Question: In patients with chronic back pain, can an Internet-based
cognitive-behavioral intervention with telephone support improve
functioning?
Design: Randomized (allocation unconcealed), unblinded, controlled
trial with 8-week follow-up.
Setting: Sweden.
Patients: 56 patients who were 18 to 65 years of age (mean age, 45
y; 63% women), had access to the Internet, were in contact with a physician,
and had back pain (i.e., lumbar, thoracic, and/or cervical pain) of
=3-month duration. Exclusion criteria were pain that resulted from
activity, need for a wheelchair or surgical treatment, and heart or vascular
disease. Duration of follow-up was
92%.
Intervention: Patients were allocated to treatment (n = 22) or a
waiting list (n = 29) for 6 weeks. The treatment required that patients read
material weekly and submit pain diaries by way of the Internet. The aim of the
program was to teach patients to identify more active ways of coping with pain
to improve functioning. The program included psychological (dealing with
unhelpful thoughts and beliefs and changing focus) and physical
(individualized, graded stretching and physical exercises) components.
Patients could use a slideshow, audio files, or a compact disc to guide them
through applied relaxation techniques. Weekly telephone conversations with a
therapist allowed patients to review the previous week's homework, ask any
questions, receive reminders, and maintain motivation.
Main outcome measures: The primary outcome measure was the Coping
Strategies Questionnaire (CSQ). Secondary outcome measures were the
Multidimensional Pain Inventory (MPI), the Pain Impairment Rating Scale
(PAIRS), and the Hospital Anxiety and Depression Scale (HADS).
Main results: Greater improvement was seen in patients in the
Internet group than in the control group with regard to the CSQ subscales of
catastrophizing, control over pain, and ability to decrease pain (Table).
Other outcomes did not differ significantly between groups.
Conclusions: In patients with chronic back pain, an Internet-based
cognitive-behavioral intervention with telephone support improved the ability
of patients to cope by reducing catastrophizing and increasing the feeling of
control over pain and the ability to decrease pain.
The authors of this study evaluated a new tool (the Internet) to deliver
cognitive behavioral therapy with the intent of enhancing patient interaction
and potentially lessening the burden on care providers. However, there was no
control group of simple waiting and there was an appreciable amount of
telephone contact with both groups, which in itself may help patients.
Furthermore, because of the limited sample size, the study may not have
detected differences in some of the outcomes. Finally, the authors did not
include typical rating scales for back pain, such as the Short Form-36
(SF-36), the Roland-Morris Disability Questionnaire, or the Oswestry
Disability Index.
Although the authors used a variety of chronic pain measures, the outcomes
that achieved significance were decreased catastrophizing, control over pain,
and ability to decrease pain. While the change was positive, before the
alleviation of pain can be considered to be clinically significant, there
needs to be approximately a 30% reduction of the pain compared with the
pre-intervention status. With use of visual analog pain-scale ratings,
significant differences were not found between the groups with regard to the
amount of change.
The take-home message is that while the patients who used the Internet did
a better job of coping with pain (less catastrophizing), there was no
substantial effect on the pain. The Internet appears to offer promise, but,
given that there had to be frequent telephone contact as a part of this study,
the value of a strictly Internet-based program was not conclusively proven. I
see no harm in this undertaking; however, the hypothesis was not proven in
such a way that I am prepared to alter my practice at the present time.