Online Pain Management Programs Improve Pain Intensity, Quality of Life in Musculoskeletal Conditions

A systematic review revealed online pain management programs significantly improved pain intensity, health-related quality of life (QoL), and depression in patients with chronic, widespread musculoskeletal conditions, according to data published in Pain Practice.¹ Investigators emphasized future research should standardize outcome measures for evaluating pain, analyze other outcome measures including cost and long-term effects, and use active control groups.

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As pain is impacted by physiological, social, and psychological factors, investigators suggested management approaches should be interdisciplinary and utilize a patient-centered biopsychosocial model, of which pain education and/or skill-based training is becoming increasingly implemented. A remote delivery of this method, due in part to the COVID-19 pandemic, expedited the uptake of this approach.²

“Face-to-face pain management programs demonstrate positive clinical outcomes in the chronic pain population by improving pain intensity and attitudes, depression, and functional disability scores,” wrote Min Tze Chew, MPhty, Faculty of Medicine and Health, The University of Sydney, Australia, and colleagues. “The effects of this modality carried out online is less known, particularly in subgroups of chronic pain.”

The effects of online pain management in this patient population were assessed in terms of pain measurements including intensity, interference, coping, and catastrophizing, as well as health-related QoL, depression, and anxiety immediately following intervention. Adverse events, patient feedback, and completion rates were collected when available.

Databases such as Scopus, PEDro, Medline, Embase, and CINAHL were searched, and 3546 studies were identified. Eligibility criteria included full-text, peer-reviewed, and published quantitative studies of patients with chronic pain, defined as more than 3 months, relating to widespread musculoskeletal conditions. Management programs that included pain education were included.

In total, 18 randomized controlled trials (RCTs) met eligibility criteria and were included. These studies had moderate methodological quality, as determined by the Effective Public Health Practice4 Project (EPHPP) quality assessment tool; however, according to the revised Cochrane risk-of-bias bool for RCTs, most had a high risk of bias (n = 12).

Most patients were female (average 83%), most were conducted in the US (n = 8), and most included participants with fibromyalgia (n = 8).

Significant improvements in pain intensity (11 studies, 1397 participants, standardized mean difference [SMD] −.30, 95% confidence interval [CI] −.50 to −.10, P =.004), health-related quality of life (8 studies, 1054 participants, SMD .41, 95% CI .08 to .75, P = .02), and depression (9 studies, 1283 participants, SMD −.32, 95% CI −.55 to −.08, P = .008).

However, the effect sizes were small and were not able to meet the respective measure’s minimal clinically important change score. Studies focused on guided interventions, defined as regular interaction with an instructor, were superior when compared with self-completed interventions.

Investigators noted some limitations, as pain is complex and requires a multi-dimensional measurement approach to represent the full pain experience. Online pain management approaches did not have a fixed set of components between studies, which contributed to heterogeneity. Further, while investigators narrowed down the participants to subgroups of chronic pain, a variability in the resultant conditions remained.

In contrast, including only specific subgroups of patients with chronic pain allowed for clearer translation of the evidence to these clinical population. The ability to perform meta-analyses for several outcome measures strengthened the study and may help direct future studies on what aspects to include in online pain management programs.

“Some other recommendations for future reviews are to include physical outcome measures and cost analysis of online pain management programs,” investigators concluded. “These additional areas are extremely relevant to the individual and to society as they affect healthcare planning and expenditure.”

References

1. ^{Chew MT, Chan C, Kobayashi S, Cheng HY, Wong TM, Nicholson LL. Online pain management programs for chronic, widespread musculoskeletal conditions: A systematic review with meta-analysis [published online ahead of print, 2023 Apr 13]. Pain Pract. 2023;10.1111/papr.13227. doi:10.1111/papr.13227}
2. ^{Davies L, Hinman RS, Russell T, Lawford B, Bennell K, Billings M, et al. An international core capability framework for physiotherapists to deliver quality care via videoconferencing: a Delphi study. J Physiother. 2021;67(4):291–7.}