Evaluating Real-World Adherence and Effectiveness of the "Reboot Online" Program for the Management of Chronic Pain in Routine Care

Pain patterns and their association with psychological measures among people accessing an online pain management program

AIM

This study aimed to explore the association between the distribution of pain sites and psychosocial measures at baseline of patients enrolled in an online MPMP.

PATIENTS

This study analyzed baseline data from adults (N = 2002) enrolled in the 'Reboot Online' pain program.

METHODS

Participants completed measures of Pain Self-Efficacy Questionnaire (PSEQ), Tampa Scale for Kinesiophobia (TSK), Pain Disability Index (PDI), Patient Health Questionnaire (PHQ-9), and Kessler Psychological Distress Scale (K-10). Pain was categorized by the number of body regions affected: 1, 2, 3, >3. One-way ANOVA tests examined psychosocial measure differences across these groups.

RESULTS

The majority of participants had multisite pain, with multisite pain showing significantly worse psychosocial outcome measures (p < .05) compared to those with a single pain site, except for kinesiophobia, which was consistently high across groups.

CONCLUSION

Most online participants reported multisite pain, with multisite pain associated with poorer baseline psychosocial outcome measures, excluding kinesiophobia. The pattern of pain should be considered when developing and implementing online programs.

Examining the Effectiveness and Acceptability of Internet-Delivered Psychological Pain Management for Regional and Rural Australians With Chronic Pain

OBJECTIVE

To examine the characteristics, satisfaction levels and clinical outcomes of rural and remote Australians with chronic pain completing an internet-delivered psychological pain management program (PMP).

DESIGN

Longitudinal routine care cohort study.

SETTING

An Australian national digital psychology service.

PARTICIPANTS

Patients in inner regional locations (n = 401), outer regional and remote locations (n = 198), and major cities (n = 968), who used the service over a 6-year period.

MAIN OUTCOME MEASURES

Demographic and clinical data, patient-reported satisfaction and improvements, and meaningful clinical improvements (≥ 30% improvement).

RESULTS

Clinical improvements were observed from pre-treatment to post-treatment in pain-related disability (32% [95% CI: 29, 34]), depression symptoms (44% [95% CI: 39, 49]), anxiety symptoms (43% [95% CI: 39, 47]), and average pain intensity (23% [95% CI: 21, 26]), which were maintained to 3-month follow-up. High levels of satisfaction and treatment completion were also observed. Minor demographic and clinical differences were observed. However, there were similar rates of clinical improvement, treatment satisfaction and treatment completion in all groups.

CONCLUSIONS

The current findings further highlight the value of internet-delivered psychological PMPs for Australians with chronic pain living in regional and remote parts of the country. Further work is needed to raise awareness about the availability of these effective programmes and to integrate their use with traditional pain management services.

How therapeutic relationships develop in group-based telehealth and their perceived impact on processes and outcomes of a complex intervention: a qualitative study

BACKGROUND

Therapeutic relationships are a key domain in healthcare delivery. While well-understood in in-person interventions, how therapeutic relationships develop in more complex contexts is unclear. This study aimed to understand (1) how therapeutic relationships are developed during the telehealth delivery of a group-based, complex intervention and (2) the perceived impact of these relationships on intervention processes, such as intervention delivery and engagement, and patient outcomes, such as patient safety and satisfaction.

METHODS

This qualitative study, nested within a randomised controlled trial, used an interpretivist approach to explore the perceptions of 25 participants (18 patients with shoulder pain and 7 clinicians) regarding developing therapeutic relationships in a group-based, complex intervention delivered via telehealth. Semi-structured interviews were conducted within 4 weeks of the telehealth intervention period and then analysed through in-depth, inductive thematic analysis.

RESULTS

We identified six themes: (1) 'Patients trust clinicians who demonstrate credibility, promoting the development of therapeutic relationships'; (2) 'Simple features and approaches shape the therapeutic relationship', including small talk, time spent together and social observation; (3) 'A sense of belonging and support fosters connections', facilitated by clinicians providing individualised attention within the group; (4) 'Developing therapeutic relationships can impact the delivery of core intervention components', reflecting challenges clinicians faced; (5) 'Therapeutic relationships can facilitate intervention engagement', through enhanced patient understanding and confidence and (6) 'Therapeutic relationships can contribute to patient safety and satisfaction', with patients feeling more comfortable reporting intervention-related issues.

CONCLUSIONS

Therapeutic relationships were developed during group-based telehealth sessions through a set of factors that may require additional skills and effort compared with in-person interactions. While these relationships have a perceived positive impact on intervention engagement and patient outcomes, clinicians need to find a balance between building relationships and delivering the telehealth intervention with fidelity.

TRIAL REGISTRATION NUMBER

ACTRN12621001650886.

Internet-Delivered Psychological Pain Management: A Prospective Cohort Study Examining Routine Care Delivery by a Specialist Regional Multidisciplinary Pain Service

Several clinical trials have demonstrated the effectiveness of internet-delivered psychological-based pain management programs (PMPs). However, to date, no large studies have reported the outcomes of PMPs when delivered by specialist multidisciplinary pain services in routine care. The present study reports (n = 653) the outcomes of an internet-delivered PMP provided as routine care by a specialist Australian regional pain service over a 6-year period. High levels of treatment commencement (85%) and completion (72%) were observed, with more than 80% of patients reporting they were satisfied with the intervention. Clinical improvements were observed from pretreatment to post-treatment (% change, 95% confidence intervals (CI)) in pain-related disability (8.8%; 4.5, 12.8), depression (28.4%; 23.0, 33.4), anxiety (21.9%; 14.6, 28.5), and pain intensity (7%; 3.5, 10.5), which were maintained to 3-month follow-up. At 3-month follow-up, 27% (23, 31), 46% (41, 51), 44% (39, 49), and 22% (19, 26) reported clinically meaningful (defined as ≥ 30%) improvements in pain-related disability, depression, anxiety, and pain intensity, respectively. These results were obtained with relatively little therapist time per patient (M = 30.0, (standard deviation) SD = 18.8) to deliver the intervention. The current findings highlight the potential of internet-delivered PMPs as part of the services provided by specialist pain services, particularly those servicing large geographical regions and for patients unable to travel to clinics for face-to-face care. PERSPECTIVE: This study reports the outcomes of the routine delivery of an internet-delivered psychological PMP by a specialist pain service. The findings highlight the potential of this model of care when provided by specialist pain services, particularly for patients not unable to attend and not requiring intensive face-to-face care.

The association between physical intervention use and treatment outcomes in patients participating in an online and psychologically informed pain management program

BACKGROUND

The availability of multidisciplinary care for the management of chronic pain is uncommon outside specialist clinics. The present study aims to determine the physical intervention use of patients participating in an online psychological pain management program and whether exposure to physical interventions in these patients alters treatment outcomes compared with patients who do not access physical interventions.

METHODS

Data were obtained from 2 previously published randomized controlled trials of an online psychological pain management program. Physical intervention exposure (categories: none, 1-3 sessions, 4+ sessions) was assessed at baseline, after treatment, and at 3-month follow-up. Primary outcomes included depression, anxiety, pain intensity, and pain-related disability. Generalized estimating equation models were used to compare treatment outcomes among those with different physical intervention frequencies and periods of exposure. We assessed whether changes in primary outcomes differed (moderated) by the period and category of physical intervention exposure.

RESULTS

Of the patients (n = 1074) who completed the baseline questionnaire across both randomized controlled trials, 470 (44%) reported physical intervention use at baseline, 383 (38%) reported physical intervention use after treatment, and 363 (42%) reported physical intervention use at 3-month follow-up. On average, there were moderate-large reductions from baseline to after treatment with respect to all outcomes (Cohen's d = 0.36-0.82). For all outcomes, the interaction of time by physical intervention exposure was statistically nonsignificant.

CONCLUSION

A substantial proportion of patients who participated in a psychologically informed pain management program were establishing, continuing, or stopping additional physical interventions. The frequency of and period of exposure to physical interventions did not appear to moderate treatment outcomes.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12613000252718 and ACTRN12615001003561). The website for registration information is https://www.anzctr.org.au.

Virtual multidisciplinary pain treatment: Experiences and feedback from children with chronic pain and their caregivers

BACKGROUND

The onset of the coronavirus disease 2019 (COVID-19) necessitated a rapid transition to virtual care for chronic pain treatment.

OBJECTIVE

This study examined experiences of patients and caregivers who received virtual multidisciplinary pain treatment (MDT) for pediatric chronic pain between March 2020 and August 2021.

METHODS

A mixed methods design was implemented using qualitative interviews and quantitative satisfaction surveys. Satisfaction surveys were administered to a convenience sample of patients (aged 8 to 18; N = 20) and their caregivers (N = 20) who received MDT through an outpatient hospital pediatric chronic pain program. Interviews were conducted with a subset of these patients and their caregivers (n = 6).

RESULTS

Analysis of interviews revealed four themes: 1) benefits of virtual care; 2) challenges of virtual care; 3) recommendations and evaluation of virtual care; and 4) patient preferences. Analysis of the satisfaction survey data revealed that while patients and caregivers were satisfied with many aspects of virtual care, 65% (n = 13) of patients reported a preference for in-person appointments, with caregivers showing equal preference for in-person and virtual appointments, though this was a non-significant difference (p = .37). Overall, both patients and caregivers stated a stronger preference for in-person physiotherapy sessions but were willing to have psychology sessions provided virtually. Finally, the most reported preference was for a hybrid model of care incorporating at least some in-person contact with providers.

CONCLUSION

This study provides a rich exploration of virtual care for multidisciplinary pediatric chronic pain treatment. The current results may inform the future development of guidelines for virtual care delivery with pediatric chronic pain populations.

Evaluation of a therapist-guided virtual psychological pain management program when provided as routine care: a prospective pragmatic cohort study

INTRODUCTION

Numerous randomized controlled trials have evaluated the outcomes of internet-delivered psychological pain management programs (PMPs) as a way of increasing access to care for people with chronic pain. However, there are few reports of the effectiveness of these PMPs when provided as part of routine care.

METHODS

The present study sought to report the clinical and demographic characteristics of users (n = 1367) and examine the effectiveness of an established internet-delivered psychological PMP program in improving several pain-related outcomes, when offered at a national digital mental health service over a 5-year period. It also sought to comprehensively explore predictors of treatment commencement, treatment completion, and clinical improvement.

RESULTS

Evidence of clinical improvements (% improvement; Hedges g) were found for all outcomes, including pain interference (18.9%; 0.55), depression (26.1%; 0.50), anxiety (23.9%; 0.39), pain intensity (12.8%; 0.41), pain self-efficacy (-23.8%; -0.46) and pain-catastrophizing (26.3%; 0.56). A small proportion of users enrolled but did not commence treatment (13%), however high levels of treatment completion (whole treatment = 63%; majority of the treatment = 75%) and satisfaction (very satisfied = 45%; satisfied = 37%) were observed among those who commenced treatment. There were a number of demographic and clinical factors associated with commencement, completion and improvement, but no decisive or dominant predictors were observed.

DISCUSSION

These findings highlight the effectiveness and acceptability of internet-delivered psychological PMPs in routine care and point to the need to consider how best to integrate these interventions into the pathways of care for people with chronic pain.

Neurocognitive predictors of adherence to an online pain self-management program adjunct to long-term opioid therapy

INTRODUCTION

While pain self-management programs can significantly improve patient outcomes, poor adherence is common and the need for research on predictors of adherence has been noted. A potential, but commonly overlooked, predictor is cognitive function. Our aim, then, was to examine the relative influence of various cognitive functional domains on engagement with an online pain self-management program.

METHOD

A secondary analysis of a randomized controlled trial testing the impact of E-health (a 4-month subscription to the online Goalistics Chronic Pain Management Program) plus treatment as usual, relative to treatment as usual alone, on pain and opioid dose outcomes in adults receiving long-term opioid therapy of morphine equivalence dose ≥20 mg; 165 E-health participants who completed an on-line neurocognitive battery were included in this sub-analysis. A variety of demographic, clinical, and symptom rating scales were also examined. We hypothesized that better processing speed and executive functions at baseline would predict engagement with the 4-month E-health subscription.

RESULTS

Ten functional cognitive domains were identified using exploratory factor analysis and the resultant factor scores applied for hypothesis testing. The strongest predictors of E-health engagement were selective attention, and response inhibition and speed domains. An explainable machine learning algorithm improved classification accuracy, sensitivity, and specificity.

CONCLUSIONS

The results suggest that cognition, especially selective attention, inhibitory control, and processing speed, is predictive of online chronic pain self-management program engagement. Future research to replicate and extend these findings seems warranted.

CLINICALTRIALS.GOV REGISTRATION NUMBER

NCT03309188.

Community-based pain programs commissioned by primary health networks: key findings from an online survey and consultation with program managers

OBJECTIVE

There is an increasing demand for tertiary pain services, with long waiting times compounded by limited reach to regional and remote areas. Community-based pain programs are a feasible evidence-based model of care to improve access to multidisciplinary care. Australian primary health networks (PHNs) are well placed to commission pain programs to reduce the growing burden of chronic pain. The aim of this study was to support PHN decision-making by: (1) describing current PHN community-based pain programs; (2) assessing their alignment to key elements and implementation enablers of pain programs identified by an expert consensus process; and (3) describing PHN pain program adaptations during the COVID-19 pandemic.

METHODS

PHN program managers of community-based pain programs (n  = 9) were invited to participate in an online survey and follow-up email consultation about their pain program. Six PHN program managers (representing South Eastern NSW PHN, Nepean Blue Mountains PHN, North Western Melbourne PHN, Gold Coast PHN, Adelaide PHN and the WA Primary Health Alliance) participated in the study with three PHNs commissioning two different types of pain programs.

RESULTS

PHN community-based pain programs are multidisciplinary programs underpinned by a biopsychosocial model of pain, and focus on self-management (e.g. exercise, psychological strategies) and pain education. Most PHN pain programs are group-based programs that target adults with chronic non-cancer pain, provide individual allied health referrals as required and are evaluated as part of the electronic Persistent Pain Outcomes Collaboration. Gaps include pain programs for Aboriginal and Torres Strait Islander people, and people from culturally and linguistically diverse backgrounds, with one notable exception of a PHN pain program for people from culturally and linguistically diverse and refugee backgrounds co-designed with consumers and relevant services. Programs targeting subacute pain to prevent progression to chronic pain are, with one exception, another gap area. PHN pain programs demonstrated a high level of alignment with expert-agreed key elements and implementation enablers. The COVID-19 pandemic precipitated the rapid adaptation of PHN pain programs using available methods for the delivery of digitally enabled care.

CONCLUSIONS

The findings provide a greater understanding for researchers and PHN decision-makers of the key features of PHN community-based pain programs, their alignment with expert-agreed key elements and implementation enablers, the target-population gaps, and the types of program adaptations during the COVID-19 pandemic. The findings also illustrate the potential for using digitally enabled delivery methods to increase accessibility to pain programs with further research warranted.

Lived experiences of pain in children and young people with cerebral palsy

AIM

To explore the lived experiences of pain in children and young people with cerebral palsy (CP).

METHOD

Participants were recruited from the Sydney Children's Hospitals Network and the New South Wales/Australian Capital Territory CP Registers. Inclusion criteria were as follows: CP; aged 9 to 17 years; current/past experience of pain; fluent in English; no greater than mild intellectual disability. Purposive sampling ensured representation across age, motor subtypes, and Gross Motor Function Classification System (GMFCS) levels. Semi-structured face-to-face interviews were conducted. Data were analysed following an interpretative phenomenological approach.

RESULTS

Ten participants (three male) were included (mean age 14y 5mo, SD 2y), GMFCS levels I (n=4), II (n=3), III (n=2), and IV (n=1). Analysis led to three superordinate themes: (1) Everybody's experience of pain is different; (2) When the pain is winning; (3) 'I know how to deal with it'. Pain contributors and locations varied between children. Pain intruded on school, physical activity, and psychosocial functioning. Children described personalized strategies used to deal with pain.

INTERPRETATION

In this study, children self-reported highly individualized pain experiences which interfered with their daily life and psychosocial well-being. There is a need for improvement in pain assessment and a personalized approach to pain management.

The Effect of Adjunct Telephone Support on Adherence and Outcomes of the Reboot Online Pain Management Program: Randomized Controlled Trial

Background

Internet-based treatment programs present a solution for providing access to pain management for those unable to access clinic-based multidisciplinary pain programs. Attrition from internet interventions is a common issue. Clinician-supported guidance can be an important feature in web-based interventions; however, the optimal level of therapist guidance and expertise required to improve adherence remains unclear.

Objective

The aim of this study is to evaluate whether augmenting the existing Reboot Online program with telephone support by a clinician improves program adherence and effectiveness compared with the web-based program alone.

Methods

A 2-armed, CONSORT (Consolidated Standards of Reporting Trials)–compliant, registered randomized controlled trial with one-to-one group allocation was conducted. It compared a web-based multidisciplinary pain management program, Reboot Online, combined with telephone support (n=44) with Reboot Online alone (n=45) as the control group. Participants were recruited through web-based social media and the This Way Up service provider network. The primary outcome for this study was adherence to the Reboot Online program. Adherence was quantified through three metrics: completion of the program, the number of participants who enrolled into the program, and the number of participants who commenced the program. Data on adherence were collected automatically through the This Way Up platform. Secondary measures of clinical effectiveness were also collected.

Results

Reboot Online combined with telephone support had a positive effect on enrollment and commencement of the program compared with Reboot Online without telephone support. Significantly more participants from the Reboot Online plus telephone support group enrolled (41/44, 93%) into the course than those from the control group (35/45, 78%; χ²₁=4.2; P=.04). Furthermore, more participants from the intervention group commenced the course than those from the control group (40/44, 91% vs 27/45, 60%, respectively; χ²₁=11.4; P=.001). Of the participants enrolled in the intervention group, 43% (19/44) completed the course, and of those in the control group, 31% (14/45) completed the course. When considering the subgroup of those who commenced the program, there was no significant difference between the proportions of people who completed all 8 lessons in the intervention (19/40, 48%) and control groups (14/27, 52%; χ²₁=1.3; P=.24). The treatment efficacy on clinical outcome measures did not differ between the intervention and control groups.

Conclusions

Telephone support improves participants’ registration, program commencement, and engagement in the early phase of the internet intervention; however, it did not seem to have an impact on overall course completion or efficacy.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12619001076167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001076167

OUP accepted manuscript

Objectives

Societal and health system pressures associated with the coronavirus disease 2019 (COVID-19) pandemic exacerbated the burden of chronic pain and limited access to pain management services for many. Online multidisciplinary pain programs offer an effective and scalable treatment option, but have not been evaluated within the context of COVID-19. This study aimed to investigate the uptake and effectiveness of the Reboot Online chronic pain program before and during the first year of the COVID-19 pandemic.

Methods

Retrospective cohort analyses were conducted on routine service users of the Reboot Online program, comparing those who commenced the program during the COVID-19 pandemic (March 2020–March 2021), to those prior to the pandemic (April 2017–March 2020). Outcomes included the number of course registrations; commencements; completion rates; and measures of pain severity, interference, self-efficacy, pain-related disability, and distress.

Results

Data from 2,585 course users were included (n = 1138 pre-COVID-19 and n = 1,447 during-COVID-19). There was a 287% increase in monthly course registrations during COVID-19, relative to previously. Users were younger, and more likely to reside in a metropolitan area during COVID-19, but initial symptom severity was comparable. Course adherence and effectiveness were similar before and during COVID-19, with moderate effect size improvements in clinical outcomes post-treatment (g = 0.23–0.55).

Discussion

Uptake of an online chronic pain management program substantially increased during the COVID-19 pandemic. Program adherence and effectiveness were similar pre- and during-COVID. These findings support the effectiveness and scalability of online chronic pain management programs to meet increasing demand.