A systematic review of internet-based interventions for women with chronic pain

Abstract

Introduction

To evaluate the effects of internet-based interventions on physical and psychosocial outcomes in women with chronic pain through a systematic review.

Method

A search of the following electronic databases: PubMed/MEDLINE, ScienceDirect, and Web of Science. Two different authors separately tabulated the indices selected in identical predetermined forms. The methodological quality of all randomised trials was assessed using the Cochrane Collaboration’s tool for assessing the risk of bias.

Results

Seven articles were finally included. The main features of interventions included online cognitive-behavioural and/or psychoeducation therapy to improve health with an interactive component. The methodological quality showed a high risk of bias, mainly from a lack of blinding.

Conclusion

There are indicators that suggest that internet-based interventions may be useful for women with chronic pain. However, the validity of such a conclusion is limited as most trials included had a high risk of bias. More rigorous research is required before stating that such interventions can overcome the current limitations of traditional face-to-face care.

Keywords

Women chronic pain systematic review internet therapy

Introduction and literature review

Chronic pain is a distressing experience associated with actual or potential tissue damage, including sensory, emotional, cognitive and social components (Williams and Craig, 2016) that persists beyond 3 months. It is among the most costly health conditions in the developed world and has an estimated worldwide prevalence of 30% (Elzahaf et al., 2012). Currently, the financial cost of treating chronic pain is estimated at more than €200 billion per year in Europe and $150 billion per year in the United States (Van Hecke et al., 2013).

The aetiology of chronic pain includes a wide range of causes and courses that can be influenced by behavioural, psychological, environmental and social factors (Van Hecke et al., 2013). From a clinical viewpoint, previous studies have shown that women are more likely than men to report recurrent pain in multiple body areas; such pain is often described as being more severe and frequent in women compared to men (Pieretti et al., 2016). In particular, musculoskeletal pain has been reported to be frequently associated with the onset of the menopause (Watt, 2018). Previous studies from a variety of geographical regions have also shown higher prevalence rates in fibromyalgia and widespread chronic pain in women compared to men (Wijnhoven et al., 2016). Chronic pain carries a high level of disease burden, including disability affecting activities of daily living, work performance and health-related quality of life (Dueñas et al., 2016).

Interventions for chronic pain are often long term and costly (Dueñas et al., 2016). Interdisciplinary pain management protocols, particularly those employing a biopsychosocial framework, have been among the most successful approaches including a variety of therapeutic modalities, such as medication management, cognitive-behavioural therapy, manual therapy and guided exercise (Gatchel et al., 2014).

Patients with chronic pain usually report having a limited amount of money and time, which makes self-management support programmes important choices for their chronic conditions (Rod, 2016).

Information and communication technologies offer new possibilities for clinical interventions and a service delivery model within occupational therapy (Cason, 2012; Renda and Lape, 2018). In particular, internet-based systems can address accessibility and cost issues and are therefore a potential solution for women who live in remote areas, prefer home-based care or working at their own pace, and experience a loss of their independence (Rod, 2016). Moreover, some authors (Nes et al., 2017) concluded that by reporting their symptoms electronically, participants increased their awareness, thereby influencing their behaviour positively and leading to symptom reduction. Salaffi et al. (2015) reported that the internet opens many opportunities for self-care as it can be used as a powerful means to promote a healthy lifestyle and increase patients’ understanding of their condition. At present, the coronavirus disease 2019 (COVID-19) pandemic has transformed healthcare practice. The internet makes it possible to conduct many consultations remotely (Smith et al., 2020). For people not infected with the COVID-19 virus, especially those with pre-existing pathologies, such as chronic pain conditions, internet-based interventions can provide convenient access to their therapy without overtly exposing them to the virus (Smith et al., 2020). In addition, the study conducted by Pérez-López et al. (2020) showed a high incidence of COVID-19 among women in European countries, which makes them a focus for the development of this kind of intervention.

Previous systematic reviews have explored the benefits of internet-based interventions in various populations with chronic pain and shown an improvement in pain severity, activity limitation (Buhrman et al., 2016), pain interference (Slattery et al., 2019) and empowerment (Garg et al., 2016). Although the results are promising, the literature is heterogeneous, as the types of internet treatments are diverse. In addition, it is not clear yet which types of patients benefit most, given that the studies included patients with heterogeneous pain complaints (Bender et al., 2011). Women are high utilisers of healthcare. Considering biological and sociocultural characteristics, including specific work and family-related demands, they have gender-specific healthcare needs that may benefit from specific internet-based interventions (Goldstein et al., 2018). In this regard, performing a gender analysis is relevant to determine the effectiveness of internet-based interventions, which may lead women to adopt a more proactive behaviour in the treatment, maintenance and follow-up of their pain.

In the current context, it is worth noting the high prevalence of women with chronic pain and the different patterns exhibited by women in health and help-seeking patterns and use of care (Arman et al., 2019; Osika Friberg et al., 2016). Considering the above, an updated systematic review applying a gender perspective is needed to help occupational therapists to choose the appropriate intervention for specific chronic conditions. To our knowledge, no previous study has focused on the effects of internet-based interventions for women with chronic pain. Therefore, the aim of this review was to evaluate the effects of internet-based interventions in women with chronic pain focusing on physical and psychosocial outcomes.

Method

This systematic review was conducted from January to March 2018 according to the guidelines outlined in the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement (Moher et al., 2009). It was registered in PROSPERO (CRD42015030227). The searches were updated in November 2019 to identify papers that may have potentially been published during the preparation of this paper for submission. The objective was to update the systematic review conducted by Bender et al. (2011) to identify all the clinical trials focused on women with chronic pain and internet-based interventions in the PubMed/MEDLINE, ScienceDirect and Web of Science databases published from 1 January 2010 to 1 November 2019 to identify the recent areas of interest and scientific evidence in this area. The search terms used were ‘chronic pain’, ‘internet-based’, ‘internet-delivered’, ‘internet-assisted’, ‘web-based’, ‘web-delivered’, ‘web-assisted’, ‘computer’, ‘computerised’, ‘online’, ‘app’, ‘mobile applications’, ‘women’, ‘treatment’, ‘intervention’ and ‘program’. Reference lists of the articles were also examined to find additional studies.

Articles were included if they met the following inclusion criteria: prospective randomised controlled trials, a percentage of women higher than 90% among participants included, chronic pain for more than 18 years without restrictions of ethnicity or setting and internet-based interventions for chronic pain management delivered alone or supplemented by an additional modality compared to a control group or other types of interventions not using the internet. This review aimed to combine information from studies using different outcome measures to provide an overview to clarify the effects on physical and psychosocial outcomes. We excluded studies that included participants with cancer pain, visceral pain, radiculopathy and postoperative pain. We also excluded animal studies, reviews, commentaries, case studies and conference presentations. The languages of the articles included in this review were limited to English, Spanish and French.

The data and results of the articles included were extracted by two independent reviewers and discussed with a third reviewer if there was a lack of consensus. The first step was to find and exclude duplicated articles from the different databases. Next, titles and abstracts were screened to identify relevant articles. Subsequently, the full texts of relevant articles were read in detail to determine their eligibility (Figure 1).

Figure 1.

Categorisation flowchart showing clinical trial selection.

A data extraction form was developed to ensure that all relevant information was captured. Descriptive information included first author, year of publication, number of participants, aim, age of women, inclusion criteria and the number and percentage of dropouts overall and per attrition from random allocation to post-intervention assessment. The characteristics of interventions were also recorded, including the description of the interventions delivered, duration and frequency, main outcomes and results.

Methodological quality was assessed using the Cochrane Collaboration’s tool for assessing the risk of bias (Higgins et al., 2011). This scale includes the following in its score: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome, incomplete outcome data, selective reporting and other forms of bias. Two reviewers independently assessed the items as having a ‘high risk of bias’, ‘low risk of bias’ or ‘unclear risk of bias’. Discrepancies were solved by discussion and, if consensus could not be reached, a third reviewer was invited to make a final judgement.

It was not possible to undertake a meta-analysis due to the low number of studies addressing similar outcomes and the broad differences in the measures used to assess them.

Results

The initial literature search resulted in 2369 articles. After removing duplicates, 2201 titles were screened. After that, 137 full-text articles were assessed for eligibility and 130 were excluded. A total of seven articles were included in this systematic review (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Nes et al., 2017; Salaffi et al., 2015; Simister et al., 2018; Tavallaei et al., 2018; Vallejo et al., 2015) (Figure 1).

Table 1 shows the general characteristics of the studies selected. These studies included a total of 562 women with chronic pain whose mean age ranged between 32 and 67 years. No overall summaries of age were included in the studies conducted by Salaffi et al. (2015), Nes et al. (2017) or Tavallaei et al. (2018). In addition, there was no information on the age of specific groups in the study by Simister et al. (2018), and the mean age of participants in the control group was not reported in the study by Nes et al. (2017). Five studies included women with fibromyalgia (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Salaffi et al., 2015; Simister et al., 2018; Vallejo et al., 2015), one study included women with chronic primary headaches (Tavallaei et al., 2018) and one included women with chronic widespread pain (Nes et al., 2017). The aim of most studies was to assess the efficacy of internet-based or smartphone-delivered treatments in the health of women with chronic pain. Dropout rates in web-assisted trials varied significantly.

Table 1.

Main characteristics of the articles selected.

Article (first author, year, country)	Disease	Number of groups	Sample size	Mean age for total sample and groups (standard deviation)	Inclusion criteria	n (% dropouts) at post-intervention
Salaffi, 2015, Italy	Fibromyalgia	2: EG and CG	76: EG = 38; CG = 38	Total sample: not reported EG: 48.3 (11.3)CG: 49.6 (12.3)	Had an average numerical rating scale pain score of ≥4; had been on stable doses of fibromyalgia medications for ≥4 w	Overall: 4 (5.26) EG: 2 (5.26) CG: 2 (5.26)
Vallejo, 2015, Spain	Fibromyalgia	3: CBT, ICBT and WLG	60: CBT = 20; ICBT = 20; WL = 20	Total sample: 51.55 (9.87) WLG: 51.33 (10.03) CBT: 53.50 (8.56) ICBT: 49.82 (11.01)	Meet the American College of Rheumatology research classification criteria for fibromyalgia, age ≥18 y, adequate reading comprehension and access to and ability to use a computer	Overall: 7 (11.6) WLG: 0 (0) CBT: 3 (15) ICBT: 4 (20)
Friesen, 2017, Canada	Fibromyalgia	2: EG and WLG	60: EG = 30; CG = 30	Total sample: 48 (11) EG: 49 (10) WL: 46 (13)	Age ≥18 y, diagnosis of fibromyalgia, pain for more than 3 months, clinically significant symptoms of fibromyalgia and at least mild symptoms of depression or anxiety	Overall: 8 (13.33) EG: 5 (16.67) WLG: 3 (10)
Hedman-Lagerlöf, 2018, Sweden	Fibromyalgia	2: iExp and CG	140: iExp = 70; CG = 70	Total sample: 50.3 (10.9) EG: 51.8 (10.7) WLG: 49. 3 (10.0)	Age ≥18 y with a confirmed fibromyalgia diagnosis who had internet access and who would agree to refrain from any other psychological treatment for the duration of the study	Overall: 2 (1.43) EG: 2 (2.86) WLG: 0 (0)
Nes, 2017, Norway	Chronic widespread pain	2: SMI and CG	88: SMI = 48; CG = 40	Total sample: not reported SMI: 43 (11.12) CG: not reported	Not reported	Overall: 28 (20) SMI: 22 (31.43) CG: Not reported
Simister, 2018, Canada	Fibromyalgia	2: ACT+TAU and TAU	67: ACT+TAU = 33; TAU = 34	Total sample: 39.7 (9.36) Groups: not reported	Age ≥18 y, formal diagnosis of fibromyalgia, and self-reported pain intensity rating of at least 4/10	Overall: 9 (13.43) Act+TAU: 6 (18.18) TAU: 3 (8.82)
Tavallaei, 2018, Iran	Chronic primary headaches	2: EG and CG	30: EG = 15: CG = 15	Total sample: not reportedEG: 32.47 (9.11) CG: 34.87 (9.12)	Diagnosis by expert physician, age 18–50 y, least education degree of diploma and access to internet and social network of telegram	Overall 0 (0) EG: 0 (0) CG: 0 (0)

ACT: acceptance and commitment therapy; CBT: cognitive-behavioural therapy; CG: control group; EG: experimental group; ICBT: internet-delivered cognitive-behavioural therapy; iExp: internet-based exposure therapy; SMI: smartphone maintenance intervention; TAU: treatment as usual; WLG: waiting-list group; w: weeks; y: years.

The main characteristics of the interventions proposed are reported in Table 2. Cognitive-behavioural therapy (Friesen et al., 2017; Vallejo et al. 2015), exposure therapy (Hedman-Lagerlöf et al., 2018), acceptance therapy (Nes et al., 2017), mindfulness (Tavallaei et al., 2018) and multicomponent therapy (Salaffi et al., 2015; Simister et al., 2018) were the main interventions. The authors proposed a multimodal approach including psychoeducation, information and exercise (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Nes et al., 2017; Salaffi et al., 2015; Simister et al., 2018; Vallejo et al., 2015). The interventions were delivered in a period ranging between 8 and 12 weeks. The studies used web pages, internet software, applications or smartphones. The results of studies showed improvements in pain, self-efficacy, pain-related fear and avoidance, pain acceptance, positive feelings, fibromyalgia symptoms, disability, quality of life, anxiety, depression, fatigue and psychological flexibility when internet-delivered programmes were administered (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Nes et al., 2017; Salaffi et al., 2015; Simister et al., 2018; Tavallaei et al., 2018; Vallejo et al., 2015). Improvements were maintained at follow-up in the main outcomes (Friesen et al., 2017; Vallejo et al., 2015).

Table 2.

Characteristics of interventions.

Article (first author, year, country)	Description of internet-based interventions	Duration/ frequency	Main outcomes	Secondary outcomes	Main results
Salaffi, 2015, Italy	Exercise (aerobic, muscle strength and stretching training exercises) and education covering topics related to the characteristics of fibromyalgia	45 min/s 2 times/w 12 w	Fibromyalgia symptoms and impact: FIQ	Fatigue and the quality of sleep: FAS	EG: significantly improved the FIQ (P = 0.0006), fatigue and quality of sleep (P = 0.0002) in comparison with the standard approach according to the Mann–Whitney U-test. Increased the time-integrated area under the curve of the FAS scores
Vallejo, 2015, Spain	Internet-delivered cognitive-behavioural therapy: including psychoeducation about fibromyalgia, relaxation and breathing training through a web application.	120 min/s 10 times/w 10-w	Fibromyalgia symptoms and impact: FIQ	Psychological distress: HADS; Catastrophising: PCS; self-efficacy: CPSS; Coping: CPCI	CBT group: significant improvement in the primary outcome (P<0.001); ICBT group: improvement in self-efficacy; CBT and ICBT groups: significant improvement in psychological distress, depression, catastrophising, using relaxation as a coping strategy (P<0.05); CBT and ICBT groups were dissimilar in efficacy at follow-up. The effect of the three treatment groups in the pre and post-treatment comparisons was assessed using a mixed model repeated measures ANOVA. The ICBT group maintained or improved scores 6 and 12-month follow-up according to ANOVA analyses
Friesen, 2017, Canada	Pain management programme that consists of online lessons focused on information, cognitive behavioral model; and pain management strategies	5–10 min/w 8 w	Fibromyalgia severity and symptomatology: FIQR; pain severity and interference: BPI; anxiety: GAD-7; depression: PHQ-9	Anxiety and depression: HADS; pain self-efficacy: PSEQ; catastrophising and coping: PRSS; fatigue: FSI; fear of movement and re-injury: TSK; quality of life: SF-12	EG: pre- to post-treatment significant improvements in measures of fibromyalgia, depression, pain and fear of pain compared to very minimal changes for the WLG. The range of improvement in primary and secondary outcomes was 8–28% and 7–24% in the EG and –4% to 5% and –5% to 10%, respectively, in the WLG according to a generalised estimation equation analysis. Large between-group effect sizes (Cohen’s d) in BPI severity, BPI interference, PRSS coping and TSK
Hedman-Lagerlöf, 2018, Sweden	Internet-based exposure therapy through a web platform. The protocol included psychoeducation, case examples on exposure and mindfulness exercises and treatment progression based on valued based goals in everyday life	1–3 times/w 10 w	Fibromyalgia symptoms and impact: FIQ	Fatigue: FSS; disability: WHODAS II; quality of life: BBQ; depressive symptoms: PHQ-9; general anxiety symptoms: GAD-7; insomnia: insomnia severity index; pain-related distress: PRS; avoidance behaviours: PIPS	iExp group: superior improvements and significant interaction effects of group and time compared to WLG on fibromyalgia symptoms and impact, and on secondary outcomes based on mixed-effects model analyses, with sustained results. Medium to large effect sizes were shown for most of the measures
Nes, 2017, Norway	Smartphone-delivered maintenance intervention with daily electronic diaries and personalised written feedback based on acceptance and commitment therapy following a 4 w rehabilitation programme	9 w	Pain catastrophising: PCS	Pain intensity: VAS; pain acceptance: CPAQ general health: GHQ; chronic pain values: CPVI, performed physical activity, pain self-management, pain fear and avoidance and positive Feelings: 5-Likert scale (strongly agree-strongly disagree)	SMI: Participants’ pain fear and avoidance decreased. Self-management, pain acceptance, and positive feelings increased significantly. Participants’ performance of physical activity decreased slightly, but the level of commitment was high. The analysis performed was multilevel modeling
Simister, 2018, Canada	Online acceptance and commitment therapy focused on psychoeducation, acceptance, values, cognitive defusion, mindfulness and willingness and committed action	8 w	FM impact: FIQR	Depression: CES-D; pain: McGill pain questionnaire; sleep: Pittsburgh sleep quality index; physical measures: 6-minute walk test and 1-minute sit to stand test	ACT + TAU: Significant improvement (P<0.001) on fibromyalgia impact compared to TAU participants, with large effect sizes Increases in pain acceptance significantly mediated these improvements. Significant improvements in favour of online intervention on measures of depression (P = 0.020), pain (P = 0.010) and kinesiophobia (P = 0.001). The results were analysed using linear mixed effects modeling
Tavallaei, 2018, Iran	Mindfulness-based stress reduction developed using an internet-based bibliotherapy intervention	8 w	Pain intensity: DASS-21; distress: MIDAS; disability: MPQ-SF; mindfulness: MAAS	–	EG: Significant difference between the mean scores of the EG and CG in pain intensity index (P = 0.035), distress (P<0.0001), disability (P<0.0001) and mindfulness (P<0.0001), being higher the in the EG. The analyses were based on multivariate analysis of covariance test at inferential level

ANOVA: analysis of variance; ACT + TAU: acceptance and commitment therapy + treatment as usual; BBQ: Brunnsviken brief quality of life scale; BPI: brief pain inventory; CBT: cognitive-behavioural therapy; CES-D: Center for Epidemiological Studies depression scale; CPAQ: chronic pain acceptance questionnaire; CPCI: chronic pain coping inventory; CPSS: chronic pain self-efficacy scale; CPVI: chronic pain values inventory; DASS-21: depression, anxiety, stress scale – short form; EG: experimental group; FAS: fibromyalgia activity score; FSS: fatigue severity scale; FIQ: fibromyalgia impact questionnaire; FIQR: fibromyalgia impact questionnaire–revised; FSI: fatigue symptom inventory; GAD-7: generalised anxiety disorder 7-item; GHQ: general health questionnaire; HADS: hospital anxiety and depression scale; ICBT: internet-delivered cognitive-behavioural therapy; iExpG: internet-based exposure therapy; MAAS: mindfulness inventory; MIDAS: migraine disability assessment scale; MPQ-SF: McGill’s short form questionnaire; PCS: pain catastrophising scale; PHQ-9: patient health questionnaire 9-item; PIPS: psychological inflexibility in pain scale; PRS: pain reactivity scale; PRSS: pain responses self-statements; PSEQ: pain self-efficacy questionnaire; S: session; SF-12: medical outcomes study short form-12; SMI: smartphone maintenance intervention; TSK: Tampa scale of kinesiophobia; TAU: treatment as usual; VAS: visual analogue scale; w: weeks; WHODAS II: WHO disability assessment schedule; WLG: waiting list group.

Details regarding the risk of bias are shown in Table 3. Five trials were at low risk of bias due to random sequence generation (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Salaffi et al., 2015; Simister et al., 2018; Vallejo et al., 2015) and incomplete outcome data (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Salaffi et al., 2015; Tavallaei et al., 2018; Vallejo et al., 2015). However, six studies were at high risk of bias in relation to the blinding of participants and personnel (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Nes et al., 2017; Salaffi et al., 2015; Simister et al., 2018; Tavallaei et al., 2018) and five were at high risk of bias regarding the blinding of the outcome assessment (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Nes et al., 2017; Salaffi et al., 2015; Vallejo et al., 2015). In addition, four trials had an unclear risk of bias related to allocation concealment (Friesen et al., 2017; Nes et al., 2017; Tavallaei et al., 2018; Vallejo et al., 2015) and selective reporting (Nes et al., 2017; Salaffi et al., 2015; Tavallaei et al., 2018; Vallejo et al., 2015).

Table 3.

Quality assessment using the Cochrane Collaboration’s tool for assessing risk of bias.

Article (first author, year, country)	Random sequence generation	Allocation concealment	Blinding of participants and personnel	Blinding of outcome assessment	Incomplete outcome data	Selective reporting	Other bias
Salaffi, 2015, Italy	Low	Low	High	High	Low	Unclear	Low
Vallejo, 2015, Spain	Low	Unclear	Unclear	High	Low	Unclear	Low
Friesen, 2017, Canada	Low	Unclear	High	High	Low	Low	Low
Hedman-Lagerlöf, 2018, Sweden	Low	Low	High	High	Low	Low	Low
Nes, 2017, Norway	Unclear	Unclear	High	High	High	Unclear	Low
Simister, 2018, Canada	Low	Low	High	Low	High	Low	Low
Tavallaei, 2018, Iran	Unclear	Unclear	High	Unclear	Low	Unclear	Unclear

Discussion and implications

The purpose of the present systematic review was to assess published randomised controlled trials that explored the effects of internet-based interventions in women with chronic pain. Seven clinical trials were identified as addressing the impact of internet-based interventions in this population. These trials were assessed as having poor to fair quality, with small sample sizes; many of them were not blinded. The most frequent diagnosis was fibromyalgia, one article focused on chronic widespread pain and one article focused on chronic primary headaches. The delivery, format and timeline of the interventions also varied. The main features of interventions included online cognitive-behavioural and/or psychoeducation therapy to improve health with an interactive component.

In our review, most studies that used internet-based interventions to treat women with chronic pain showed improvements in pain intensity, depression and pain-related fear and avoidance (Friesen et al., 2017; Hedman-Lagerlöf et al., 2018; Nes et al., 2017; Simister et al., 2018; Vallejo et al., 2015). These findings are relevant given that fear of movement is associated with functional outcomes, pain severity and depressed mood in individuals with chronic pain (Nijs et al., 2013).

All studies used psychoeducation to treat women, but it was always combined with other therapies. For example, two trials included cognitive-behavioural therapy (Friesen et al., 2017; Vallejo et al., 2015) and both showed improvements in depression and catastrophising. Vallejo et al. (2015) demonstrated that the group receiving internet-delivered cognitive-behavioural therapy improved in several self-efficacy measures (i.e. global, pain and coping with symptoms), whereas the cognitive-behavioural group did not improve in these measures.

Behaviour change strategies have been shown to be reliably delivered in an internet-based healthcare environment and have been perceived to build client engagement (Nalder et al., 2018). Internet-delivered therapy is carried out in patients’ home environments. This setting could be a facilitator for the generalisation of treatment effects. A previous review (Macea et al., 2010) reported that cognitive-behavioural therapy is also useful to treat pain-related depression. Women who underwent this therapy also exhibited better self-pain management and attitudes toward their pain. The internet delivery may lead to an increase in the personal power of the patient with chronic pain. Nes et al. (2017) combined acceptance and commitment therapy with exercises through web pages and smartphones and showed improvements in self-efficacy, fear, pain acceptance and positive feelings. Various authors (Buhrman et al., 2016; Trompetter et al., 2016) have demonstrated the benefits of online acceptance and commitment therapy for chronic pain patients, with changes in pain intensity, pain interference, depressive symptoms, acceptance of pain, psychological distress, pain catastrophising, psychological inflexibility and satisfaction. In addition, Hedman-Lagerlöf et al. (2018) combined exposure therapy with psychoeducation and obtained improvements in fear, disability, pain, quality of life, anxiety, depression, fatigue and sleep, but they did not assess self-efficacy. Vugts et al. (2018) showed that computer-based interventions that facilitate compliance and exposure are indicated for relatively young, highly educated female patients with depressed mood. However, there is not enough scientific evidence to verify these results, so future clinical trials are needed to assess internet-delivered exposure therapy in women with chronic pain. A previous study explored the differences between male and female patients with the same level of pain, severity of symptoms, discomfort and somatic health. The results showed a significantly higher activity level, pain acceptance and social support in women while men reported higher kinesiophobia, mood disturbances and lower activity levels (Rovner et al., 2017). The results could potentially be useful to consider while designing rehabilitation programmes.

Internet-based interventions make it possible to tailor healthcare considering gender-specific healthcare needs. According to a recent review, there is a need to examine the effects, efficiency and acceptability of telehealth for women to inform efforts to implement it (Goldstein et al., 2018). In our review, we focused on the effects of internet-based interventions for women with chronic pain in order to analyse the options, results and methodological quality of research.

Previous systematic reviews (Bender et al., 2011; Macea et al., 2010) have reported high quality in their selected trials including both men and women. Regarding the methodological quality of the studies included, most had a high risk of bias.

There is a need for future studies with larger sample sizes and better methodological designs.

This systematic review has certain limitations. For example, the relevant literature published in other languages may have been excluded. We combined studies with different arms of treatment as there are not yet sufficient data within the same comparison group. Moreover, different measures were included in the articles. In addition, the studies selected had small sample sizes and most of them were not blinded. Another limitation was that women in the trials included only had fibromyalgia, chronic primary headaches or widespread chronic pain. Nevertheless, the aim was to provide a summary of the results and main effects to encourage quality research in this area, given the importance and novelty of internet-based treatments now.

Conclusion

There are indicators that suggest that internet-based interventions may be useful for women with chronic pain. However, the validity of such a conclusion is limited as most trials included had a high risk of bias. More rigorous research including adequately powered double-blinded controlled clinical trials is required before it can be stated that such interventions can overcome the current limitations of traditional face-to-face care.

Key findings

Internet-based interventions are a promising approach for women with chronic pain.

Although some benefits were found in women receiving internet-based interventions, more rigorous research is needed in this area.

What the study has added

There are indicators that internet-based interventions may be useful for women with chronic pain; however, more rigorous research is required given the high risk of bias shown.

Footnotes

Research ethics

Ethical approval was not required for this manuscript as it is a systematic review that involves no participants.

Consent

This study was a systematic review and did not involve human participants.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of the article.

Funding

None declared.

Contributorship

All named authors have contributed to and take shared accountability for the study.

ORCID iDs

Esther Prados-Román

Marie Carmen Valenza

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