Web Interventions Promote Behavioral Change in Chronic Pain Patients

Are Internet-based interventions, therapeutic Interactive Voice Response technology, and other interactive applications useful tools for promoting and supporting behavioral change in children and adults with chronic pain? The presenters of the session titled “Interactive Health and Communication Technologies for Behavioral Change in Children and Adults with Chronic Pain,” held Friday, May 7, during the American Pain Society 29th Annual Scientific Meeting explored this question, reviewing data from clinical trials that investigated the use of these technologies for management of chronic pain and relapse prevention.

Moderator Tonya M. Palermo, PhD, a pediatric psychologist and an associate professor in the Department of Anesthesiology and Peri-Operative Medicine at Oregon Health and Science University, began by defining what “eHealth” is — basically the delivery of health services and information through the Internet, but it can take so many forms and iterations, including online counseling or conferencing (use technology to bring the clinician to the patient), online “bibliotherapy” (using the Internet to deliver information to patients via static Web pages), all the way to truly interactive health and communication Web resources.

Palermo reviewed results from a study that undertook to “see what was available online for pediatric chronic pain management.” Researchers found a couple dozen websites that fit the criteria; most were static Web pages that presented one-way communication about basic information about pain and chronic pain. Clearly, there is room for improvement, provided researchers and site creators can ascertain the elements that make an effective website.

Palermo said that interactive health and communication applications are used to “supplement face-to-face care” with a clinician, but can also replace face-to-face care, be used in a “stepped care” approach (in which patients receive online intervention first, followed by in-person care based on the needs uncovered during the online interaction), and be used for “booster or maintenance care” (which uses the technology to maintain care over time).

Potential benefits of this approach outlined by Palermo included reducing the inconvenience of scheduling appointments, missing work and school, etc and reducing the barriers of distance from and/or lack of access to healthcare professionals. Barriers to care for individuals with chronic pain include poor access to these technologies.

Clearly, the time seems to be right for greater integration of these technologies into the care of patients; Palermo cited several statistics regarding the degree of penetration of broadband Internet access in the US (75% of households have a broadband connection) and the popularity of healthcare information among Internet search queries (75-80% of users have searched for eHealth information online).

Key questions and issues for online resource developers to consider:

• Do site delivery and appearance have an impact on users’ engagement and outcomes from the intervention?

• Tech costs — what can you do within your budget? Consider evidence regarding actual usefulness of specific design features before incorporating into the resource.

• What are the needs of the intended audience? Developers must conduct a needs assessment and evaluate the requirements and capabilities of intended users of the intervention (perhaps with focus groups and interviews)

• How will you transform and present content? Decide on essential technology components, sequence of treatment/level of tailoring, etc.

• Don’t skip beta and usability testing — you must gauge users’ perception of program’s ease-of-use, attractiveness, usability, etc.

This area of research and technology application is ripe for development, said Palermo because “psychological interventions for chronic pain are ideally suited for Internet interventions.” Now it’s up to the research and development community to add to the evidence base, test specific features of eHealth interventions to understand essential components, and incorporate novel and emerging areas such as social media technology, chat forums, etc.

Online interventions for arthritis

Jennifer N. Stinson, PhD, RN, CPNP, assistant professor at the University of Toronto, and a Clinician Scientist and Advance Practice Nurse in the Chronic Pain Program in the Department of Anesthesia and Pain Medicine at the Hospital for Sick Children in Toronto, discussed the development and testing of Teens Taking Charge: Managing Arthritis Online, an Internet intervention to “promote self-management and transitional care for adolescents with arthritis.”

Stinson noted that juvenile idiopathic arthritis (JIA) is the most common rheumatic condition in children, and that one of the challenges for patients, parents, and clinicians is that as children mature, they are expected to take greater responsibility for their own disease management due to growing independence and maturity. However, adherence to disease management in this population is less than optimal. One potentially effective way to overcome this challenge, said Stinson, is to refocus our efforts in healthcare to focus on disease self-management and provide more care at home, including through the use of online tools and resources.

The problem is that existing self-management programs for arthritis are limited in scope, too often directed at parents rather than children, are delivered in individual or group sessions by highly trained personnel in special clinical settings, and thus are not suitable for widespread distribution.

Online programs, such as Teens Taking Charge: Managing Arthritis Online, offer a newer, potentially more effective approach at engaging patients with chronic diseases such as JIA and encouraging them to take greater responsibility for adhering to their disease management regimen. During the early stages of development of Teens Taking Charge, results of focus groups revealed that adolescents were prepared to take on a greater self-management role but needed their parents and providers to “let go” — they also needed more knowledge of their disease and greater opportunities for social support from their peers (many didn’t know another kid with arthritis)

Researchers set about developing a multi-component, multimedia interactive program that included disease-related information, guidance on improving self-management skills, a moderated social support discussion board, “stories of hope” that featured real patients discussing challenges and successes, video clips of patients’ stories, and other elements. The program featured 12 modules for teens and two for parents that explained “the effect of arthritis on you and your family” and offered tips and advice on letting go and enabling children to take more control of disease management.

The program featured animations that explain key concepts in pain (“how we feel pain” and “things you can do to change how you feel pain”). The site provided information on meds and explained how anti-inflammatory drugs work, explained how to incorporate relaxation techniques, explored concepts in stress management, and explained how negative thinking and can adversely affect symptoms. The social support elements of the intervention included the “stories of hope” at beginning of each session, featuring peers talking about challenges of communicating, dealing with, and treating pain. Patients could also use an “ask the expert” to e-mail questions to be answered by healthcare professionals. The site included weekly quizzes for teens to test their knowledge at the end of each module.

Phase 2 of development focused on ease-of-use testing, determining whether the content provided was relevant and accurate, and other quality and user-experience factors. The developers found out from feedback that adolescents did not want to scroll down the pages to get all of the information, they the designers had to ensure that the essential information was “packed in” at the top of each page. Users also wanted the site to make greater use of diagrams, graphics, and animations.

Stinson said that data from testing revealed that the experimental group had “significantly higher disease knowledge and lower average weekly pain intensity ratings compared to the control group and high compliance with completing weekly modules.” These results show that “the Internet holds great promise as a mode for delivering psycho-educational interventions for youth with chronic health conditions.” Web programs are “a good first step in stepped care programs,” but creators “need to develop a plan for sustainability,” said Stinson. These types of interventions can also be used to educate other key stakeholders about childhood chronic illnesses (friends, teachers, etc). Further research is needed to harness the full potential of the Internet as a medium for delivering psychological treatments.

Interactive Voice Response technology

Magdalena R. Naylor, MD, PhD, professor of psychiatry at the University of Vermont College of Medicine, director of the MindBody Medicine Clinic, and associate director of the Clinical Neuroscience Research Unit in the Department of Psychiatry, next discussed the use of therapeutic Interactive Voice Response technology (IVR) and telephone interventions to reinforce the coping skills learned by patients with chronic pain during group cognitive behavioral therapy (CBT).

Naylor stated that patients with chronic pain have “altered pain processing and emotional processing, cognitive deficits, and loss of brain gray matter.” Because these changes appear to be related to the duration of pain, it’s important to address and treat pain as early as possible, and provide patient with the tools and skills to enhance their ability to cope with and decrease pain.

Research has shown that group cognitive behavioral therapy is an effective strategy for chronic pain management. However, said Naylor, “maintenance of coping skills after completing CBT is variable and patients often experience a decline in therapeutic benefit within several weeks.” One possible solution to this challenge is the use of telephone-based IVR technologies.

Naylor defined therapeutic interactive voice response as a “method for interaction between an individual and a computer through the medium of a telephone through the use of a touch-tone keypad.” An automated script poses questions following a branching logic format and the patient keys in responses.

She reviewed results from a study that looked at the use of a telephone intervention and tested if interactive voice response could be used as a tool to enhance and extend the use of coping skills that patients learned in CBT. The study also tested whether a therapeutic interactive voice response system could significantly reduce relapse into pain behavior.

The therapeutic IVR system in this study had four components: a self-monitoring 21-item daily questionnaire, a didactic skills review-maintenance enhancement intervention, guided behavioral rehearsal of pain coping skills, and monthly therapist feedback. The IVR system also featured recorded personalized message summarizing clinical progress based on the IVR daily reports.

Monthly message data analysis found strong correlation between patients’ pain level and coping skills; pain and daily relaxation practice; sleep quality and activity level; pain vs. catastrophizing, depression, and perception of control. Seventy percent participants reported using five or more coping strategies per day; therapeutic IVR reinforced what patients learned in group therapy.

These and other results indicate that IVR is a valuable technology for patient self-directed treatment and can be used as a therapeutic tool to enhance and extend the coping skills that patients learn in group CBT. IVR interventions reduce significant relapse into pain behaviors and may also help reduce medication use.