eHealth
eHealth refers to the deployment of information communication technologies in the healthcare and health research sectors [
1,
2]. Technological advancements and the now ubiquitous nature of technology in daily life offer unprecedented options for delivering health-related interventions. In particular, eHealth interventions for chronic long-term health conditions are becoming increasingly popular, as they offer solutions to some of the typical barriers people experience, including, for example, travel and mobility issues, treatment availability, lack of clinicians with adequate expertise, and financial barriers [
3‐
5]. Indeed, as the value of technology in health research is realised and as the exponential growth and sophistication of eHealth modalities continues, researchers are experimenting with an increasing variety of these modalities in an effort to deliver, assist and support treatment interventions for chronic conditions [
3,
6‐
9]. Examples of eHealth interventions in health research include online interventions, telephone support [
6,
10‐
12], interactive voice response (IVR) [
8], virtual reality [
7] and mobile phone applications [
9]. Importantly, research has found that these technology-assisted interventions for chronic health conditions are efficacious, and promising results have emerged for eHealth research where chronic pain is the outcome of interest.
eHealth and chronic pain
Chronic pain (CP) refers to an unpleasant sensory and emotional experience that relates to actual or potential tissue damage (or described by a person in terms of such damage) that persists for more than 3 months [
13]. CP is a highly prevalent condition and one of the most common causes of long-term disability [
14]. Due to these factors, and as the treatment of chronic conditions more generally turns toward self-management [
15], there is increasing support for eHealth interventions for chronic pain, as evidenced by their increasing numbers in the research literature. The most common eHealth interventions for chronic pain are Internet-based self-management programmes that typically provide psychotherapeutic content [
3,
16].
Recently, a systematic review with a meta-analysis was conducted to evaluate the effectiveness of Internet-delivered psychological therapies for chronic pain. Eccleston et al. found that participants with headache conditions experienced reduced pain, and they also identified a moderate effect for participant disability post-treatment [
16]. In participants with non-headache conditions, the researchers found that psychological treatments improved pain symptoms post-treatment, disability at post-treatment and at follow-up. In addition, moderate effects for depression and anxiety post-treatment were found. However, in their review, Eccleston et al. note that the majority of included studies were online cognitive behavioural therapy (CBT), and as such, the results cannot be extrapolated to other treatment types or modalities [
16].
Heapy et al. [
3] have highlighted that technology literature in other health-related research areas is more advanced than it is in the research domain of chronic pain. For example, several reviews with meta-analyses exist examining the effects of different technology-assisted interventions for depression and anxiety (e.g. Newman et al. [
17], Richards et al. [
18]). Moreover, as Heapy et al. [
3] argue that despite the increasing use of different eHealth modalities deployed in chronic pain interventions specifically, most studies and reviews focus on one modality (e.g. Eccleston et al. [
16]). As a result, this type of research negates the important contribution of comparing the relative strengths and weaknesses of different modalities. In an effort to address these issues and extend the research on technology-assisted treatments for chronic pain, Heapy et al. conducted a systematic review of the different types of technology-assisted interventions; specifically, they examined the efficacy of telephone, interactive voice response (IVR) and Internet-assisted treatments for chronic pain. From their review, Heapy et al. concluded that telephone, IVR and Internet-based interventions were effective for the treatment of chronic pain.
While Heapy et al. were the first to explore and summarise the scope and efficacy of eHealth treatment modalities for chronic pain, there are limitations in their work. For example, Heapy et al. restricted their review to three forms of technology. Furthermore, their findings were based on a systematic review that included a variety of study types, not just randomised controlled trials, and although effect sizes were calculated, the review was primarily descriptive and the effect sizes could only be used for illustrative purposes, as opposed to being used to quantitatively compare technologies. As a result, and as Heapy et al. conclude, ‘current research has yet to find that one of the technology-assisted interventions is superior to the others’ [
3]. In fact, Heapy et al. argue that future research should directly compare different technology-assisted modalities in an effort to identify the most effective approach for the provision of chronic pain self-management [
3].
Why is it important to do this review?
Though there has been a rise in the number of technology-assisted interventions for chronic pain, there is a dearth of research to evaluate the efficacy and relative strengths and weaknesses of these modalities [
3]. From the perspectives of research, healthcare provision and patient well-being, it is extremely important to identify the most effective modality and, in turn, highlight its most efficacious components, such as administrative contact level, therapist contact level, use of automatic feedback and attrition rates, that would inform and improve future eHealth interventions. Therefore, the aim of the current research is to evaluate the efficacy of interventions delivered via eHealth modalities for chronic pain and build upon the research conducted by Eccleston et al. and Heapy et al. [
3,
16]. Specifically, the current review will combine the robustness of the search strategy from Eccleston’s Cochrane review with the research aims of Heapy et al. The current review will further extend their work by using quantitative analysis, namely a network meta-analysis (NMA), to compare and rank the eHealth modalities used for interventions in chronic pain. In the context of a systematic review, an NMA is a statistical technique that enables multiple treatments to be compared using direct and indirect comparisons across trials using a common comparator (see, Jansen et al. [
19], Naci et al. [
20], for further discussion).