web-Based Interventions for Pain: Systematic Review and Meta-Analysis

BACKGROUND

Efforts have multiplied in the past decade to underline the importance of pain management. For both acute and chronic pain management, various barriers generate considerable treatment accessibility issues, thereby providing an opportunity for alternative intervention formats to be implemented. Several systematic reviews on Web-based interventions with a large emphasis on chronic pain and cognitive behavioral therapy have been recently conducted to explore the influence of these interventions on pain management However, to our knowledge, the specific contribution of tailored Web-based interventions for pain management has not been described and their effect on pain has not been evaluated.

OBJECTIVE

The primary aim of this systematic review was to answer the following research question: What is the effect of tailored Web-based pain management interventions for adults on pain intensity compared with usual care, face-to-face interventions, and standardized Web-based interventions? A secondary aim was to examine the effects of these interventions on physical and psychological functions.

METHODS

We conducted a systematic review of articles published from January 2000 to December 2015. We used the DerSimonian-Laird random effects models with 95% confidence intervals to calculate effect estimates for all analyses. We calculated standardized mean differences from extracted means and standard deviations, as outcome variables were measured on different continuous scales. We evaluated 5 different outcomes: pain intensity (primary outcome), pain-related disability, anxiety, depression, and pain catastrophizing. We assessed effects according to 3 time intervals: short term (<1 month), medium term (1-6 months), and long term (6-12 months).

RESULTS

After full-text review, we excluded 31 articles, resulting in 17 eligible studies. Only 1 study concerned acute pain and was removed from the meta-analysis, resulting in 16 studies available for quantitative assessment. Compared with standard care or a waiting list, tailored Web-based intervention showed benefits immediately after, with small effect sizes (<0.40) for pain intensity (10 randomized controlled trials [RCTs], n=1310, P=.003) and pain-related disability (6 RCTs, n=953, P<.001). No other improvements were observed at follow-up in the medium and long terms. Compared with the active control group, no improvements were found for the primary outcome (pain intensity) or any of the outcomes except for a small effect size on pain catastrophizing (2 RCTs, n=333, P<.001) immediately after the intervention.

CONCLUSIONS

Tailored Web-based interventions did not prove to be more efficacious than standardized Web-based interventions in terms of pain intensity, pain-related disability, anxiety, and depression. An interesting finding was that some efficacy was shown on pain catastrophizing compared with active control interventions. Considering the diversity of approaches used in tailored Web-based interventions for chronic pain management, their efficacy is yet to be explored. Moreover, their contribution to acute pain management is embryonic.

TRIAL REGISTRATION

International prospective register of systematic reviews (PROSPERO): CRD42015027669; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42015027669 (Archived by WebCite at http://www. webcitation.org/6uneWAuyR).

Impact of telephone prompts on the adherence to an Internet-based aftercare program for women with bulimia nervosa: A secondary analysis of data from a randomized controlled trial

INTRODUCTION

Poor adherence is a common challenge in self-directed mental health interventions. Research findings indicate that telephone prompts may be useful to increase adherence.

METHOD

Due to poor adherence in a randomized controlled trial evaluating an Internet-based aftercare program for women with bulimia nervosa we implemented regular short telephone prompts into the study protocol halfway through the trial period. Of the 126 women in the intervention group, the first 63 women were not prompted by telephone (unprompted group) and compared with 63 women who subsequently enrolled into the study and were attempted to prompt bimonthly by a research assistant (telephone prompt group). Completed telephone calls took less than 5 min and did not include any symptom-related counseling.

RESULTS

Most of the women in the telephone prompt group (67%) were reached only once or twice during the intervention period. However, overall adherence in the telephone prompt group was significantly higher than in the unprompted group (T = - 3.015, df = 124, p = 0.003).

CONCLUSION

Our findings from this secondary analysis suggest that telephone prompts can positively affect adherence to an Internet-based aftercare intervention directed at patients with bulimia nervosa.

Guided Internet-based Psycho-educational Intervention Using Cognitive Behavioral Therapy and Self-management for Individuals with Chronic Pain: A Feasibility Study

When considering barriers to chronic pain treatment, there is a need to deliver nonpharmacological therapies in a way that is accessible to all individuals who may benefit. To conduct feasibility testing using a guided, Internet-based intervention for individuals with chronic pain, a novel, Internet-based, chronic pain intervention (ICPI) was developed, using concepts proven effective in face-to-face interventions. This study was designed to assess usability of the ICPI and feasibility of conducting larger-scale research, and to collect preliminary data on effectiveness of the intervention. Data were collected at baseline, after each of the six intervention modules, and 12 weeks after intervention completion. Forty-one participants completed baseline questionnaires, and 15 completed the 12-week postintervention questionnaires. At baseline, all participants reported satisfaction with the structure of the intervention and ease of use. Internet-based platforms such as Facebook aided in accrual of participants, making further large-scale study of the ICPI feasible. There is preliminary evidence suggesting that the ICPI improves emotional function but not physical function, with a small but significant decrease in pain intensity and pain interference. Most participants felt they benefited at least minimally as a result of using the ICPI. The ICPI was well received by participants and demonstrated positive outcomes in this preliminary study. Further research with more participants is feasible and necessary to fully assess the effect of this intervention.

Protocol for a systematic review with network meta-analysis of the modalities used to deliver eHealth interventions for chronic pain

BACKGROUND

As eHealth interventions prove both efficacious and practical, and as they arguably overcome certain barriers encountered by traditional face-to-face treatment for chronic pain, their number has increased dramatically in recent times. However, there is a dearth of research that focuses on evaluating and comparing the different types of technology-assisted interventions. This is a protocol for a systematic review that aims to evaluate the eHealth modalities in the context of psychological and non-psychological (other than non-drug) interventions for chronic pain.

METHODS/DESIGN

We will search the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library), MEDLINE, Embase and PsycINFO. Randomised controlled trials (RCTs) with more than 20 participants per trial arm that have evaluated non-drug psychological or non-psychological interventions delivered via an eHealth modality and have pain as an outcome measure will be included. Two review authors will independently extract data and assess the study suitability in accordance with the Cochrane Collaboration Risk of Bias Tool. Studies will be included if they measure at least one outcome variable in accordance with the IMMPACT guidelines (i.e. pain severity, pain interference, physical functioning, symptoms, emotional functioning, global improvement and disposition). Secondary outcomes will be measures of depression and health-related quality of life (HRQoL). A network meta-analysis will be conducted based on direct comparisons to generate indirect comparisons of modalities across treatment trials, which will return rankings for the eHealth modalities in terms of their effectiveness.

DISCUSSION

Most trials that use an eHealth intervention to manage chronic pain typically use one modality. As a result, little evidence exists to support which modality type is the most effective. The current review will address this gap in the literature and compare the different eHealth modalities used for technology-assisted interventions for chronic pain. With the growing reliance and use of technology as a medium for delivering treatment for chronic conditions more generally, it is imperative that research identify the most efficacious eHealth modalities and systematically identify the most important features of such treatment types, so they may be replicated and used for research and in the provision of care.

TRIAL REGISTRATION

PROSPERO, CRD42016035595.

Electronic behavioral interventions for headache: a systematic review

BACKGROUND

There is increasing interest in using electronic behavioral interventions as well as mobile technologies such as smartphones for improving the care of chronic disabling diseases such as migraines. However, less is known about the current clinical evidence for the feasibility and effectiveness of such behavioral interventions.

OBJECTIVE

To review the published literature of behavioral interventions for primary headache disorders delivered by electronic means suitable for use outside of the clinician's office.

METHODS

An electronic database search of PubMed, PsycINFO, and Embase was conducted through December 11, 2015. All eligible studies were systematically reviewed to examine the modality in which treatment was delivered (computer, smartphone, watch and other), types of behavioral intervention delivered (cognitive behavioral therapy [CBT], biofeedback, relaxation, other), the headache type being treated, duration of treatment, adherence, and outcomes obtained by the trials to examine the overall feasibility of electronic behavioral interventions for headache.

RESULTS

Our search produced 291 results from which 23 eligible articles were identified. Fourteen studies used the internet via the computer, 2 used Personal Digital Assistants, 2 used CD ROM and 5 used other types of devices. None used smartphones or wearable devices. Four were pilot studies (N ≤ 10) which assessed feasibility. For the behavioral intervention, CBT was used in 11 (48 %) of the studies, relaxation was used in 8 (35 %) of the studies, and biofeedback was used in 5 (22 %) of the studies. The majority of studies (14/23, 61 %) used more than one type of behavioral modality. The duration of therapy ranged from 4-8 weeks for CBT with a mean of 5.9 weeks. The duration of other behavioral interventions ranged from 4 days to 60 months. Outcomes measured varied widely across the individual studies.

CONCLUSIONS

Despite the move toward individualized medicine and mHealth, the current literature shows that most studies using electronic behavioral intervention for the treatment of headache did not use mobile devices. The studies examining mobile devices showed that the behavioral interventions that employed them were acceptable to patients. Data are limited on the dose required, long term efficacy, and issues related to the security and privacy of this health data. This study was registered at the PROSPERO International Prospective Register of Systematic Reviews (CRD42015032284) (Prospero, 2015).

Psychological interventions for migraine: a systematic review

Migraine causes major health impairment and disability. Psychological interventions offer an addition to pharmacotherapy but they are not currently recommended by the National Institute of Clinical Excellence (NICE) or available in the National Health Service. We aimed to systematically review evidence on the efficacy of psychological interventions for migraine in adults. A search was done of MEDLINE, psychINFO, http://www.opengrey.eu , the meta-register of controlled trials and bibliographies. Twenty-four papers were included and rated independently by two people using the Yates scale, which has 35 points. Cochrane recommendations are that high quality reports score above the mid-point (18 points). Methods used in 17/24 papers were rated 'high quality'. However, frequently descriptions of key areas such as randomisation methods were omitted. Eighteen studies measured effects of psychological interventions on headache-related outcomes, fifteen reporting significant improvements, ranging 20-67 %. Interventions also produced improvements in psychological outcomes. Few trials measured or reported improvement in disability or quality of life. We conclude that evidence supports the efficacy of psychological interventions in migraine. Over half of the studies were from the USA, which did not provide universal health care at the time of the study, so it is difficult to generalise results to typical populations in receipt of publically funded health services. We agree with the NICE recommendation that high quality pragmatic randomised controlled trials are needed in the UK.

Internet interventions for chronic pain including headache: A systematic review

Chronic pain is a major health problem and behavioral based treatments have been shown to be effective. However, the availability of these kinds of treatments is scarce and internet-based treatments have been shown to be promising in this area. The objective of the present systematic review is to evaluate internet-based interventions for persons with chronic pain. The specific aims are to do an updated review with a broad inclusion of different chronic pain diagnoses and to assess disability and pain and also measures of catastrophizing, depression and anxiety. A systematic search identified 891 studies and 22 trials were selected as eligible for review. Two of the selected trials included children/youth and five included individuals with chronic headache and/or migraine. The most frequently measured domain reflected in the primary outcomes was interference/disability, followed by catastrophizing. Result across the studies showed a number of beneficial effects. Twelve trials reported significant effects on disability/interference outcomes and pain intensity. Positive effects were also found on psychological variable such as catastrophizing, depression and anxiety. Several studies (n = 12) were assessed to have an unclear level of risk bias. The attrition levels ranged from 4% to 54% where the headache trials had the highest drop-out levels. However, findings suggest that internet-based treatments based on cognitive behavioural therapy (CBT) are efficacious measured with different outcome variables. Results are in line with trials in clinical settings. Meta-analytic statistics were calculated for interference/disability, pain intensity, catastrophizing and mood ratings. Results showed that the effect size for interference/disability was Hedge's g = - 0.39, for pain intensity Hedge's g = - 0.33, for catastrophizing Hedge's g = - 0.49 and for mood variables (depression) Hedge's g = - 0.26.

Internet-Delivered Psychological Treatments

During the past 15 years, much progress has been made in developing and testing Internet-delivered psychological treatments. In particular, therapist-guided Internet treatments have been found to be effective for a wide range of psychiatric and somatic conditions in well over 100 controlled trials. These treatments require (a) a secure web platform, (b) robust assessment procedures, (c) treatment contents that can be text based or offered in other formats, and (d) a therapist role that differs from that in face-to-face therapy. Studies suggest that guided Internet treatments can be as effective as face-to-face treatments, lead to sustained improvements, work in clinically representative conditions, and probably are cost-effective. Despite these research findings, Internet treatment is not yet disseminated in most places, and clinical psychologists should consider using modern information technology and evidence-based treatment programs as a complement to their other services, even though there will always be clients for whom face-to-face treatment is the best option.

A New Zealand pilot randomized controlled trial of a web-based interactive self-management programme (MSInvigor8) with and without email support for the treatment of multiple sclerosis fatigue

Objective:

To pilot and compare the efficacy of an internet-based cognitive behavioural therapy self-management programme with (MSInvigor8-Plus) and without (MSInvigor8-Only) the use of email support in reducing fatigue severity and impact (primary outcomes), and depressed and anxious mood (secondary outcomes).

Design:

Randomized controlled trial using an independent randomization system built into the website and intention-to-treat analysis.

Setting:

Participants were recruited through the local Multiple Sclerosis Society and hospital neurological services in New Zealand.

Subjects:

A total of 39 people (aged 31–63 years), experiencing multiple sclerosis fatigue, able to walk with and without walking aids, were randomized to MSInvigor8-Only ( n = 20) or to MSInvigor8-Plus ( n = 19).

Interventions:

MSInvigor8 is an eight-session programme based on cognitive behaviour therapy principles including psycho-education, self-monitoring, and changing unhelpful activity and thought patterns.

Main measures:

Outcome measures included fatigue severity (Chalder Fatigue Scale) and impact (Modified Fatigue Impact Scale), and anxiety and depression (Hospital Anxiety and Depression Scale). Assessments were performed at baseline and at 10 weeks.

Results:

The MSInvigor8-Plus condition resulted in significantly greater reductions in fatigue severity ( F [1,36] = 9.09, p < 0.01) and impact ( F [1,36] = 6.03, p < 0.02) compared with the MSInvigor8-Only condition. Large between-group effect sizes for fatigue severity ( d = 0.99) and fatigue impact ( d = 0.81) were obtained. No significant differences were found between the groups on changes in anxiety and depression.

Conclusions:

MSInvigor8 delivered with email-based support is a potentially promising, acceptable, and cost-effective approach to treating fatigue in people with multiple sclerosis in New Zealand.

The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial

Background: Internet-based cognitive therapy with monitoring via text messages (mobile CT), in addition to treatment as usual (TAU), might offer a cost-effective way to treat recurrent depression. Method: Remitted patients with at least 2 previous episodes of depression were randomized to mobile CT in addition to TAU (n = 126) or TAU only (n = 113). A linear mixed model was used to examine the effect of the treatment condition on a 3-month course of depressive symptoms after remission. Both an intention-to-treat analysis (n = 239) and a completer analysis (n = 193) were used. Depressive symptoms were assessed using the Inventory of Depressive Symptomatology (IDS-SR₃₀) at baseline and 1.5 and 3 months after randomization. Results: Residual depressive symptoms showed a small but statistically significant decrease in the intention-to-treat group over 3 months in the mobile CT group relative to the TAU group (difference: -1.60 points on the IDS-SR₃₀ per month, 95% CI = -2.64 to -0.56, p = 0.003). The effect of the treatment condition on the depressive symptomatology at the 3-month follow-up was small to moderate (Cohen's d = 0.44). All analyses among completers (≥5 modules) showed more pronounced treatment effects. Adjustment for unequally distributed variables did not markedly affect the results. Conclusions: Residual depressive symptoms after remission showed a more favorable course over 3 months in the mobile CT group compared to the TAU group. These results are a first indication that mobile CT in addition to TAU is effective in treating recurrently depressed patients in remission. However, demonstration of its long-term effectiveness and replication remains necessary. © 2015 S. Karger AG, Basel.

Outcomes for patients with the same disease treated inside and outside of randomized trials: a systematic review and meta-analysis

BACKGROUND

It is unclear whether participation in a randomized controlled trial (RCT), irrespective of assigned treatment, is harmful or beneficial to participants. We compared outcomes for patients with the same diagnoses who did ("insiders") and did not ("outsiders") enter RCTs, without regard to the specific therapies received for their respective diagnoses.

METHODS

By searching the MEDLINE (1966-2010), Embase (1980-2010), CENTRAL (1960-2010) and PsycINFO (1880-2010) databases, we identified 147 studies that reported the health outcomes of "insiders" and a group of parallel or consecutive "outsiders" within the same time period. We prepared a narrative review and, as appropriate, meta-analyses of patients' outcomes.

RESULTS

We found no clinically or statistically significant differences in outcomes between "insiders" and "outsiders" in the 23 studies in which the experimental intervention was ineffective (standard mean difference in continuous outcomes -0.03, 95% confidence interval [CI] -0.1 to 0.04) or in the 7 studies in which the experimental intervention was effective and was received by both "insiders" and "outsiders" (mean difference 0.04, 95% CI -0.04 to 0.13). However, in 9 studies in which an effective intervention was received only by "insiders," the "outsiders" experienced significantly worse health outcomes (mean difference -0.36, 95% CI -0.61 to -0.12).

INTERPRETATION

We found no evidence to support clinically important overall harm or benefit arising from participation in RCTs. This conclusion refutes earlier claims that trial participants are at increased risk of harm.

Medium-term effectiveness of online behavioral training in migraine self-management: A randomized trial controlled over 10 months

AIM

This randomized, controlled trial examined the medium-term effectiveness of online behavioral training in migraine self-management (oBT; N = 195) versus waitlist control (WLC; N = 173) on attack frequency, indicators of self-management (primary outcomes), headache top intensity, use of rescue medications, quality of life and disability (secondary outcomes).

METHODS

An online headache diary following the ICHD-II and questionnaires were completed at baseline (T0), post-training (T1) and six months later (T2). Missing data (T1: 24%; T2: 37%) were handled by multiple imputation. We established effect sizes (ES) and tested between-group differences over time with linear mixed modelling techniques based on the intention-to-treat principle.

RESULTS

At T2, attack frequency had improved significantly in oBT (-23%, ES = 0.66) but also in WLC (-19%; ES = 0.52). Self-efficacy, internal and external control in migraine management--and triptan use--improved only in oBT, however. This indicates different processes in both groups and could signify (the start of) active self-management in oBT. Also, only oBT improved migraine-specific quality of life to a sizable extent.

CONCLUSIONS

oBT produced self-management gains but could not account for improved attack frequency, because WLC improved as well. The perspective that BT effects develop gradually, and that online delivery will boost BT outreach, justifies further research.

Internet-based cognitive behavioral therapy for patients with chronic somatic conditions: a meta-analytic review

Background

Patients with chronic somatic conditions face unique challenges accessing mental health care outside of their homes due to symptoms and physical limitations. Internet-based cognitive behavioral therapy (ICBT) has shown to be effective for various psychological conditions. The increasing number of recent trials need to be systematically evaluated and quantitatively analyzed to determine whether ICBT is also effective for chronic somatic conditions and to gain insight into the types of problems that could be targeted.

Objective

Our goal was to describe and evaluate the effectiveness of guided ICBT interventions for chronic somatic conditions on general psychological outcomes, disease-related physical outcomes, and disease-related impact on daily life outcomes. The role of treatment length was also examined.

Methods

PubMed, PsycINFO, and Embase were searched from inception until February 2012, by combining search terms indicative of effect studies, Internet, and cognitive behavioral therapy. Studies were included if they fulfilled the following six criteria: (1) randomized controlled trial, (2) Internet-based interventions, (3) based on cognitive behavioral therapy, (4) therapist-guided, (5) adult (≥18 years old) patients with an existing chronic somatic condition, and (6) published in English. 23 randomized controlled trials of guided ICBT were selected by 2 independent raters after reviewing 4848 abstracts. Demographic, clinical, and methodological variables were extracted. Standardized mean differences were calculated between intervention and control conditions for each outcome and pooled using random effects models when appropriate.

Results

Guided ICBT was shown to improve all outcome categories with small effect sizes for generic psychological outcomes (effect size range 0.17-0.21) and occasionally larger effects for disease-specific physical outcomes (effect size range 0.07 to 1.19) and disease-related impact outcomes (effect size range 0.17-1.11). Interventions with a longer treatment duration (>6 weeks) led to more consistent effects on depression.

Conclusions

Guided ICBT appears to be a promising and effective treatment for chronic somatic conditions to improve psychological and physical functioning and disease-related impact. The most consistent improvements were found for disease-specific outcomes, which supports the possible relevance of tailoring interventions to specific patient groups. Explorative analyses revealed that longer treatment length holds the promise of larger treatment effects for the specific outcome of depression. While the current meta-analysis focused on several chronic somatic conditions, future meta-analyses for separate chronic somatic conditions can further consolidate these results, also in terms of cost-effectiveness.

Psychological therapies (Internet-delivered) for the management of chronic pain in adults

BACKGROUND

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.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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).

MAIN RESULTS

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.

Long-term follow-up of home-based behavioral management training provided by migraine patients

BACKGROUND

Behavioral migraine approaches are effective in reducing headache attacks. Availability of treatment might be increased by using migraine patients as trainers. Therefore, Mérelle and colleagues developed and evaluated a home-based behavioral management training (BMT) by lay trainers (1). The maintenance of effects at long-term follow-up is studied in the present study.

METHOD

Measurements were taken pre-BMT (T0), post-BMT (T1), at six-month follow-up (T2), and at long-term follow-up, i.e. two to four years after BMT (T3). Data of 127 participants were analyzed with longitudinal multi-level analyses.

RESULTS

Short-term improvements in attack frequency and self-efficacy post-BMT were maintained at long-term follow-up ( DT0T3  = -.34 and DT0T3  = .69, respectively). The level of internal control that increased during BMT decreased from post-BMT to long-term follow-up ( DT0T3  = .18). Quality of life and migraine-related disability improved gradually over time ( DT0T3  = .45 and DT0T3  = -.26, respectively).

CONCLUSIONS

Although the results should be interpreted with caution because of the lack of a follow-up control group and the inability to gather information about additional treatments patients may have received during the follow-up period, the findings suggest that lay BMT for migraine may be beneficial over the long term. If so, this could make migraine treatments more widely available.

A systematic review of internet-based self-help therapeutic interventions to improve distress and disease-control among adults with chronic health conditions

The evidence base of internet-based self-help interventions has been rapidly growing for mental health conditions over the past decade. However, to date a systematic review of the application of this technology to chronic health conditions has not been reported. The objective of the present review was to therefore critically appraise the research on the efficacy of internet self-help interventions for distress and disease outcomes in adults with physical health complaints. Electronic searches were conducted in Embase, CINAHL, MEDLINE and PsychINFO, and reference lists were examined. Twenty four studies met inclusion criteria, covering 8 health conditions. Across health conditions, consistent evidence was obtained that online therapeutic interventions were efficacious in improving disease-symptoms and control, with the exception of diabetes. Mixed evidence was obtained for distress outcomes: 3 health conditions demonstrated consistent benefit (irritable bowel syndrome, tinnitus, and one heterogeneous chronic illness population); one condition obtained moderate support (chronic pain); while results were not promising for diabetes. The limited research conducted among epilepsy, cancer, and chronic fatigue precluded conclusions from being drawn. Few studies met all methodological quality criteria. This review demonstrates that internet-based self-help interventions hold guarded promise in the amelioration of distress and disease-control, and further research implications are discussed.

Self-Management of Wellness and Illness in an Aging Population

In this chapter, we review the last 10 years of literature on self-management of illnesses (acute/episodic and chronic) and wellness (e.g., health promotion). We focus on health self-management in the context of an aging population, wherein middle-aged adults are more likely to be managing wellness activities and older adults are often managing both maintenance of health and chronic illnesses. The critical issues related to self-management of health are discussed, including those imposed by health care demands and those stemming from individual differences in general abilities (e.g., motor, perception, cognition) and socioemotional characteristics. The dynamic relationship between theory and practice is highlighted. Health care demands reflect the nature of the illness or wellness activity and include managing comorbidities, symptoms, and medications; engaging in health promotion activities (e.g., exercise, diet); the required use of health technologies; the need for health-related information; and coordination of the care network. Individual differences in motor, perceptual, and cognitive abilities, as well as in the severity and complexity of the illness and the consequent demands, also impact how a person self-manages health. Cognitive abilities, such as decision making, knowledge, literacy (i.e., general, health, and e-health literacy), and numeracy are particularly implicated in the process of managing one’s own health and are especially important in the context of an aging population; therefore we give these cognitive abilities special attention in this chapter. Socioemotional characteristics, and attitudes and beliefs about one’s health, impact an individual’s self-management of health as well, impacting his or her motivation and goal-setting behaviors. Moreover, we discuss literature on interventions that have been used to improve self-management of health, and we examine the potential for technology. We conclude with guidelines for technology design and instruction, and discuss emerging themes.

Effects of an individually tailored Web-based chronic pain management program on pain severity, psychological health, and functioning

BACKGROUND

It is estimated that 30% of adults in the United States experience daily chronic pain. This results in a significant burden on the health care system, in particular primary care, and on the workplace. Chronic pain management with cognitive-behavioral psychological treatment is effective in reducing pain intensity and interference, health-related quality of life, mood, and return to work. However, the population of individuals with chronic pain far exceeds the population of therapists that can provide this care face-to-face. The use of tailored, Web-based interventions for the management of chronic pain could address limitations to access by virtue of its unlimited scalability.

OBJECTIVE

To examine the effects of a tailored Web-based chronic pain management program on subjective pain, activity and work interference, quality of life and health, and stress.

METHODS

Eligible participants accessed the online pain management program and informed consent via participating employer or health care benefit systems; program participants who completed baseline, 1-, and 6-month assessments were included in the study. Of the 645 participants, the mean age was 56.16 years (SD 12.83), most were female (447/645, 69.3%), and white (505/641, 78.8%). Frequent pain complaints were joint (249/645, 38.6%), back (218/645, 33.8%), and osteoarthritis (174/654, 27.0%). The online pain management program used evidence-based theories of cognitive behavioral intervention, motivational enhancement, and health behavior change to address self-management, coping, medical adherence, social support, comorbidities, and productivity. The program content was individually tailored on several relevant participant variables.

RESULTS

Both pain intensity (mean 5.30, SD 2.46), and unpleasantness (mean 5.43, SD 2.52) decreased significantly from baseline to 1-month (mean 4.16, SD 2.69 and mean 4.24, 2.81, respectively) and 6-month (mean 3.78, SD 2.79 and mean 3.78, SD 2.79, respectively) assessments (P<.001). The magnitude of the 6-month effects were large. Trends for decreases in pain interference (36.8% reported moderate or enormous interference) reached significance at 6 months (28.9%, P<.001). The percentage of the sample reporting fair or poor quality of life decreased significantly from 20.6% at baseline to 16.5% at 6 months (P=.006).

CONCLUSIONS

Results suggest that the tailored online chronic pain management program showed promising effects on pain at 1 and 6 months posttreatment and quality of life at 6 months posttreatment in this naturalistic study. Further research is warranted to determine the significance and magnitude of the intervention's effects in a randomized controlled trial.

Meeting them where they are: Using the Internet to deliver behavioral medicine interventions for pain

Pharmacological and interventional pain medicine treatments are emphasized in the routine treatment of chronic pain despite strong evidence for the efficacy and safety of behavioral approaches. Most medical professionals have not incorporated behavioral pain treatments into their practices. Internet-based interventions have the potential to increase clinical use of these treatments. We discuss the strengths and weaknesses of current Internet-based behavioral pain management interventions, focusing on three broad intervention categories: therapist-guided interventions, unguided (automated) interventions, and pain-relevant applications for mobile platforms. Examples of each category are discussed, revealing a high degree of variation in approaches, user interfaces, and components as well as variability in the degree to which these interventions have been subjected to empirical testing. Finally, we highlight key issues for research and clinical implementation, with the goal of advancing this field so that it can meet its potential to increase access to evidence-based behavioral medicine treatments for chronic pain.

The status of telerehabilitation in neurological applications

We systematically reviewed the evidence for the effectiveness of tele-neurorehabilitation (TNR) applications. The review included recent reports on rehabilitation for any disability associated with a neurological deficit or condition. Study quality was assessed using an approach that considered both study performance and study design. Judgements were made on whether each application had been successful, and whether further data were needed to establish the application as suitable for routine use. Nineteen credible studies that reported patient outcomes or administrative changes were identified. These studies related to 13 conditions. The focus of rehabilitation included Internet-supported treatments for management of fatigue, pain and depression; promotion of physical activity; and speech therapy. Sixteen studies were of high or good quality and three were fair to good, with some limitations. In 13 of the 19 studies the TNR application was successful in providing at least equivalent outcomes to conventional approaches. Additional work would be needed on eight applications to establish suitability for routine use, and would be desirable in five. Thus the recent literature provides further support for TNR applications, showing the promise of this field in a number of areas. However, the database of credible studies remains small.

A systematic review of minimal-contact psychological treatments for symptom management in irritable bowel syndrome

OBJECTIVE

Psychological treatments are effective in alleviating symptoms of IBS but are not widely available. The need for wider dissemination of treatments has encouraged the development of 'minimal-contact' therapies requiring fewer resources than existing psychological treatments which rely on face-to-face contact.

METHOD

Using comprehensive search terms, the Embase, Medline and PsychInfo databases (all years) were searched.

RESULTS

Twelve studies--nine RCTs and three non-controlled preliminary studies - meeting inclusion criteria were reviewed and assessed for quality using objective criteria. Apart from one study of expressive writing, all interventions were based on cognitive (and/or) behavioural principles or hypnosis and tended to be adaptations of existing therapist-led interventions. Compared to control conditions, minimal-contact interventions were efficacious, the majority of studies showing statistically significant improvements by the end of treatment. For cognitive-behaviour-therapy-based interventions effects sizes were large. The two studies that compared minimal-contact with therapist-delivered interventions broadly suggest comparable outcomes between these modalities.

CONCLUSIONS

Minimal-contact cognitive-behavioural interventions show promise in the treatment of IBS. Because of the lower quality of studies of hypnosis and those involving interventions delivered entirely remotely, further support is needed before such approaches can be recommended for widespread use. More generally, future research should use representative samples, active control conditions, and intention to treat analysis. Nonetheless, existing high quality studies suggest that minimal-contact therapies may be a safe, effective means of achieving scaleability of psychological treatments for IBS.