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Chronic low back pain is one of the most common presenting complaints to a physician’s office. Treatment is often challenging and recovery depends on various factors, often resulting in significant investments of time and resources.
The aim of this review is to determine which Web-based interventions aimed at chronic low back pain are of benefit to patients.
Randomized controlled trials (RCTs) studying Web-based interventions directed at adults with chronic low back pain were included. Retrospective studies, narrative reviews, nonrandomized trials, and observational studies were excluded. Electronic databases and bibliographies were searched.
In total, nine unique RCTs were identified (total participants=1796). The number of patients randomized in each trial ranged from 51 to 580. Four trials studied online cognitive behavioral therapy (CBT) and five trials studied other Web-based interventions with interactive features. Empowerment/control was improved in six studies. Use of CBT was associated with reduced catastrophization among patients. Mixed results were reported with regards to reduction in pain levels and disability, although some studies showed promise in reducing disability in the short term. One study that measured health care utilization reported reduced utilization with the use of moderated email discussion.
Limited data are available regarding effective Web-based interventions to improve outcomes for patients with chronic low back pain. Nine RCTs with small sample sizes were identified in this review. Online CBT appears to show some promise in terms of reducing catastrophization and improving patient attitudes. Further research in this area with larger-scale studies focusing on appropriate outcomes appears to be a priority.
Low back pain is one of the most common presenting complaints in physicians’ offices in North America [
Although the prognosis for low back pain remains good if the pain resolves in the acute phase (less than 3 months), individuals unable to do so may face a slow recovery at significant cost to self and the health care system [
Due to the complex nature of chronic low back pain, effective treatment may include use of a multidisciplinary team (MDT). A MDT may be composed of a number of professionals, including a kinesiologist, physiotherapist, psychologist, occupational therapist, and pharmacist. A recent review reports that intensive multidisciplinary rehabilitation improves function in chronic back pain [
Recently, there has been some interest in using the Internet as a channel to offer interventions to treat chronic low back pain. This has several advantages. Some of the barriers that apply to face-to-face meetings with medical professionals may be ameliorated through the Internet. For example, patients can use online resources at their own convenience and may be able to reduce their health care-related costs. It is possible that Web-based interventions may lead to patient empowerment by supporting ownership over their health thereby encouraging patients to be more proactive about the treatment, maintenance, and follow-up of their condition.
The purpose of this review is to summarize randomized controlled trials (RCTs) that assess the effectiveness of Web-based interventions to support patients with chronic low back pain.
Electronic databases were searched for relevant citations between January 2000 and September 2014, including MEDLINE, PUBMED, and EMBASE. Search terms included: “Internet based,” “Internet-based,” “Internet Delivered,” “Internet-Delivered,” “Web based,” “Web-based,” “World Wide Web,” “Online,” “Telemedicine,” “Tele-medicine,” “Email,” “E-mail,” “Mobile,” “Phone,” “Smartphone,” “Tablet,” “intervention,” “treatment,” “therapy,” “communication,” “counseling,” “education,” “educational,” “instruction,” “management,” “self management,” “chronic,” “recurrent,” “duration greater than 3 months,” “low back pain,” “low-back pain,” “lower back pain,” “lumbar,” “lumbosacral region,” “mechanical,” “degenerative disc disease,” “sciatica,” “myofascial back pain,” “nonspecific back pain,” and “adult”. Publication types and study designs of interest including systematic reviews, meta-analyses, practice guidelines, RCTs, and controlled clinical trials. Bibliographies of eligible articles were also searched for relevant studies. Selected journals were also searched individually for any relevant publications.
Articles were eligible for inclusion in this review if they were RCTs studying Web-based interventions directed at adults with chronic low back pain. Retrospective studies, narrative reviews, nonrandomized trials, and observational studies were excluded. However, references listed in these publications were reviewed to look for any studies that may match inclusion criteria for this review. Trials including children or trials including patients with acute pain were also excluded. RCTs studying interventions aimed at prophylaxis or other types of chronic pain were excluded. Studies published in languages other than English were excluded.
After the literature search identified potentially relevant articles, the articles were screened based on titles and abstract. Articles were excluded if they were not RCTs, the patient population was unsuitable for this review, the intervention was not Internet-based, or for other reasons (
PRISMA flow diagram.
Citations identified by the literature search strategy were screened for eligibility by two of the authors (SG, DG) and discrepancies were resolved using the opinion of the other authors. Information regarding the patient characteristics, intervention, duration, study characteristics, study design, and outcome measures was extracted from each eligible trial by one author (SG) and then reviewed independently by the other authors. Information required to assess the characteristics of studies was reviewed, including method of randomization, whether statistical analyses were performed by intention-to-treat, and allocation concealment [
The search revealed nine RCTs published between 2002 and 2014.
Trial design and details regarding the interventions used in the studies are presented in
Patient characteristics including demographics are listed in
A variety of diverse outcome measures were used; outcome measures used by each study are available in
Study characteristics (N=9).
Study | Year | Randomization | Intention-to-treat analysis | Allocation | Lost to follow-up, n (%) |
Lorig et al [ |
2002 | Not described | Performed by using last known data | Unclear | 159 (27.4) |
Burhman et al [ |
2004 | Not described | Not performed | Unconcealed | 5 (9) |
Chaiuzzi et al [ |
2010 | Adaptive/stratified randomization | Yes | Unclear | 10 (5) |
Burhman et al [ |
2011 | Webpage (random.org) | Yes | Performed through webpage | 4 (7.4) |
Carpenter et al [ |
2012 | Random number table | Not performed | Unclear | 23 (16.3) |
Moessner et al [ |
2012 | Not described | Yes | Unclear | 4 (5.3) |
Krein et al [ |
2013 | Random number generator | Yes | Assignment of participants through automated email message | 19 (8.2) |
Riva et al [ |
2014 | Random number generator (permuted block randomization method) | Yes | No face-to-face contact; no identifying information linked to patient assessment | 0 (0) |
Weymann et al [ |
2015 | Simple computerized randomization procedure | Yes | Concealed random allocation automatically performed using software | 180 (47) |
Trial design of included studies.
Study | Patients randomized | Intervention | Control | Duration | Measurement Time |
Lorig et al [ |
580 | Moderated email discussion group; back pain help book; videotape | Control group received usual care | 1 year | Baseline, 6 and 12 months |
Burhman et al [ |
56 | Web-based multimodal pain management program (CBT, stretching and exercise); weekly submission of pain diaries; weekly telephone support | Waitlist | 8 weeks | Baseline, 8-weeks and 3-months postintervention |
Chiauzzi et al [ |
228 | painACTION back pain website based on CBT and chronic pain management principles that provided tailored information to participants logging in twice weekly | Control group received copy of back pain help book | 6 months | Baseline, 1, 3, and 6 months |
Burhman et al [ |
54 | Web-based multimodal pain management program based on CBT; no weekly telephone support | Waitlist | 12 weeks | Baseline and 12 weeks |
Carpenter et al [ |
141 | Web-based wellness workbook | Waitlist | 6 weeks | Baseline, 3 and 6 weeks |
Moessner et al [ |
75 | Intervention consisted of: individualized self-monitoring module, moderated Internet-based chat | Treatment as usual | 15 weeks | Baseline, 115 and 202 days |
Krein et al [ |
229 | Intervention: pedometer with access to uploaded personal walking data, walking goals, feedback, participation in e-community | Enhanced usual care group also received pedometers but no access to walking goals or feedback | 12 months | Baseline, 6 and 12 months |
Riva et al [ |
51 | RCT with two arms: intervention and control group | Intervention group received access to back pain management website with interactive features (virtual gym, action plan, testimonials, quiz game); control group also used website, but no interactivity | 8 weeks | Baseline, 4 and 8 weeks |
Weymann et al [ |
382 (chronic low back pain) | Web-based information system for patients which was tailored for individual needs and dialog based | Access to information through website without tailoring or use of dialogs | 12 weeks | Baseline, first visit, and 3 months |
Patient characteristics of included studies.
Study | Patients randomized | Demographics | Inclusion criteria | Exclusion criteria |
Lorig et al [ |
580 | Control group: 61% male, mean age 45 years; intervention group: 62% male, mean age 46 years | One outpatient visit for back pain within last year | Continuous back pain for >90 days causing major activity intolerance; no physician visits for back pain in past year; receiving disability payments; red flag symptoms; planned back surgery; back pain due to systemic illness; pregnancy; unable to understand English |
Burhman et al [ |
56 | 62.5% female; mean age 44.6 years (SD 10.4) | Age 18-65 years; access to Internet; previous contact with physician; lumbar/thoracic/cervical back pain; chronic pain ≥3 months | Wheelchair bound; planned surgery; cardiovascular disease |
Chiauzzi et al [ |
228 | 67% female; mean age 46.14 years (SD 11.99) | Presence of back pain for ≥10 days, for ≥3 consecutive months; spinal origin of pain; English language fluency | Nonspinal medical or systemic conditions that explain the back pain; cervical pain without low back pain; psychiatric hospitalization within past year |
Burhman et al [ |
54 | 68.5% female; mean age 43.2 years (SD 9.8) | Access to Internet; chronic pain ≥3 months duration | Planned surgery; wheelchair bound; cardiovascular disease |
Carpenter et al [ |
141 | 83% female; mean age 42.5 years (SD 10.3) | Non-cancer-related back pain; duration ≥6 months; mean pain rating >4; access to Internet; | Age <40 years (applied after start of study); CBT within past 3 years; pain duration <6 months |
Moessner et al [ |
75 | Control group: 54.3% female, mean age 46.6 years (SD 7.7); intervention group: 57.5% female mean age 45.2 years (SD 10.2) | Age >18 years; prior multidisciplinary treatment for 1 week | Cancer-related pain; insufficient Language skills; treatment duration <1 week |
Krein et al [ |
229 | Control group: 86% male, mean age 51.9 years (SD 12.8); intervention group: 89% male, mean age 51.2 years (SD 12.5) | Persistent back pain; ≥3 months; self-reported sedentary lifestyle (<150 min of physical activity per week); Internet access | Inability to walk one block; pregnancy |
Riva et al [ |
51 | Control group: 50% female, mean age 51 years (SD 14.1); intervention group: 51.9% female, mean age 44 years (SD 13.6) | Age >18 years; back pain >3 months; Italian native speakers | Concurrent involvement in other study |
Weymann et al [ |
382 (chronic low back pain) | Control group: 59.1% female, mean age 52.7 years (SD 13); intervention group: 58.5% female, mean age 52.2 years (SD 13.1) | Age >18 years; chronic back pain defined as pain almost every day for period >12 weeks; diabetes type 2 | Age <18 years; duration of pain <12 weeks; lack of Internet access |
Outcomes of included studies.
Study | Outcome measuresa | Catastrophizationb | Empowerment/Controlb | Painb | Disabilityb |
Lorig et al [ |
Pain (VNS); disability (RMQ); role function; health distress (MOS); health care utilization | NA | Increase | Increase | Increase |
Burhman et al [ |
CSQ; MPI; PAIRS; HADS; pain diary; treatment credibility; satisfaction with treatment format | Increase | Increase | No effect | NA |
Chaiuzzi et al [ |
BPI; ODQ; DASS; PGIC; CPCI-42; PCS; PSEQ; FABQ | Increase | Increase | No effect | No effect |
Burhman et al [ |
CSQ; MPI; PAIRS; QOLI | Increase | No effect | No effect | NA |
Carpenter et al [ |
Primary: SOPA; others: FABQ, NMRS, PCS, RMQ, SES | Increase | Increase | No effect | No effect |
Moessner et al [ |
Pain intensity (NRS); SF-36; RMQ; KPD-38; Secondary: HADS (anxiety,; depression), general psychologic impairment | NA | NA | Increase | Increase |
Krein et al [ |
Primary: RMQ, MOS; others: pain intensity, Fear-Avoidance Beliefs Questionnaire physical activity subscale | NA | Increase | No effect | Increase (6-month assessment); no effect (12-month assessment); |
Riva et al [ |
Empowerment (PES); exercise; medication misuse; pain burden | NA | Increase | Increase | NA |
Weymann et al [ |
heiQ; patient knowledge; decisional conflict; preparation for decision making | NA | No effect | NA | NA |
aBPI: Brief Pain Inventory; CPCI-42: Chronic Pain Coping Inventory; CSQ: Coping Strategies Questionnaire; DASS: Depression Anxiety Stress Scale; FABQ: Fear-Avoidance Beliefs Questionnaire; HADS: Hamilton Anxiety and Depression Scale; heiQ: Health Education Impact Questionnaire; KPD-38: Clinical Psychological Diagnostic System; MOS: Medical Outcomes Study; MPI: Multidimensional Pain Inventory; NMRS: Negative Mood Regulation Scale; NRS: Numeric Rating Scale; PAIRS: Pain and Impairment Relationship Scale; PCS: Pain Catastrophizing Scale; PES: Psychological Empowerment Scale; PGIC: Patients’ Global Impression of Change Scale; PSEQ: Pain Self-efficacy Questionnaire; QOLI: Quality of Life Inventory; RMQ: Roland-Morris Disability Questionnaire; SES: Pain Self-efficacy Scale; SOPA: Survey of Pain Attitudes; VNS: Visual Numeric Scale.
bIn intervention group. NA: not available.
The studies were presented in two subsections: studies using online cognitive behavioral therapy (CBT) and studies using Web-based approaches to improve knowledge (with an interactive component to provide coping support).
The following trials were registered: Burhman et al [
Psychological factors, such as depressed mood, negative beliefs, and somatization, have been shown to affect chronicity of pain and disability related to the pain [
Burhman et al [
Burhman et al [
Carpenter et al [
Chaiuzzi et al [
In summary, four small RCTs reporting the effects of Web-based CBT for chronic back pain have been identified. All studies found reduced catastrophization in patients receiving online CBT.
Each of the trials used different measures to report pain levels. These measures included the Pain and Impairment Relationship Scale (PAIRS), Pain Self-efficacy Scale (SES), a pain diary, and self-reported pain levels for least, average, and worst pains. Of the studies that examined CBT, only Carpenter et al [
Web-based interventions with interactive features are being increasingly studied for their potential role in the management of chronic diseases. The results from a recent review indicated Web-based interactive interventions for patients with a variety of chronic conditions may have a positive impact on patient empowerment and may facilitate enhanced physical activity [
The studies discussed in this section target knowledge about chronic low back pain by providing online resources and also provide support for coping through Web-based interactive features.
Lorig et al [
Moessner et al [
Krein et al [
Riva et al [
Weymann et al [
The study aimed to detect differences with conventional levels of confidence and 80% power; however, due to attrition, only 202 of 382 chronic low back pain participants performed the 3-month follow-up. No significant differences were detected in outcomes with the intention-to-treat analysis.
Two of the studies [
Four of the studies did measure empowerment/self-efficacy and mixed results were reported. Empowerment was reported to be improved in one of the studies [
A variety of diverse outcome measures have been used in the studies. Lorig et al [
Nine unique RCTs were identified addressing the impact of Web-based interventions on chronic low back pain. The major categories of interventions included online CBT and to improve knowledge with an interactive component to provide coping support. The trials identified had small sample sizes and many of them were not blinded. In terms of power calculations, three of the trials reported being underpowered. There is considerable concern with external validity for these study results. The demographics of the population included for the different studies were heterogenous. The delivery, format, and timeline of the interventions were also heterogenous. Most studies only reported posttreatment data and there is a lack of long-term follow-up. In the studies that do report longer-term data, the treatment effects seem to taper off with time [
Many of the studies excluded patients receiving disability payments, a significant part of the population that experiences chronic back pain. As such, the absence of research on this subpopulation is a major gap that should be addressed in future studies. The effect of Web-based interventions on health care utilization was reported by only one study [
Four RCTs reporting the effects of Web-based CBT for chronic back pain were identified for this review. Three of the studies report reduced catastrophization in patients receiving online CBT. In previous studies on chronic pain, catastrophization has been linked to increased severity of pain, poor treatment outcomes, and increased disability [
Further, there are various limitations to the studies using online CBT. All studies randomized small numbers of patients at single centers. Some of the studies are not adequately powered. One study was waitlist controlled, which can be problematic because this can make the results of the treatment effect appear more significant than it actually is. Intention-to-treat analysis was not conducted in two of the studies; therefore, participants with suboptimal compliance are excluded from parts of the analysis. Also, the form and type of delivery of supports in addition to online intervention were variable. For example, Burhman et al [
Another limitation is that most of the participants in the studies were females, which may affect the generalizability of the results. Some of the studies excluded patients with comorbidities such as heart disease; this may affect how results can be interpreted because many patients seen in practice with low back pain have significant comorbidities, which may also limit generalizability. In general, the samples in the studies may have been so carefully selected that their external validity is questionable.
Further, none of the studies included groups receiving face-to-face CBT as controls; therefore, it is not possible to estimate the efficacy of online CBT in comparison with the traditional approach. Overall, the research indicates that online CBT may be effective in reducing catastrophization and improving patient attitudes toward back pain, particularly when supported with telephone or email follow-up. However, additional RCTs with larger and more diverse samples are required to further investigate whether this intervention can be effective in reducing pain, disability, and health care costs. Furthermore, studies must be conducted to consider independent effects from total effects for each aspect of treatment.
Five RCTs reporting effects of Web-based approaches to improve knowledge and coping support. Three of these studies reported a reduction in disability [
These studies have a number of limitations. One omission is that Riva et al [
Although research on many of the Web-based interventions for back pain reviewed here had mixed results or do not appear to have high external validity, we did find evidence that that there are likely some benefits to online CBT for reduced catastrophization. As such, online interventions may be a useful solution to overcome current limitations of traditional face-to-face CBT because, for example, access to professionals that are able to deliver high-quality CBT remains limited. Second, many patients may not be able to afford access to such professionals or counseling. Third, physical access may also be limited due to the nature of pain, patient comorbidities, or other social factors, and large geographical distances may preclude eligible patients from accessing specialized rehabilitation or chronic pain centers. Fourth, in some cases, there may be a stigma associated with the use of a therapist or counselor. Therefore, online access to CBT may help to alleviate some of the barriers to access and provide patients a convenient alternative to face-to-face visits. Future studies using CBT as an intervention should consider including appropriate numbers of male participants to improve the generalizability of the results.
Further, empowerment/control did show improvement in six of the studies. Three of these used CBT, whereas three of the studies used other forms of Web-based support, such as email/chat or other interactive features. It appears that forms of social support other than formalized counseling or CBT may have some positive effect on the patient’s ability to manage and cope with their chronic condition.
Disability was only assessed in five of the studies and mixed results were reported. Further research in this area with studies having longer follow-up should be a priority. One study reporting health care utilization reported positive effects with the intervention. It would be important for future studies to assess this further because it is important to focus resources on interventions that can reduce use of health care resources. Further research that includes these outcomes could provide insight into future planning for the health care system and implications for clinical practice.
Brief Pain Inventory
cognitive behavioral therapy
Chronic Pain Coping Inventory
Coping Strategies Questionnaire
Depression Anxiety Stress Scale
Fear-Avoidance Beliefs Questionnaire
Hamilton Anxiety and Depression Scale
Health Education Impact Questionnaire
Medical Outcomes Study
multidisciplinary team
Multidimensional Pain Inventory
Negative Mood Regulation Scale
Numeric Rating Scale
Pain and Impairment Relationship Scale
Pain Catastrophizing Scale
Psychological Empowerment Scale
Patients’ Global Impression of Change Scale
Pain Self-efficacy Questionnaire
Quality of Life Inventory
randomized controlled trial
Roland-Morris Disability Questionnaire
Self-Efficacy Scale
Survey of Pain Attitudes
Visual Numeric Scale
The authors wish to acknowledge support from the Department of Family Medicine at the University of Calgary.
None declared.