PAIN+ CPN

OBJECTIVE: To evaluate the effectiveness of remote rehabilitation interventions for people living with chronic musculoskeletal pain and depression. DESIGN: A systematic review with network meta-analysis (NMA) of randomized controlled trials. LITERATURE SEARCH: We searched the Cochrane Central Register of Controlled Trials, CINAHL, EMBASE, LILACS MEDLINE, PSYNDEX, and PsycINFO databases from inception to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials that evaluated the effectiveness of remote rehabilitation interventions in people with chronic musculoskeletal pain and depression. DATA SYNTHESIS: We used Bayesian random-effects models for the NMA. Effect estimates were comparisons between rehabilitation interventions and waitlist. We performed a sensitivity analysis based on bias in the randomization process, large trials (>100 patients per arm) and musculoskeletal condition. RESULTS: Fifty-eight randomized controlled trials involving 10 278 participants (median sample size: 137; interquartile range [IQR]: 77-236) were included. Interactive voice response cognitive behavioral therapy (CBT; standardized mean difference [SMD] -0.66, 95% credible interval [CrI] -1.17 to -0.16), CBT in person (SMD -0.50, 95% CrI -0.97 to -0.04), and mobile app CBT plus exercise (SMD -0.37, 95% CrI -0.69 to -0.02) were superior to waitlist at 12-week follow-up for reducing pain (> 98% probability of superiority). For depression outcomes, Internet-delivered CBT and telecare were superior to waitlist at 12-week follow-up (SMD -0.51, 95% CrI -0.87 to -0.13) (> 99% probability of superiority). For pain outcomes, the certainty of evidence ranged from low to moderate. For depression outcomes, the certainty of evidence ranged from very low to moderate. The proportion of dropouts attributed to adverse events was unclear. No intervention was associated with higher odds of dropout. CONCLUSION: Interactive voice response CBT and mobile app CBT plus exercise showed similar treatment effects with in-person CBT on pain reduction among people living with chronic musculoskeletal pain and depression had over 98% probability of superiority than waitlist control at 12-week follow-up. Internet-delivered CBT and telecare had over 99% probability of superiority than waitlist control for improving depression outcomes at 12-week follow-up. J Orthop Sports Phys Ther 2024;54(6):1-16. Epub 26 February 2024. doi:10.2519/jospt.2024.12216.

Physician rater

Despite the low certainty of the evidence and the short follow-up period of the studies included in the NMA (8-16 weeks), remote cognitive-behavioral therapy (CBT) is emerging as an effective treatment for chronic musculoskeletal pain and depression. This treatment modality, delivered via internet platforms, mobile applications, interactive voice response, and telephone interventions, is accessible and cost-effective with results comparable to in-person interventions. Remote CBT may represent a viable therapeutic alternative, particularly when traditional in-person treatments are not feasible.

Physician rater

The NMA results support using remote cognitive-behavioral therapy (CBT), although with low certainty of evidence and with the limitations of the short follow-up of the included studies (12 +/- 4 wks) by internet platforms, mobile applications, interactive voice response, and telephone-delivered intervention as an option that are as accessible, affordable, and effective as interventions delivered in person to reduce chronic musculoskeletal pain and depression. This alternative may be considered especially when in-person treatments are not available or feasible.

Rehab Clinician (OT/PT) rater

Interesting, significant, and well-conducted research collecting randomized controlled trials on the effectiveness of remote rehabilitation interventions for people with chronic musculoskeletal pain and depression. The results were similar between cognitive behavioral therapy plus mobile app for cognitive behavioral therapy with exercise and in-person cognitive behavioral therapy, on pain reduction. This could facilitate treatments and reduce waiting lists.

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