Internet-Delivered Cognitive and Behavioural Based Interventions for Adults With Chronic Pain

A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Milena Gandy; Sharon T.Y. Pang; Amelia J. Scott; Andreea I. Heriseanu; Madelyne A. Bisby; Joanne Dudeney; Eyal Karin; Nickolai Titov; Blake F. Dear


Pain. 2022;163(10):e1041-e1053. 

In This Article

Abstract and Introduction


This study examined the efficacy of internet-delivered cognitive and behavioural interventions for adults with chronic pain AND explored the role of clinical and study characteristics as moderators of treatment effects. PubMed, Embase, PsycINFO, CENTRAL and CINAHL were searched to identify randomized controlled trials published up to October 2021. A meta-analysis of 36 studies (5778 participants) was conducted, which found small effect sizes for interference/disability (Hedges' g = 0.28; 95% confidence interval [CI] 0.21–0.35), depression (g = 0.43; 95% CI 0.33–0.54), anxiety (g = 0.32; 95% CI 0.24–0.40), pain intensity (g = 0.27; 95% CI 0.21–0.33), self-efficacy (g = 0.39; 95% CI 0.27–0.52) and pain catastrophizing (g = 0.31; 95% CI 0.22–0.39). Moderator analyses found that interventions which involved clinician guidance had significantly greater effect sizes for interference/disability (g = 0.38), anxiety (g = 0.39), and pain intensity (g = 0.33) compared with those without (g = 0.16, g = 0.18, and g = 0.20, respectively). Studies using an inactive control had greater effects for depression (g = 0.46) compared with active control trials (g = 0.22). No differences were found between treatments based on traditional cognitive behaviour therapy vs acceptance and commitment therapy. Sample size, study year, and overall risk of bias (Cochrane rating) did not consistently moderate treatment effects. Overall, the results support the use of internet-delivered cognitive and behavioural interventions as efficacious and suggest guided interventions are associated with greater clinical gains for several key pain management outcomes.


A recent 2020 Cochrane update concluded that there is now robust evidence across a large evidence base that face-to-face treatments based on Cognitive Behavioural Therapy (CBT) result in small beneficial effects for reducing outcomes of pain, disability, and distress among people with chronic pain.[58] There have, however, been calls for innovative approaches for providing pain management programs and psychological therapies, which have the potential to increase access to such care.[46] The recent events of the COVID-19 pandemic have also highlighted the value of alternative delivery methods for psychological therapies, with many face-to-face pain services forced to close in some jurisdictions.[22] Cognitive and behavioural based interventions are the most commonly used psychological therapies for pain management and include traditional CBT and newer forms of acceptance and commitment therapy (ACT) and mindfulness based cognitive therapy (MBCT).[7,23,58]

Internet-delivered forms of psychological therapy may be one means of increasing remote access to psychological care for people with chronic pain. These remotely delivered treatments are designed to provide the same information and skills as face-to-face psychological therapy but are delivered and accessed via the internet, either with or without therapeutic support usually termed guided or unguided.[34] While the most recent Cochrane update excluded internet-delivered trials,[58] some early reviews in the area highlight their potential. For instance, a 2014 Cochrane review of internet-delivered psychological therapies for adults with chronic pain (k = 15, n = 2012) concluded that these remote treatments appeared promising, with positive effects for pain, disability, depression, and anxiety at posttreatment.[23] However, uncertainty remained about the estimates of the effects because of the small number of trials at the time and the high risk of bias across trials. A subsequent meta-analysis in 2016 (k = 22; n = 2354) reported small to moderate effects of internet-delivered cognitive and behavioural based interventions compared with controls on measures of interference/disability (Hedges' g = 0.39), pain intensity (g = 0.33), pain catastrophizing (g = 0.49), and depression (g = 0.26).[7] However, given the small number of heterogeneous studies included (eg, combining both child and adult pain patients), conclusions were tentative, and it was not possible to conduct meaningful moderator analyses. Since these reviews, the literature has steadily grown with many additional clinical trials examining internet-delivered psychological interventions published.

Currently, little is known about whether certain clinical, treatment, or study characteristics influence treatment response to internet-delivered psychological therapies for chronic pain.[7] This information is important as it can help guide the adoption and implementation of these treatments, as well as inform future clinical research.[25,59] Reflecting this, a recent topical issue within the general internet-delivered CBT (iCBT) literature has focussed on the role of level of clinical guidance on treatment effects.[1] Although unguided interventions are often favoured as they are considered a more cost-effective and scalable option, a recent meta-analysis of iCBT for depression suggest that guided iCBT is more clinically effective than unguided iCBT, especially for individuals with moderate-to-severe depression.[34] There may be a similar impact of guidance level on treatment outcomes for people with chronic pain. Furthermore, factors related to treatment modality and the conduct and quality of clinical trials, such as control type, sample size, year, and risk of bias reporting, can also influence effects of psychological therapies.[15] However, the association of these clinical, treatment, and study characteristics have yet to be examined in relation to internet-delivered psychological treatments for chronic pain.

The current study provides an updated meta-analysis of the efficacy of internet-delivered cognitive and behavioural based interventions, for adults with chronic pain on several key primary (ie, interference/disability, anxiety, depression) and secondary outcomes (ie, pain intensity, pain self-efficacy and pain catastrophizing) of interest in pain management. The study also examined the influence of key clinical and study characteristics on treatment effects, including level of clinician guidance, intervention modality, and study quality.