Despite advances in neurophysiology and pharmacology, unrelieved pain continues to be a major public health challenge [7,18,25,52]. Current estimates suggest that it is more widespread than heart disease, cancer and diabetes combined, and associated with equivalent health care costs . The “epidemic” of unrelieved pain  has been attributed to a range of nonmedical barriers that prevent good and cost-effective pain management [22,35,56]. These include inadequate training and education of health professionals, inadequate reporting and identification of pain, myths and misconceptions about pain and its treatment [35,56], and inadequate access to multidimensional pain programs, considered the gold standard in pain care .
One method proposed to improve the management of pain, as well as other health conditions involves providing patients with self-management support to enable them to participate actively in the management of their health . Self-management support is an umbrella concept that refers to efforts to increase patients’ knowledge, skills and confidence to manage their health condition [1,6]. Chronic disease self-management support programs, including those focused on pain, have demonstrated improvements in clinical and behavioral outcomes, and reductions in health care utilization . However, traditional self-management programs, which are delivered face-to-face by specialized health care professionals are limited by low participation rates as a result of physical symptoms that limit mobility, transportation requirements and cost constraints—all of which are also significant barriers to traditional clinic-based therapy for a great many patients suffering with pain .
Internet-based interventions have surfaced as a potential adjunct or alternative that could overcome access barriers to clinic-based pain management support such as time, mobility and geography , and may assist health care providers in meeting the needs of a larger patient population at reduced personnel costs over the continuum of care . These could include health information Web sites, clinical decision-support or health risk assessment tools, Internet-delivered psychosocial therapies, and multidimensional self-management support programs . The evidence to date suggests that Internet-based health interventions for people with chronic conditions that provide some combination of information, decision management support, behavior change support or social support have a positive impact on users, lead to improvements in knowledge and perceptions of support, as well as behavioral and clinical outcomes [40,59].
As the public demand for online health resources increases [20,51] and meeting the needs of an aging population through clinic-based methods becomes more costly  Internet-based interventions for pain management may become increasingly popular. To date, there have been no systematic efforts to synthesize the evidence on the impact of Internet-based interventions for people in pain. One study  assessed the effects of Internet-based cognitive and behavioral therapy (CBT) for variety of health problems, demonstrating positive effects on pain in particular. The present study was designed to synthesize the evidence on a broader scope of Internet-based interventions for people in pain, and expand upon the previous review  by conducting a more in-depth analysis of Internet-based CBT interventions.
Articles were identified through a search of MEDLINE, CINAHL, PsycINFO and all of the databases in the latest version of The Cochrane Library from January 1, 1990 to December 31, 2009 The search strategy, developed in consultation with a medical librarian (ME) included a string of Internet-related terms cross-matched with the terms used by the Cochrane Pain, Palliative and Supportive Care Review Group to find pain-related trials (Appendix A). The yield from the bibliographic databases was supplemented with a review of reference lists from potentially eligible articles and other recent reviews.
Two of us (CD and ARJ) reviewed the titles and abstracts of the total search yield to identify potentially eligible articles. The full text of the article was retrieved if any reviewer considered a citation potentially relevant. Articles were deemed potentially eligible if they met the following criteria: described an Internet-based intervention; involved patients of any age, sex, ethnocultural, or socioeconomic background with pain of any kind; included original data from patients who had been allocated to the study groups using any form of randomization; and were published in English. Two of us (JLB and AR) independently reviewed the full text of articles meeting the eligibility criteria and extracted information on the following: general study characteristics (eg, primary author, publication title, source of funding, year of publication, country of study); participants, recruitment strategy, and withdrawal rate; pain condition (eg, headache, back pain, or arthritis); intervention or interventions (eg, educational Web sites, online support groups, online cognitive-behavioral therapy programs); and outcome measures and main findings (eg, pain relief, disability, work capacity). Disagreements were resolved by a third reviewer or by consensus. We contacted the primary authors of the included studies to collect additional information when necessary.
Two reviewers (JLB and AR) independently assessed the methodological quality of all trials using the Jadad scale . In addition, we used the Yates scale , which was specifically designed for assessing the quality of psychological trials in pain, to assess the quality of studies evaluating CBT interventions. High-quality studies were defined as randomized controlled trials that scored 3 or more points out of 5 on the Jadad scale, or 17 or more points out of 35 on the Yates scale.
Evidence tables were produced to summarize the information extracted from the articles, descriptive statistics were calculated using SPSS version 17 (IBM, Somers, NY). We did not conduct a quantitative meta-analysis of the aggregate data as there were important perceived differences in patient populations, interventions and outcome measures.
The search strategy yielded 6724 citations from indexed journals. One hundred forty articles were retrieved for further review; 17 articles were included in the final analysis (Fig. 1). Selected characteristics of the included studies are summarized in Table 1.
3.1. Description of studies
As shown in Table 1, the 17 included studies examined the impact of Internet-based interventions on a total of 2503 people in pain (median=65.5, IQR=80.5). (Two studies [11,36] used the same sample of participants.) The studies were published over a 10-year period, with the majority (n=11, 64.7%) published between 2006 and 2009. Most studies were conducted in the United States (n=9, 52.9%), followed by Sweden (n=5, 29.4%) and Germany (n=2, 11.7%); one study was conducted in Canada. Funding information was found for all but 2 studies [9,53]. Of these, 86.7% reported receiving funding from the public sector, and 2 studies from the private sector. Funding sources included national research agencies [2,11,12,14,23,26,36,37,50,54,55], special national funds , academic and health care institutions , private foundations [5,26], professional associations , and chronic pain advocacy groups .
3.2. Participants and health conditions
Most studies (n=15, 88.2%) targeted people with chronic pain syndromes including headache, back pain, musculoskeletal pain, abdominal pain and fibromyalgia. Two studies evaluated the effects of patient education Web sites for people with acute postsurgical pain. Most interventions were administered to adults (n=12, 70.6%), 5 studies involved participants younger than 18years of age, and all but 1 study involved mostly female subjects. Only 7 studies reported the educational level, income, or cultural background of the study participants [5,11,12,26,36,37,50]. These studies indicate a predominantly white and college-educated study population.
3.3. Interventions and control conditions
The studies evaluated Internet-based interventions that provided CBT (n=11), moderated peer support groups or programs (n=3), or support for preparation and/or follow-up related to clinical visits (n=3) for chronic or acute pain management. Most CBT studies (72.7%) used wait list control conditions [2,5,8,9,12,14,26,53], and 3 used a comparable Internet-based control intervention [54,55]. All of the peer support [11,36,37] and clinical support studies [23,41,50] compared their interventions to usual care, one of which  used an existing nursing Web site as the control condition. Most of the studies did not describe other pain management methods that the participants (in either the intervention or control groups) may have been using during the course of the study. Two studies tracked medication use [14,53] but did not describe the type of pain medications used by the participants.
3.4. Withdrawal from study
The number of participants that withdrew from the studies ranged from 5.7% to 58.9%. The median withdrawal rate was 27.4% (IQR=25.5). Twelve studies assessed differences between the characteristics of completers and withdrawals at baseline [2,5,9,12,14,23,26,37,41,50,53,55]. Of these studies, 2 reported that the withdrawals had less severe symptoms [14,53], 1 reported that they had more severe symptoms , 3 reported that they were younger [23,26,53], and 1  reported that they had less perceived benefit from treatment and less years computing.
3.5. Methodological quality
Six studies (35.3%) received scores associated with high quality according to the Jadad scale [5,8,9,41,44,55]. Eleven studies did not as a result of lack of double blinding (unfeasible in most cases), and insufficient description of the numbers and reasons for participant withdrawal (always feasible). Nine studies [2,5,9,12,14,36,37,53,54] relied on recruitment via postings on Web sites alone or in combination with notices in newspapers or physical settings, which can make follow-up of withdrawals challenging, particularly if the only contact information collected is an e-mail address. The methodological quality of the studies increased with time. None of studies published before 2006 were scored as high quality, compared to 54.5% of studies after this time.
A comparison of the Jadad and Yates quality scores for the CBT studies revealed that the Jadad score was lower than or on par with the Yates score in all but one instance (Table 2). On the basis of the Jadad rating instrument, 4 of the 11 CBT studies were rated as high quality, whereas according to the Yates scale 8 of the 11 CBT studies were rated as high quality. We chose to use the Jadad scale to describe the methodological quality of the body of evidence included in this review because of its documented reliability and validity for a variety of interventions and settings .
3.6. CBT interventions
The Internet-based CBT interventions consisted of structured, self-administered therapy programs offered in weekly modules ranging in length from 6 to 20weeks. Ten of the 11 interventions required participants to submit weekly reports summarizing their program activities and/or outcome measures to facilitate program adherence. In place of weekly reports, the Brattberg  CBT intervention included a message board moderated by a therapist and expert patient, which participants were encouraged to use to discuss their weekly program activities. All interventions were supplemented by support from a clinical or research staff person via telephone, e-mail, e-mailing-list, asynchronous or synchronous message boards. The support offered by the staff person was minimal and typically involved providing feedback on weekly reports, reminders to complete program activities, and administrative or technical assistance.
Ten studies evaluated a program of CBT for pain. Six of the studies evaluating CBT programs were designed for adults: 3 for individuals with chronic headache [2,14,53], 1 for low back pain , 1 for chronic musculoskeletal pain , and 1 for people with a variety of chronic pain syndromes . Four CBT interventions were designed for children and adolescents with chronic headaches, abdominal or musculoskeletal pain [26,54,55]. One study  evaluated a form of CBT called emotional freedom techniques (EFT) for adults with fibromyalgia.
In the proceeding section we have summarized the evidence on the effects of 2 or more of the CBT interventions on specific outcome variables for adults vs children and adolescents (Table 3). The pilot study by Trautmann et al.  was excluded from the summary of the evidence because it did not report whether there was a statistical difference between the effects sizes of the treatment and control groups. Likewise, the study by Andersson et al.  was excluded from the summary of the evidence because it evaluated the addition of telephone support to the CBT intervention and not the intervention itself.
3.7. Effect of Internet-based CBT interventions on pain
Three studies [26,44,55] evaluated the effect of Internet-based CBT on pain in children and adolescents. All 3 were high quality and all 3 yielded statistically and/or clinically significant positive effects on pain among a total of 75 intervention participants compared to wait list controls [26,44], or active treatment controls . Six studies evaluated the effect of Internet-based CBT on pain in adults [5,8,9,12,14,53]. Four (2 of high quality) of the 6 studies (66.7%) yielded statistically and/or clinically significant positive effects on pain among a total of 118 intervention participants compared to wait list controls [5,8,9,53].
3.8. Effect of Internet-based CBT on depression
One study (47 intervention participants)  evaluated the effect of Internet-based CBT on depression in children and adolescents and reported nonsignificant findings. Six studies evaluated the effect of Internet-based CBT on depression in adults [5,8,9,12,14,53]. Two (both high quality) of the 6 studies (33.3%), yielded statistically significant and/or clinically relevant positive effects among a total of 57 intervention participants compared to wait list controls [8,9]; however, both studies were conducted by the same research group.
3.9. Effect of Internet-based CBT on anxiety
Anxiety was not assessed in any of the CBT interventions for children and adolescents. Four studies evaluated the effect of Internet-based CBT on anxiety in adults [5,8,9,14]. Two (both high quality) of 4 studies (50%) demonstrated statistically significant and/or clinically relevant positive effects among a total of 57 intervention participants compared to wait list controls [8,9]; however, both studies were conducted by the same research group.
3.10. Effect of Internet-based CBT on disability, pain interference or work capacity
One study (25 intervention participants)  evaluated the effect of Internet-based CBT on functional measures in children and adolescents and found a statistically significant improvement in activity limitation compared to wait list control. Six studies evaluated the effect of Internet-based CBT on functional measures in adults [5,8,9,12,14,53]. Three (2 high quality and 1 low quality) of the 6 studies (50%) demonstrated statistically significant and/or clinically relevant positive effects among a total of 96 intervention participants compared to wait list controls [8,9,14].
3.11. Cost effectiveness of Internet-based CBT
Three studies (all low quality), 2 involving adults and 1 involving children and adolescents, demonstrated a significant reduction in treatment cost among a total of 84 intervention participants compared to conventional clinic based therapy [14,26,53].
3.12. Peer support interventions
Three studies evaluated moderated online peer support groups or programs for adults. These interventions provided participants with a computer-mediated forum (eg, a mailing list or message board) to exchange information and support with people in similar circumstances. Two studies evaluated an e-mail-based discussion group (e-mailing list) for adults with chronic back pain that was facilitated by 2 professional moderators and 3 content experts (physician, physical therapist and psychologist) [11,36]. The third study evaluated an asynchronous message board-based self-management support program for adults with arthritis that was facilitated by 2 peer moderators, and included weekly learning modules and symptom assessment tools . The main role of the moderator in all 3 interventions was to facilitate and monitor the discussion group.
The evaluation of the mailing list discussion group for individuals with chronic back pain  demonstrated significant reductions in disability, pain, distress, and a nonsignificant reduction in physician visits (202 intervention participants). A follow-up study examining the use of the same mailing list discussion group among the same sample of individuals with chronic back pain  obtained equivocal effects on the use of complementary and alternative medicine (CAM) therapies: similar proportions of individuals in the treatment and control groups reported using similar CAM therapies (acupuncture, chiropractic services, glucosamine, magnets and yoga). The evaluation of the peer-moderated self-management support program for people with arthritis demonstrated significant reductions in health distress, activity limitation and pain, and improvements in global health status (433 intervention participants) .
3.13. Clinical visit support interventions
Three studies (one high quality) evaluated Internet-based tools to support preparation and/or follow-up related to clinical visits. Two studies evaluated educational Web sites with information on acute postoperative pain: one aimed to prepare adolescents for tonsillectomy and related postoperative self-care , and the other aimed to prepare adults for postoperative self-care after outpatient surgical procedures . The third study evaluated an Internet-based question-prompting program that provided personalized feedback to migraine sufferers, including a list of questions that they should consider asking their doctor, to help them prepare for their upcoming clinical visits .
The use of the Web site on postoperative pain for adults demonstrated statistically significant reductions in postoperative pain intensity the night and day after surgery (32 intervention participants) . The Web site on postoperative pain for adolescents, which was rated as having high methodological quality, demonstrated statistically significant improvements in satisfaction and knowledge among 32 intervention participants . The question-prompting tool for migraine sufferers led to significantly greater amount of migraine specific topics discussed during the clinical visit and a trend toward greater patient satisfaction (28 intervention participants) .
3.14. Starbright World
Four studies evaluated Starbright World [4,28–30], a multidimensional social networking support program that links pediatric patients with chronic conditions in an interactive online community in which they can play games, learn about their medical condition, or talk with other chronically ill children or teens. These studies were included and analyzed separately because they were conducted while the program was on private computer networks of participating hospitals in the United States, and hence did not meet the inclusion criteria for this study at the time (Table 4). However, since the publication of the study findings, the program has migrated to the Internet (http://www.starbrightworld.org/).
Three of the 4 studies of Starbright World were conducted with samples of pediatric patients aged 7 to 19, who had a range of chronic conditions and who were recruited from the same hospital [28–30]. Two of the studies reported significant outcomes. Holden et al.  (22 intervention participants) demonstrated significant reductions in pain intensity, pain aversiveness, and anxiety, while Battles and Wiener  (32 intervention participants) demonstrated a significant reduction in loneliness, withdrawn behavior and a greater willingness to return for treatment. A meta-analysis  of the 3 Holden studies that used the same outcome measures (92 intervention participants), revealed significant reductions in pain intensity for females, and significant reductions in pain aversiveness and anxiety for both females and males.
None of the studies included in this review reported any adverse effects.
We identified 17 studies that evaluated the impact of Internet-based interventions on 2503 people in pain. Both the number and methodological quality of studies increased over time. The majority of CBT studies showed an improvement in pain (n=7, 77.8%), activity limitation (n=4, 57.1%) and costs associated with treatment (n=3, 100%), whereas the effects on depression (n=2, 28.6%) and anxiety (n=2, 50%) were less consistent. We found limited (2 studies from the same research group) but promising evidence that Internet-based peer support programs can lead to improvements in pain intensity, activity limitation, health distress and self-efficacy; limited (4 studies from the same research group) but promising evidence that social networking programs can reduce pain in children and adolescents; and insufficient evidence on the effects of Internet-based clinical support interventions for people in pain.
This study confirms the findings of a systematic review  on the effects of Internet-based CBT for a variety of health conditions (which included 6 of the 11 CBT studies assessed in this review), which that found significant positive effects on chronic pain and headache. Of note, the authors found the effects of Internet-delivered CBT to be comparable to the effects of face-to-face treatments for people in pain reported by Morley et al. . Our review expands on the findings of this earlier review by synthesizing the evidence from more studies and outcome measures and providing a more nuanced understanding of the evidence on the effects of Internet-based CBT for children vs adults.
We found inconsistent results concerning the effects of Internet-based CBT on psychosocial outcomes (eg, anxiety and depression). Inconsistent results have been reported in other reviews of computer-based patient education interventions  and continue to be a source of concern. Fox  has hypothesized that this is likely due to the wide variation in program features, learning environments, viewing protocols, integration methods and control conditions in studies that evaluate Internet-based programs. However, the variability in Internet-based health resources may be inevitable given the increasingly collaborative, adaptive and interactive nature of the Web  and the resultant proliferation in user-generated health content online .
This study does not yield definite conclusions about whether Internet-based interventions are as effective as or different than face-to-face interventions for pain. Although many interventions were Internet versions of an existing program, none were compared to their face-to-face counterparts, which could help elucidate the unique advantages associated with Internet as a delivery method . Nevertheless, a comparison of our findings to the evidence on the effects of face-to-face CBT reveals important differences. Psychological treatments (primarily CBT) have proven effective for pain control in children with chronic headache , promising for children with chronic musculoskeletal and abdominal pain , inconsistent for adults with chronic headache [47,57] and weak for adults with nonheadache chronic pain . Whereas our preliminary findings suggest that Internet-based CBT is a promising method of pain treatment for children and adults, producing consistent positive effects for both groups.
One of the clear advantages of Internet-based pain interventions is their availability. Patients can use them at their convenience and pace, which may provide them with a greater sense of control over their situations, and in turn yield better outcomes . People who believe that they can exercise control over pain, interpret pain more benignly, experience fewer pain behaviors, and better psychological wellbeing and physical functioning . Other advantages include the relative anonymity of the medium and the resultant lack of stigmatization . In addition, if the intervention includes a forum where participants can interact and support each other (which 6 studies included in this review did), they can benefit from the similarity of users’ experiences and diversity of resources . Online forums and communities have been suggested to offer a form of peer support that cannot be achieved face to face , and hence may represent a new form of treatment rather than new method of delivery.
We identified several important limitations of the research in this area. First, most studies relied on notices in newspapers and Web sites to recruit study participants; only 3 studies [23,41,44] recruited participants from clinical settings. It is possible that the participants recruited in these studies may be different from the typical patient seeking treatment in a clinic setting. In addition, open recruitment via local media and on the Internet is likely to attract individuals who are more motivated to participate.
Second, the studies received low quality Jadad scores primarily because of a lack of double-blinding and incomplete descriptions of reasons for participant withdrawal. In many of the studies masking the interventions was not possible because a comparable Internet-based control condition was not employed. However, blinding of assessors during randomization could have been possible and was reported in only 2 studies [8,26]. Although follow-up of withdrawals may have been challenging, particularly for those studies that relied on e-mail contact information, this information could have enhanced the generalizability of the findings and provided insight onto whom these types of interventions are best suited.
Third, several studies reported high dropout withdrawal rates, which has been documented in other reviews of Internet-based psychological interventions . As others  have noted, there is a greater risk of attrition in Internet-based interventions compared to clinic-based interventions as a result of the relative anonymity and distance that the medium provides. In their review of technology-assisted behavior change programs for chronic illness, Rosser et al.  found significantly lower withdrawal rates in studies with some therapist involvement compared to those with no therapist involvement. In contrast, one study included in our review  found that the addition of therapist-initiated telephone support had minimal effect on the withdrawal rate. Information on the reasons why participants withdraw from Internet-based interventions is crucial in this regard, and could inform the development of strategies to improve the efficacy of these interventions, as well as facilitate participant retention.
Fourth, most studies did not examine the impact of their intervention in relation to conventional pharmacotherapeutic approaches for pain. Although 2 studies [14,53] tracked medication consumption, the types of pain medications used were not described. Research is required to determine the role of Internet-based interventions for pain in relation to pharmacotherapy in order to identify how they could be used as an adjunct or alternative pain management option.
Fifth, most studies targeted adults between the ages of 19 to 65years, and all but one involved mostly female subjects. Given the widespread use of the Internet among youth and the increasing use of the Internet by people 65 and older , more studies are required to assess the role of Internet-based interventions for pain among these groups. In addition, only 7 studies reported the educational level, income, or cultural background of the study participants [5,11,12,26,36,37,50]. These studies indicate a predominantly white and college-educated study population.
Last, aside from the Starbright program (which was not included in our analysis because it was evaluated while it was on a closed computer network), no trials evaluated the impact of social media software on people in pain. Blogs, wikis and social network sites such as PatientsLikeMe.com are creating new ways for patients to build knowledge related to their illness, inform each other about treatment decisions and care strategies, and engage in self-management . These new tools, which could offer new ways and forms of pain management support, warrant further exploration.
4.1. Implications for practice
Despite these limitations it is clear from these studies that the Internet could play a supportive role in pain management efforts; what remains unclear is to what extent and for whom. In terms of availability, the Starbright program, and 9 of the interventions described in this review are available publicly through the Web [2,5,12,50,53] or on a conditional basis for research or clinical purposes [8,9,26,37] (Table 1). The availability of these programs will limit their role as an adjunct in the management of pain by clinicians working outside the institutions where the research was conducted.
4.2. Implications for research
Future research should examine the needs and perspectives of people in pain regarding Internet-based therapies (including when and under what conditions the Internet is preferred to face-to-face) in order to tailor pain management efforts to individual preferences. In addition, a better understanding is needed of the ways in which Internet-based interventions are perceptibly or functionally different from face-to-face interventions, and the effects of these differences on people in pain. Lastly, given the increasingly dynamic and interactive nature of the Web, continued efforts should focus on developing standardized reporting and evaluation guidelines for Internet-based interventions to facilitate synthesis of best evidence in order to guide practice .
In conclusion, Internet-based interventions seem promising for people in pain, but it is still unknown what types of patients benefit most. More well-designed studies of novel interventions with diverse patient groups is required to strengthen the evidence base concerning Internet-based interventions for people in pain.
Conflict of interest statement
No conflicts of interest.
JLB was supported by the Canadian Institutes of Health Research (CIHR) Doctoral Fellowships in Cell Signaling in Mucosal Inflammation and Pain, and in Health Care, Technology and Place (HCTP) Research Training Programs. AR was supported through ARJ’s Canada Research Chair in eHealth Innovation. ARJ Jadad was supported through the Rose Family Chair in Supportive Care, and the Canada Research Chair in eHealth Innovation, which he holds.
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Appendix A Supplementary data
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.pain.2011.02.012.
Appendix A Supplementary data