Am Fam Physician. 2024;109(4):314-315
Author disclosure: No relevant financial relationships.
Clinical Question
Does remote delivery of psychological therapies reduce pain and disability and improve quality of life in adults with chronic pain?
Evidence-Based Answer
Remotely delivered cognitive behavior therapy reduces pain intensity and improves functional ability compared with treatment as usual.1 (Strength of Recommendation: B, moderate-quality evidence from randomized controlled trials.) However, the benefit does not persist at follow-up, and more research is needed to assess other forms of therapy, such as acceptance and commitment therapy, and the effectiveness of psychotherapy as an adjunct treatment.
Practice Pointers
Chronic pain affects the daily life and work of more than 20% of the U.S. population.2 People with chronic pain are at greater risk of depression, dementia, substance abuse, and suicide.3 A previous Cochrane review demonstrated that face-to-face psychotherapy results in sustained improvement in chronic pain.4 Addressing chronic pain may also require a multidisciplinary approach that includes psychotherapy.5
This Cochrane review evaluated whether remote delivery of psychotherapy improves pain, disability, and quality of life and whether it causes any unintended harm.1 The review included 32 randomized controlled trials and 4,924 patients, with studies comparing cognitive behavior therapy or acceptance and commitment therapy with treatment as usual, defined as the standard support typically available. Participants were adults with a range of chronic pain conditions, but those with headaches were excluded. The average age of participants was 24 to 67 years. Treatment duration ranged from 3 to 24 weeks. The five studies that included follow-up collected data for 3 to 12 months after the treatment ended. The authors reported the data as a standardized mean difference (SMD) because multiple outcome measures were used in the studies. A SMD of 0.2 represents a small, clinically significant difference between groups; 0.5 is a moderate difference; and 0.8 is a large difference. All the treatments studied were delivered online as stand-alone therapy and were performed in many countries, including the United States and Canada.
Online cognitive behavior therapy improved pain intensity compared with treatment as usual (SMD = −0.3; 95% CI, −0.4 to −0.2). Online therapy also improved functional disability vs. treatment as usual (SMD = −0.4; 95% CI, −0.5 to −0.2). Cognitive behavior therapy delivered remotely was more likely to provide a 30% reduction in pain intensity (number needed to treat = 8; 95% CI, 5 to 14) and a 50% improvement in pain intensity (number needed to treat = 35; 95% CI, 12 to 333) on completion compared with treatment as usual.
At assessments performed 3 to 12 months after treatment, patients who received remote therapy were no better or worse than patients who received treatment as usual. The data were insufficient to assess the value of remote therapy for quality of life or therapies other than standard cognitive behavior therapy. Very low-certainty evidence suggested that remote therapy may dramatically increase adverse effects (34% risk among patients receiving online cognitive behavior therapy vs. 6% receiving treatment as usual; RR = 6; 95% CI, 2.2 to 16.4; one study; 140 participants). It was not clear what those adverse effects were.
Guidelines recommend psychotherapy for the treatment of chronic pain but do not state whether face-to-face treatment or remote treatment is more effective.5 Research about whether remote treatments are helpful in combination with other therapies is ongoing, and further research may change these conclusions.
Editor's Note: The numbers needed to treat and associated CIs reported in this Cochrane for Clinicians were calculated by the authors based on data provided in the original Cochrane review.
The practice recommendations in this activity are available at https://www.cochrane.org/CD013863.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Department of Defense, the U.S. Navy, or the U.S. government.
