Review Psychological therapies delivered remotely for the management of chronic pain (excluding headache) in adults, 2023, Rosser et al

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.

Open access, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013863.pub2/full

 

I assume, but could not see confirmation, that this now supersedes this review, Cochrane Review: Psychological therapies for the management of chronic pain (excluding headache) in adults, 2020, C De C Williams et al.

 

Exactly as expected from ineffective treatments where there is a strong therapist bias who are coaxing patients into reporting themselves better in order to feel better. It's as if they can't believe that it can't work, that it should, it must. They just have to find the right words for it.

They don't even trust their own research confirming that none of this actually works at all. What is even the point of doing research when you can simply choose to disbelieve the results when you don't like them, and hype them like 100% certainty when they appear to?

How can they even qualify the evidence for pain intensity as moderate when they only have small benefits immediately after treatment, and no follow-up evidence? This can't be qualified as moderate, it's very weak. If this is what moderate evidence means in this discipline, it basically means nothing.

And how would it make sense for there being a reduction in pain intensity, which there isn't, but no difference in functionality, when the reduction in functionality is strictly based on... pain? There is just no reasoning here, it's all just applying numbers without thinking, and most of the numbers are fake anyway. They talk about 30% and 50% as if they actually mean the numbers 30 and 50, when they're actually very rough figures, guesstimates at best.

So it's all useless, and their conclusions? More research of the exact same ineffective BS. So the loop of failure keeps spinning, easy no-effort jobs that deliver nothing at all. But it has to keep spinning and spinning.

Is this the only field of study that exists only to perpetuate itself? They really do nothing at all, yet always conclude that they should keep doing exactly the same things anyway. You can go back decades finding the exact same conclusions, of which we are technically seeing the results, and still they can't think of doing anything else because they simply can't believe that they could ever have been wrong about this. Absurd.

 

Presumably because they can get more research funding from government departments keen to look as if they're taking action to address long-term ill-health? From what I can see, funding research like this isn't much different to paying an ad agency to deliver a campaign.

 

The authors included “education” as an active control even though it only consists of receiving a leaflet on pain management techniques and not benefiting from the same therapist-patient interaction, so it does not seem surprising that they still found a small benefit for pain intensity for CBT over “active” controls.

Even then, they found no difference on any other outcome, including functional disability, and the supposed benefit on pain intensity after the end of the treatment vanished at follow-up. It is thus disappointing to see that the authors opened their conclusions with a positive spin, in that they fail to mention all of their negative results:

 

Marketers are sometimes called spin doctors. But clearly, doctors deserve that title far better. Except marketing today is better regulated than medicine, since it would not allow to make such marketing claims. It could hint to the idea that you could have some benefits, but it wouldn't allow to state those benefits, since there is no evidence for them.

The marketing really is the product here. Mirage medicine, built on deception and egocentrism.

 

Technically marketing is orienting to customer need, this is sales of stories or I suspect not marketing to the end-user at all but propaganda and sales to internal markets based on stating their cost is low and fudging the idea that it has any 'use'.

The inclusion of the following line at all in the conclusion is very important here. But disheartening how it wasn't the conclusion:

There is obviously a flaw in the system of buying where if something is useless or harms it doesn't matter in the 'value for money' calculations:

- the main product they are 'selling' is for those who have 'bought' to 'not see' it 'not working' or 'harming' after having mis-sold them it based on fake promises, hence the weaponising every 'mental health' slur or inference they can[read false accusation of madness in the old, nasty, stigmatic sense] explicitly as a tool to remove the voice of sane, mentally healthy people. The con for the participants is they were open-minded enough to think these people were trying to help or make them happier when once labelled it was merely about that.

There is something called 'reassurance marketing' - the best known case study for which is Jaguar car ads being targeted at those who own a Jaguar so they feel really happy and glad to have bought one - I suspect that all of this and many of the dodgy articles are a lot of that type of thing for those who commissioned such ideology and have to explain why.

And as BPS will well know once you've got someone to hand over large sums of taxpayer or their own or their bosses/company's money then confirmation bias tends to rule hence the 'it's a debate' or 'both-sides ism' being used as an excuse to carry on allowing the pumping out of poor non-impactful research once there has already been more than enough holds no weight. Surely after enough papers using short-term noting not maintained at follow-up someone should have to be addressing the lack of follow-up and how it was them all fooling themselves - the short-term questionnaire-boost effect (rather than placebo).

When its CBT or whatever coercive communication technique teaching to the test of 'remember to be positive in your answers', in the promise if you do that long enough it will 'change how you feel' the real measure is whether after two years of no change you lose heart and say it doesn't work, fairly.

This phenomena of 'short-term questionnaire-boost effect research using coercive communication' is getting away with methodology as poor as the equivalent of testing whether the advice 'dressing for the job you want, not the one you have' by asking people who've just been made to say mantras and have their language reworded by a coach intensively for weeks 'do you feel more likely to get the job you want' just after they've spent a huge amount of time and money investing in rolling the dice on that very principle working. Instead of the real test of it working: how many who 'dressed for the job they want' ended up in people getting the job they wanted vs those who 'dressed for the job they have'.

I think it is also why what might start as a seeming 'worth a try, even if it is wild-cat and illogical perhaps' ends up, in paradigms that are nonsense and don't work, with patient-slander. Particularly where there is no objective measure one has to disempower the voice/testimony of the end-user. The classic 'they are just bitter' kind of nonsense. Because somehow the profession and journals aren't stomping down on 'this is the measure', the one where it is long-term and they are independent of coercion, and in a way the more 'full of hope' you made them in that first round the more of an inappropriate 'treatment'/con you actually delivered 'effectively' was to the problem at hand.