Are We Really Ready for Telehealth Cognitive Behavioral Therapy for Pain?

There has been an explosion of Internet-based programs and smartphone applications (apps) that have been used to track health data and that have influenced the approach to management of chronic diseases. Information andmobile communication technology is the fastest growing sector of the communication industry with dramatic performance improvements in technology, ubiquitous Internet availability, increased data transmission speed, and greater affordability of devices. This has lead to an increased availability of Internet-based programs that allow information to be accessed by interested parties everywhere and that offer interventions to a greater number of patients than could be seen individually, particularly among high-cost patients who require chronic disease management. The field of mHealth (mobile health) technology and telemedicine has gained much attention recently. Increasingly, text messaging, apps, social media, and movement monitors are being used as part of clinical treatment. In 2011, the Institute of Medicine’s report on chronic pain encouraged self-management strategies for chronic pain and implied that technology can be useful in improving access to these strategies. Clinicians have focused on overcoming the barriers of making mHealth programs available and accessible to all individuals with pain, including children, adolescents, the elderly, those with lower household incomes, and individuals in rural environments who do not have access to local specialty care. There is strong evidence that electronic monitoring and Internet-based education can be superior in many ways to paper diaries and self-help books with respect to compliance, user-friendliness, and patient satisfaction. Indeed,momentary electronic assessmentmethodswith ratings of current symptoms are better than retrospective assessments (eg, minimization of recall bias) and are generally considered to be “state-of-the-art”measures for evaluation of pain and other health-related outcomes. A recent review article by the Commonwealth Fund evaluated mHealth programs designed to activate patients to change behavior. They suggested that levels of engagement increases when Internet-based programs can offer guidance based on information entered by the user and communication and support from their providers. Friesen et al, in this issue, examine the use of an Internetdelivered cognitive behavioral pain management program, known as Pain Course, designed for persons with fibromyalgia (www.onlinetherapyuser.ca). Sixty patients with self-reported fibromyalgia were randomized to either participate in a 5-session program over 8 weeks, with teleconferences and e-mail support and guidance, or were assigned to a wait-list control. The 8-week program offered information about the management of pain, ways to address pain-related disability, and tips for dealing with emotional distress. On the website, the user was able to watch a helpful introductory cartoon video that promoted the program and to sign up for the study. To be included in the study, participants had to be aged 18 years or older with self-reported fibromyalgia and access to a computer and to the Internet. Interested subjects completed a 30-minute online screening with a telephone conversation follow-up. All measures were completed online. Those assigned to receive the program were offered online cognitive behavioral therapy for pain. The program was presented in a PowerPoint slide format with summaries and patient stories. Automated e-mails were sent particularly to remind the user about material that they had not accessed, and each participant was assigned a “guide” to offer general support and encouragement. The results showed that those who completed the program showed significant improvements in depression, pain, and fear of pain compared with those in the control group. This is an innovative and clinically relevant article that targets a difficult-to-recruit population. Patients with fibromyalgia often report heightened anxiety and depression and have other physical symptoms, including fatigue, that can interfere with active participation in a behaviorally designed program to improve function and coping. Most of the subjects who participated in this study were white women (95%) who were married (62%), well educated (97% with a high school education or higher), and averaged over 16 years of wide spread pain. The article draws on previous research that positively evaluated the Pain Course. The study design has many commendable features, including being a prospective randomized controlled trial with incorporation of reliable and validated measures, quantitative and qualitative satisfaction ratings, and well-explained statistics. The study limitations, however, include a relatively small sample size among a specific patient cohort, lack of an active control condition (to counter the nonspecific effects of the attention in the treatment group), only a 4-week follow-up, and no assessment of other ongoing treatments, including medication for pain. It is well established that knowledge alone is not particularly effective in changing behavior, and this program seems to follow what would likely be found in a self-help book. Nonetheless, the results of this intervention are encouraging and point to significant reductions in self-reported fibromyalgia symptoms and improvements in mood and fear of movement. No significant changes, however, were found in self-efficacy, coping, catastrophizing, and quality of life. Overall, the users were very satisfied with the program. Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.