Psychological therapies delivered remotely for the management of chronic pain (excluding headache) in adults.

BACKGROUND: Chronic pain (pain lasting three months or more) is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Common types (excluding headache) include back pain, fibromyalgia, and neuropathic pain. Access to traditional face-to-face therapies can be restricted by healthcare resources, geography, and cost. Remote technology-based delivery of psychological therapies has the potential to overcome treatment barriers. However, their therapeutic effectiveness compared to traditional delivery methods requires further investigation. OBJECTIVES: To determine the benefits and harms of remotely-delivered psychological therapies compared to active control, waiting list, or treatment as usual for the management of chronic pain in adults. SEARCH METHODS: We searched for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, and PsycINFO to 29 June 2022. We also searched clinical trials registers and reference lists. We conducted a citation search of included trials to identify any further eligible trials. SELECTION CRITERIA: We included RCTs in adults (≥ 18 years old) with chronic pain. Interventions included psychological therapies with recognisable psychotherapeutic content or based on psychological theory. Trials had to have delivered therapy remote from the therapist (e.g. Internet, smartphone application) and involve no more than 30% contact time with a clinician. Comparators included treatment as usual (including waiting-list controls) and active controls (e.g. education). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. MAIN RESULTS: We included 32 trials (4924 participants) in the analyses. Twenty-five studies delivered cognitive behavioural therapy (CBT) to participants, and seven delivered acceptance and commitment therapy (ACT). Participants had back pain, musculoskeletal pain, opioid-treated chronic pain, mixed chronic pain, hip or knee osteoarthritis, spinal cord injury, fibromyalgia, provoked vestibulodynia, or rheumatoid arthritis. We assessed 25 studies as having an unclear or high risk of bias for selective reporting. However, across studies overall, risk of bias was generally low. We downgraded evidence certainty for primary outcomes for inconsistency, imprecision, and study limitations. Certainty of evidence ranged from moderate to very low. Adverse events were inadequately reported or recorded across studies. We report results only for studies in CBT here. Cognitive behavioural therapy (CBT) versus treatment as usual (TAU) Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to TAU (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.39 to -0.16; 20 studies, 3206 participants; moderate-certainty evidence). Participants receiving CBT are probably more likely to achieve a 30% improvement in pain intensity compared to TAU (23% versus 11%; risk ratio (RR) 2.15, 95% CI 1.62 to 2.85; 5 studies, 1347 participants; moderate-certainty evidence). They may also be more likely to achieve a 50% improvement in pain intensity (6% versus 2%; RR 2.31, 95% CI 1.14 to 4.66; 4 studies, 1229 participants), but the evidence is of low certainty. At follow-up, there is likely little to no difference in pain intensity between CBT and TAU (SMD -0.04, 95% CI -0.17 to 0.09; 8 studies, 959 participants; moderate-certainty evidence). The evidence comparing CBT to TAU on achieving a 30% improvement in pain is very uncertain (40% versus 24%; RR 1.70, 95% CI 0.82 to 3.53; 1 study, 69 participants). No evidence was available regarding a 50% improvement in pain. Functional disability Immediately after treatment, CBT may demonstrate a small beneficial improvement compared to TAU (SMD -0.38, 95% CI -0.53 to -0.22; 14 studies, 2672 participants; low-certainty evidence). At follow-up, there is likely little to no difference between treatments (SMD -0.05, 95% CI -0.23 to 0.14; 3 studies, 461 participants; moderate-certainty evidence). Quality of life Immediately after treatment, CBT may not have resulted in a beneficial effect on quality of life compared to TAU, but the evidence is very uncertain (SMD -0.16, 95% CI -0.43 to 0.11; 7 studies, 1423 participants). There is likely little to no difference between CBT and TAU on quality of life at follow-up (SMD -0.16, 95% CI -0.37 to 0.05; 3 studies, 352 participants; moderate-certainty evidence). Adverse events Immediately after treatment, evidence about the number of people experiencing adverse events is very uncertain (34% in TAU versus 6% in CBT; RR 6.00, 95% CI 2.2 to 16.40; 1 study, 140 participants). No evidence was available at follow-up. Cognitive behavioural therapy (CBT) versus active control Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to active control (SMD -0.28, 95% CI -0.52 to -0.04; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (mean difference (MD) 0.50, 95% CI -0.30 to 1.30; 1 study, 127 participants). No evidence was available for a 30% or 50% pain intensity improvement. Functional disability Immediately after treatment, there may be little to no difference between CBT and active control on functional disability (SMD -0.26, 95% CI -0.55 to 0.02; 2 studies, 189 participants; low-certainty evidence). The evidence at follow-up is very uncertain (MD 3.40, 95% CI -1.15 to 7.95; 1 study, 127 participants). Quality of life Immediately after treatment, there is likely little to no difference in CBT and active control (SMD -0.22, 95% CI -1.11 to 0.66; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (MD 0.00, 95% CI -0.06 to 0.06; 1 study, 127 participants). Adverse events Immediately after treatment, the evidence comparing CBT to active control is very uncertain (2% versus 0%; RR 3.23, 95% CI 0.13 to 77.84; 1 study, 135 participants). No evidence was available at follow-up. AUTHORS' CONCLUSIONS: Currently, evidence about remotely-delivered psychological therapies is largely limited to Internet-based delivery of CBT. We found evidence that remotely-delivered CBT has small benefits for pain intensity (moderate certainty) and functional disability (moderate to low certainty) in adults experiencing chronic pain. Benefits were not maintained at follow-up. Our appraisal of quality of life and adverse events outcomes post-treatment were limited by study numbers, evidence certainty, or both. We found limited research (mostly low to very low certainty) exploring other psychological therapies (i.e. ACT). More high-quality studies are needed to assess the broad translatability of psychological therapies to remote delivery, the different delivery technologies, treatment longevity, comparison with active control, and adverse events.

Pain Acceptance in Adolescents: Development of a Short Form of the CPAQ-A.

OBJECTIVE: Acceptance of pain is a predictor of pain-related disability and treatment outcome in adolescents with pain. This variable has been previously measured using the Chronic Pain Acceptance Questionnaire for Adolescents (CPAQ-A, McCracken, Gauntlett-Gilbert, & Eccleston, European Journal of Pain, 14, 316-320, 2010). We set out to create a short, eight-item, form of this instrument that retained its factor structure and clinical utility. METHODS: We used data collected from two independent samples of adolescents attending residential treatment for disabling chronic pain (N = 187 and N = 159). Both groups completed the 20-item CPAQ-A and indices of functioning and distress. We carried out item reduction and confirmatory factor analysis (CFA) on the first sample, repeating this on the second sample and examining the new scale's correlations with clinically relevant variables. RESULTS: An eight-item scale was created with four items assigned to each established factor (Pain Willingness and Activity Engagement). CFA confirmed this factor structure and it replicated in Sample 2. The new scale (the CPAQ-A8) was sensitive to treatment and correlated as well with clinically important variables as its full-length version. Some items in the new scale differed from the adult CPAQ-8. CONCLUSIONS: Measures of pain acceptance have been previously developed and validated in pediatric and adult samples. This study showed that pain acceptance can be indexed by a brief, yet factorially valid, short form of the CPAQ-A that uses fewer than 50% of the items of the full-length scale and has demonstrated acceptable validity and sensitivity-to-treatment.

Predicting Short-Term Remembering as Boundedly Optimal Strategy Choice.

It is known that, on average, people adapt their choice of memory strategy to the subjective utility of interaction. What is not known is whether an individual's choices are boundedly optimal. Two experiments are reported that test the hypothesis that an individual's decisions about the distribution of remembering between internal and external resources are boundedly optimal where optimality is defined relative to experience, cognitive constraints, and reward. The theory makes predictions that are tested against data, not fitted to it. The experiments use a no-choice/choice utility learning paradigm where the no-choice phase is used to elicit a profile of each participant's performance across the strategy space and the choice phase is used to test predicted choices within this space. They show that the majority of individuals select strategies that are boundedly optimal. Further, individual differences in what people choose to do are successfully predicted by the analysis. Two issues are discussed: (a) the performance of the minority of participants who did not find boundedly optimal adaptations, and (b) the possibility that individuals anticipate what, with practice, will become a bounded optimal strategy, rather than what is boundedly optimal during training.

Qualitative evaluation of the SMART2 self-management system for people in chronic pain.

PURPOSE: Technology could support the self-management of long-term health conditions such as chronic pain. This article describes an evaluation of SMART2, a personalised self-management system incorporating activity planning and review, feedback on behaviour- and acceptance-based therapeutic exercises. METHOD: The SMART2 system was evaluated over a four-week trial in the homes of people in chronic pain. At conclusion, participants were interviewed to understand the experience of using and living with the SMART2 system as a therapeutic tool. RESULTS: Qualitative analysis of the interviews found that participants liked the system and reported making associated changes to their behaviour. Goal setting and feedback were the most useful elements of the system. A third key and unexpected element was that by simulating some of the functions of a therapist, SMART2 also simulated some of the process of interacting with a therapist. CONCLUSIONS: People in chronic pain may experience positive outcomes when using a self-management system designed for behaviour change. Furthermore, some of the supportive aspects of the therapeutic context can be elicited by self-management technologies. Implications of Rehabilitation Self-management technology has the potential to assist rehabilitation by supporting goal setting and providing feedback. By simulating some of the functions of a therapist, technology can simulate some of the process of therapy during rehabilitation. People in chronic pain liked using the technology in their own home and thought it could augment services delivered by clinical practitioners. Complex programmes of therapeutic exercises delivered by technology had limited success in engaging people in chronic pain.

Psychological therapies (Internet-delivered) for the management of chronic pain in adults.

BACKGROUND: Chronic pain (i.e. pain lasting longer than three months) is common. Psychological therapies (e.g. cognitive behavioural therapy) can help people to cope with pain, depression and disability that can occur with such pain. Treatments currently are delivered via hospital out-patient consultation (face-to-face) or more recently through the Internet. This review looks at the evidence for psychological therapies delivered via the Internet for adults with chronic pain. OBJECTIVES: Our objective was to evaluate whether Internet-delivered psychological therapies improve pain symptoms, reduce disability, and improve depression and anxiety for adults with chronic pain. Secondary outcomes included satisfaction with treatment/treatment acceptability and quality of life. SEARCH METHODS: We searched CENTRAL (Cochrane Library), MEDLINE, EMBASE and PsycINFO from inception to November 2013 for randomised controlled trials (RCTs) investigating psychological therapies delivered via the Internet to adults with a chronic pain condition. Potential RCTs were also identified from reference lists of included studies and relevant review articles. In addition, RCTs were also searched for in trial registries. SELECTION CRITERIA: Peer-reviewed RCTs were identified and read in full for inclusion. We included studies if they used the Internet to deliver the primary therapy, contained sufficient psychotherapeutic content, and promoted self-management of chronic pain. Studies were excluded if the number of participants in any arm of the trial was less than 20 at the point of extraction. DATA COLLECTION AND ANALYSIS: Fifteen studies met the inclusion criteria and data were extracted. Risk of bias assessments were conducted for all included studies. We categorised studies by condition (headache or non-headache conditions). Four primary outcomes; pain symptoms, disability, depression, and anxiety, and two secondary outcomes; satisfaction/acceptability and quality of life were extracted for each study immediately post-treatment and at follow-up (defined as 3 to 12 months post-treatment). MAIN RESULTS: Fifteen studies (N= 2012) were included in analyses. We assessed the risk of bias for included studies as low overall. We identified nine high 'risk of bias' assessments, 22 unclear, and 59 low 'risk of bias' assessments. Most judgements of a high risk of bias were due to inadequate reporting.Analyses revealed seven effects. Participants with headache conditions receiving psychological therapies delivered via the Internet had reduced pain (number needed to treat to benefit = 2.72, risk ratio 7.28, 95% confidence interval (CI) 2.67 to 19.84, p < 0.01) and a moderate effect was found for disability post-treatment (standardised mean difference (SMD) ‒0.65, 95% CI ‒0.91 to ‒0.39, p < 0.01). However, only two studies could be entered into each analysis; hence, findings should be interpreted with caution. There was no clear evidence that psychological therapies improved depression or anxiety post-treatment (SMD -0.26, 95% CI -0.87 to 0.36, p > 0.05; SMD -0.48, 95% CI -1.22 to 0.27, p > 0.05), respectively. In participants with non-headache conditions, psychological therapies improved pain post-treatment (p < 0.01) with a small effect size (SMD -0.37, 95% CI -0.59 to -0.15), disability post-treatment (p < 0.01) with a moderate effect size (SMD -0.50, 95% CI -0.79 to -0.20), and disability at follow-up (p < 0.05) with a small effect size (SMD -0.15, 95% CI -0.28 to -0.01). However, the follow-up analysis included only two studies and should be interpreted with caution. A small effect was found for depression and anxiety post-treatment (SMD -0.19, 95% CI -0.35 to -0.04, p < 0.05; SMD -0.28, 95% CI -0.49 to -0.06, p < 0.01), respectively. No clear evidence of benefit was found for other follow-up analyses. Analyses of adverse effects were not possible.No data were presented on satisfaction/acceptability. Only one study could be included in an analysis of the effect of psychological therapies on quality of life in participants with headache conditions; hence, no analysis could be undertaken. Three studies presented quality of life data for participants with non-headache conditions; however, no clear evidence of benefit was found (SMD -0.27, 95% CI -0.54 to 0.01, p > 0.05). AUTHORS' CONCLUSIONS: There is insufficient evidence to make conclusions regarding the efficacy of psychological therapies delivered via the Internet in participants with headache conditions. Psychological therapies reduced pain and disability post-treatment; however, no clear evidence of benefit was found for depression and anxiety. For participants with non-headache conditions, psychological therapies delivered via the Internet reduced pain, disability, depression, and anxiety post-treatment. The positive effects on disability were maintained at follow-up. These effects are promising, but considerable uncertainty remains around the estimates of effect. These results come from a small number of trials, with mostly wait-list controls, no reports of adverse events, and non-clinical recruitment methods. Due to the novel method of delivery, the satisfaction and acceptability of these therapies should be explored in this population. These results are similar to those of reviews of traditional face-to-face therapies for chronic pain.

The disruptive effects of pain on complex cognitive performance and executive control.

Pain interferes and disrupts attention. What is less clear is how pain affects performance on complex tasks, and the strategies used to ensure optimal outcomes. The aim of the current study was to examine the effect of pain on higher-order executive control processes involved in managing complex tasks. Sixty-two adult volunteers (40 female) completed two computer-based tasks: a breakfast making task and a word generation puzzle. Both were complex, involving executive control functions, including goal-directed planning and switching. Half of those recruited performed the tasks under conditions of thermal heat pain, and half with no accompanying pain. Whilst pain did not affect central performance on either task, it did have indirect effects. For the breakfast task, pain resulted in a decreased ability to multitask, with performance decrements found on the secondary task. However, no effects of pain were found on the processes thought to underpin this task. For the word generation puzzle, pain did not affect task performance, but did alter subjective accounts of the processes used to complete the task; pain affected the perceived allocation of time to the task, as well as switching perceptions. Sex differences were also found. When studying higher-order cognitive processes, pain-related interference effects are varied, and may result in subtle or indirect changes in cognition.

Giving up problem solving.

How do people decide to abandon a problem? Participants were presented with unsolvable water jar problems, having been accurately informed of the prior probability of solvability. Across three experiments, we discovered effects of prior probability of solvability and of problem size (number of distinct problem states) on measures of effort and confidence. If a problem is more likely to be solvable and allows more problem states, a problem solver spends longer trying to solve the problem. Giving-up decisions are informed by the same judgments of probability of success and costs of solution that inform move-choice in a rational model of problem solving.

The influence of goal-state access cost on planning during problem solving.

Two problem-solving experiments investigated the relationship between planning and the cost of accessing goal-state information using the theoretical framework of the soft constraints hypothesis (Gray & Fu, 2004; Gray, Simms, Fu, & Schoelles, 2006). In Experiment 1, 36 participants were allocated to low, medium, and high access cost conditions and completed a problem-solving version of the Blocks World Task. Both the nature of planning (memory based or display based) and its timing (before or during action) changed with high goal-state access cost (a mouse movement and a 2.5-s delay). In this condition more planning before action was observed, with less planning during action, evidenced by longer first-move latencies, more moves per goal-state inspection, and more short (≤ 0.8 s) and long (>8 s) "preplanned" intermove latencies. Experiment 2 used an eight-puzzle-like transformation task and replicated the effect of goal-state access cost when more complex planning was required, also confirmed by sampled protocol data. Planning before an episode of move making increased with higher goal-state access cost, and planning whilst making moves increased with lower access cost. These novel results are discussed in the context of the soft constraints hypothesis.

Evaluation of the breathworks mindfulness-based pain management programme: effects on well-being and multiple measures of mindfulness.

Two studies of a mindfulness training programme are presented. Study 1 reports on a pilot investigation of the impact on well-being of the Breathworks mindfulness-based pain management programme. Significant positive change was found on self-report measures of depression, outlook, catastrophizing and pain self-efficacy in the Intervention Group, but not the Comparison Group. Particularly large effects were found for pain acceptance. These results support the short-term efficacy of the Breathworks programme and reinforce the importance of acceptance for positive outcome with chronic pain patients. Study 2 investigated alterations in mindfulness following participation in the Breathworks programme. Subjective and non-subjective measures of mindfulness were used. Scores on the Mindful Attention Awareness Scale were significantly higher at Time 2 in the Intervention Group, but not in the Comparison Group. There was no change on a measure of sustained attention. Results from an Implicit Association Test provided some support for an increased awareness of positive stimuli, following the intervention. These results are discussed with reference to the mechanisms of mindfulness.

Text skimming: the process and effectiveness of foraging through text under time pressure.

Is Skim reading effective? How do readers allocate their attention selectively? The authors report 3 experiments that use expository texts and allow readers only enough time to read half of each document. Experiment 1 found that, relative to reading half the text, skimming improved memory for important ideas from a text but did not improve memory of less important details or of inferences made from information within the text. Experiment 2 found no advantage of skimming over reading the first or second half of every paragraph. Two final experiments using a hierarchical, Website-like layout of documents showed that the advantage of skimming found in Experiment 1 was dependent on the linkages between pages and, thus, the ease with which participants could navigate through the text. Data on page-by-page reading times and eye-tracking analyses from Experiment 2 indicated that Skim readers spent more time reading text that was earlier in the paragraph, toward the top of the page and in an earlier page of the document. These findings were interpreted as evidence in support of a "satisficing" account of skimming process.

Designing information fusion for the encoding of visual-spatial information.

In a simulated aircraft navigation task, a fusion technique known as triangulation was used to improve the accuracy and onscreen availability of location information from two separate radars. Three experiments investigated whether the reduced cognitive processing required to extract information from the fused environment led to impoverished retention of visual-spatial information. Experienced pilots and students completed various simulated flight missions and were required to make a number of location estimates. Following a retention interval, memory for locations was assessed. Experiment 1 demonstrated, in an applied setting, that the retention of fused information was problematic and Experiment 2 replicated this finding under laboratory conditions. Experiment 3 successfully improved the retention of fused information by limiting its availability within the interface, which it is argued, shifted participants' strategies from over-reliance on the display as an external memory source to more memory-dependent interaction. These results are discussed within the context of intelligent interface design and effective human-machine interaction.

Discretionary task interleaving: heuristics for time allocation in cognitive foraging.

When participants allocated time across 2 tasks (in which they generated as many words as possible from a fixed set of letters), they made frequent switches. This allowed them to allocate more time to the more productive task (i.e., the set of letters from which more words could be generated) even though times between the last word and the switch decision ("giving-up times") were higher in the less productive task. These findings were reliable across 2 experiments using Scrabble tasks and 1 experiment using word-search puzzles. Switch decisions appeared relatively unaffected by the ease of the competing task or by explicit information about tasks' potential gain. The authors propose that switch decisions reflected a dual orientation to the experimental tasks. First, there was a sensitivity to continuous rate of return--an information-foraging orientation that produced a tendency to switch in keeping with R. F. Green's (1984) rule and a tendency to stay longer in more rewarding tasks. Second, there was a tendency to switch tasks after subgoal completion. A model combining these tendencies predicted all the reliable effects in the experimental data.

Age of acquisition, ageing, and verb production: normative and experimental data.

Young and old adults were shown pictured or written verbs and asked to name them as quickly as possible. Simultaneous multiple regression was used to investigate which of a set of potential variables predicted naming speed. Age of acquisition was found to be an important predictor of naming speed in both young and old adults, and for both word and picture naming. Word frequency predicted picture-naming speed only in older adults and failed to make any significant contribution to word-naming speeds for either group of participants. The respective loci and roles of age of acquisition and frequency in lexical processing are discussed in the light of these findings.