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

ABSTRACT

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.

Summary.

• What is already known

  • ○
    Multidisciplinary care is recommended for many patients with chronic pain.
  • ○
    Psychological pain management programmes are a key component of care.
  • ○
    Access to effective psychological pain management is limited, particularly for patients in regional and remote locations.
  • ○
    Internet‐delivery of management programmes is proving an effective and acceptable way of increasing access to care.
• What this study adds

  • ○
    This is the first study to comprehensively examine the outcomes of an internet‐delivered pain management programme for regional and remote Australians.
  • ○
    The study finds high levels of treatment completion and acceptability as well as good clinical outcomes for regional and remote Australians.
  • ○
    The study highlights the potential of these programs to support primary care and increase access to psychological pain management for regional and remote Australians.

1. Introduction

Chronic pain is a common and costly health condition, significantly affecting about one in twenty adults [1], and is associated with significant functional and psychological impairment, including high rates of anxiety and depression [2, 3, 4]. Multidisciplinary treatment is now recommended for the treatment of chronic pain, especially for more severely affected patients [5, 6]. Moreover, pain is a subjective experience that is recognised to be influenced by mood states and coping skills [5] that are modifiable with psychological interventions, which are now key components of care for many patients [7]. Psychological interventions are designed to help people manage persistent pain and its impacts by supporting the use of a broad range of cognitive and behavioural self‐management skills.

Chronic pain is predominantly managed by general practitioners (GPs) in Australia who coordinate the involvement of other disciplines, such as physical therapists and psychologists, and referral to specialist pain services [8, 9, 10, 11]. A recent survey identified 109 specialist pain services across the country, most of which (75%) were located in urban centres [12, 13]. An increase in the number of services in the last 10 years has resulted in a significant reduction in waiting times, but the median wait time for an initial consultation at a public pain service was 110 days, with a large range (12–1277 days). Most specialist pain services (83%) offered some form of allied health‐led pain management intervention or programme, although there was wide variation in the content, structure and intensity, ranging from 2‐h educational group interventions to highly intensive, multi‐week programmes with as much as 120 h of content, including integrated physical restoration and psychological therapy [12]. Unfortunately, the recent survey provided only limited data on the provision of psychological interventions, although previous surveys found only a small proportion of all patients seen in specialist pain services are offered evidence‐based psychological care [9].

In addition to the limited capacity of specialist services, barriers to accessing psychological treatment for chronic pain include the distance from services, especially for people whose mobility is limited by pain; the limited numbers of clinicians trained to deliver evidence‐based programmes, and the direct and indirect costs for both patients and health providers [8, 9, 14, 15]. Hence there is considerable interest in the potential of internet‐ and telehealth‐delivered programs to improve access to psychological care for patients with chronic pain [16]. Internet‐delivered programmes use online learning management systems to provide access to the same therapeutic information and to teach the same self‐management skills as face‐to‐face programmes, with clinician support provided via telephone and secure messaging systems [17, 18], making them highly accessible and scalable for suitable patients.

There is now a large evidence base confirming the efficacy of internet‐delivered pain management programmes. For example, a recent meta‐analysis (k = 36; n = 5778) found significant improvements in pain‐related disability, pain intensity, depression and anxiety, with the better outcomes for programmes provided with clinician support [16]. Reflecting this, several Australian digital psychological services now offer these programs “direct‐to‐the‐public” as part of routine care [19, 20]. For example, the MindSpot Clinic [21], which is funded by the Australian Government, has offered an internet‐delivered pain management program (PMP) since mid‐2017 for both self‐referred and clinician‐referred patients with chronic pain [19]. A recent report of outcomes from this program (n = 1367) found significant clinical improvements (defined as ≥ 30% improvements) in pain‐related disability (37%), pain intensity (27%), depression (47%) and anxiety (47%) by 3‐month follow‐up [19] as well as high levels of treatment satisfaction, confirming their potential to increase access to psychologically based pain management for patients who do not require intensive face‐to‐face care.

Internet‐delivered PMPs have particular potential for rural and regional patients with chronic pain, given the limited availability of pain services outside of major metropolitan regions. To date, only one study has examined the use of internet‐delivered PMPs for rural and regional patients with chronic pain [22]. This study (n = 653) examined the delivery of an internet‐delivered PMP by a regional pain service, the North Queensland Persistent Pain Service (NQPPMS), directly to its patients. NQPPMS is a multidisciplinary pain service receiving referrals from general practice and medical specialists and integrated the internet‐delivered PMP into its routine services with the aim of increasing access to psychological pain management among its patients, in part by removing the burden of repeated travel (e.g., 8 times over 4 weeks) to the clinic to participate in their traditional face‐to‐face program. Importantly, that study observed high levels of treatment completion and satisfaction and good rates of clinical improvements (defined as ≥ 30%) in pain‐related disability (27%), depression (46%), anxiety (44%), and pain intensity (22%) at 3‐month follow‐up. While encouraging of their potential for rural patients, most patients with chronic pain never receive referral to specialist tertiary care, and no studies have examined internet‐delivered PMPs for rural and regional patients when provided “direct‐to‐the‐public” by digital psychological services.

The current study reports on the results of an internet‐delivered PMP for regional and rural Australians with chronic pain when offered as routine care by the MindSpot Clinic. It reports: (1) the clinical and demographic characteristics of regional and rural patients; (2) the effectiveness of the programme across several pain‐related outcomes and (3) levels of patient satisfaction and treatment engagement. For benchmarking and comparison purposes, the data of regional and rural patients is compared with those living in major cities.

2. Method

2.1. Design and Participants

Participants were patients of the MindSpot Clinic (https://www.mindspot.org.au) between April 2017 and December 2023 [23]. The MindSpot Clinic was launched in 2012 and is funded by the Australian government to increase access to psychological assessment and treatment for residents across Australia. MindSpot is a high‐volume digital psychology service that provides services to approximately 30 000 Australians each year, at no cost to patients. It provides online and telephone‐based mental health assessments with brief assessment reports, advice, information and referral, and in the 12 years of operation has introduced a range of internet‐delivered interventions for common mental health disorders and other conditions associated with psychological distress and impairment, such as chronic pain. Patients can self‐refer into the service or are referred by GPs and medical specialists. All services are provided with access (via telephone and secure messaging systems) to therapists who are employed, trained and supervised by the service.

Entry into the service starts with the completion of a brief online assessment via the clinic's website. The online assessment takes 20–30 min and involves the completion of various self‐report symptom scales and collecting questions about disability, medication, treatment history and reasons for engaging with the service. Once complete, a brief assessment report is automatically generated, and patients are invited to schedule an appointment with a therapist to discuss their symptoms and difficulties, answer questions and confirm their suitability for remote treatment. All patients are actively triaged within the service, and those requiring urgent care are actively supported to access appropriate services [24].

Over the study period, 1913 patients were enrolled in the services' internet‐delivered PMP, and 1577 (82%) started the programme. Location data was not provided by 10 patients, resulting in a final cohort of 1567 patients available for analysis. All patients needed to discuss their assessment results with a therapist to ensure their suitability for enrolment into the PMP. Therapists ensured that patients were ≥ 18 years of age, experienced chronic pain as a primary problem, the pain was affecting their day‐to‐day function or mental health, and that their pain had been assessed and was being managed by a doctor. Patients whose pain has not been appropriately assessed or who were not under the active care of a doctor were advised to consult a medical professional before enrolling in the course. Some of the data in the current study has previously been reported without examination of patient region [19]. Approval for the current study was provided by the Macquarie University Medical Sciences Human Research Ethics Committee (520221101840066) using an ‘opt‐out’ consent approach.

2.2. The Pain Course

The internet‐delivered PMP used by the clinic, the Pain Course, comprises 5 core modules which are delivered over 8 weeks. The programme was developed over more than 10 years and has been evaluated in several large randomised controlled trials [17, 18, 25, 26]. It is modelled on traditional face‐to‐face PMPs and is based on transdiagnostic cognitive and behavioural principles. It is designed to be suitable for people with pain from a range of causes and aims to reduce the impact of chronic pain on patient's day‐to‐day function and mental health. It provides evidence‐based pain and mental health education while also supporting patients to learn a broad range of psychological self‐management skills. The program content and format are described in detail elsewhere [17, 18, 25, 26]. In brief, the education covers the physiology of chronic pain and the importance of psychological responses to pain, while patients are taught psychological symptom formulation, thought and belief challenging, controlled breathing, activity scheduling, activity pacing, graded exposure, lapse management and goal setting as core skills for pain management. Several additional optional modules are made available to patients, which provide information and skills for managing sleep, working with health professionals, problem‐solving, attention management, managing relationships, and effective communication. After the active 8‐week component of the treatment, patients have access to the programme for a further 5 months.

The intervention is accessed via the clinic's website and software platform using a unique patient account and password. Each module is presented in the form of a slide show, comprising 30–40 slides and taking 10–20 min to read. The modules are released according to a weekly schedule, which is designed to support the patient's progression through the course. Each module is a combination of didactic information and case stories and examples from previous patients, sharing their experiences living with and learning to manage pain.

2.3. Therapist Support

The programme is provided with support by trained and supervised therapists employed by the service. Therapists introduce themselves in the first week of the programme via telephone or secure messaging system and inform patients that they are available throughout the programme to provide a range of support them, including answering questions, helping to tailor the programme to individual difficulties and goals, helping to understand and practise skills, and providing general psychotherapeutic support. Working with a therapist through the programme is optional, but therapists attempt to engage patients reporting more severe symptoms or difficulties or who are struggling with the programme content. The training encourages therapists to keep their contacts and support sessions brief (e.g., 20–30 min per week), although they can spend more time if clinically indicated. The therapists are mostly psychologists, but there are also social workers, occupational therapists and nurses, who are all trained in the delivery of remote treatment. All therapists are supervised using a purpose‐built learning and supervision pathway until they are assessed as competent and feel confident to deliver the intervention independently.

2.4. Measures and Outcomes

All data were collected via MindSpot's management platform, which collects demographic and clinical information and presents relevant questionnaires to participants at pre‐treatment, mid‐treatment, post‐treatment and 3‐month follow‐up. The questionnaires and their administration are described in detail elsewhere [19], and only some of the questionnaire results are reported here.

The primary clinical outcomes were pain‐related disability, depression and anxiety, assessed using the interference items of the Brief Pain Inventory (BPI; score range 0–70) [27], the Patient Health Questionnaire 9‐item (PHQ‐9; score range 0–27) [28] and the Generalised Anxiety Disorder 7‐Item (GAD‐7; score range 0–21) [29], respectively. The secondary clinical outcome was average pain intensity over the previous month, which was assessed using the average pain item of the Wisconsin Brief Pain Questionnaire (WBPQ; item score range 0–10) [30].

Three standardised questions were used to assess participant satisfaction, consistent with past studies [19]. These questions asked if they would “recommend the [programme] to others?”, if the “[programme] was worth their time?”, and “overall, how satisfied [they] were?”. Participants responded to the first two questions with a “yes” or “no” response, and the last using a 5‐point scale from “very dissatisfied” to “very satisfied”. Participants were also asked about their perception of improvements in their confidence to manage “day‐to‐day activities with pain”, “low mood and depression” and “stress and anxiety”. Participants responded on a 5‐point scale ranging from “greatly increased” to “greatly decreased” with a sixth option to indicate that this was not an area they had difficulties.

2.5. Statistical Analyses

Statistical analyses were conducted using R v4.3.1, the MICE v3.16.0 [31], geepack v1.3.9 [32] and ggplot2 [33] packages. Patients' location was categorised based on the Australian Bureau of Statistics Australian Statistical Geography Standard (ASGS Edition 3) Remoteness Structure using patient postcode data. This structure involves five classes of relative geographical remoteness: Major Cities of Australia, Inner Regional Australia, Outer Regional Australia, Remote Australia, and Very Remote Australia. In the current study, patients within the Outer Regional (n = 176), Remote (n = 14) and Very Remote (n = 8) categories were collapsed into a single Outer Regional and Remote category (n = 198). Consistent with past research [19, 21], patients completing 4 or more of the core modules were considered to have completed treatment.

Descriptive statistics were calculated for participant demographic and baseline clinical characteristics, and logistic and linear regressions were used to compare participants in Inner Regional and Outer Regional and Remote patients with patients in Major Cities. These regression analyses examined whether region was associated with demographic or clinical variables. All regressions used patients living in major cities as the reference category to identify differences between patients in major cities and those in inner regional and regional and remote locations. Where there were multiple levels to a variable (e.g., pain duration), these regressions also focused on the differences within each level (e.g., less than 1 year). An intent‐to‐treat approach was adopted for all outcome analyses. Missing data was handled through the Multiple Imputation procedure with the generation of 5 modelled datasets, considering module completion, pre‐treatment severity and region.

Consistent with recommendations in the evaluation of treatments for chronic pain populations [19, 34, 35], the proportions of participants reporting ≥ 30% and ≥ 50% improvement from pre‐treatment to post‐treatment and to 3‐month follow‐up were calculated. Patients improving by ≥ 30% were considered to have made a meaningful change, and patients improving by ≥ 50% were considered to have made a major clinical change. The proportions of participants making changes were analysed using a series of binary logistic regressions. All analyses focused on differences between patients in major cities (the reference category) and those in inner regional and outer regional and remote locations, rather than differences between the groups of regional patients. The level of statistical significance was set at 0.01 for all analyses given the large number of analyses undertaken.

3. Results

3.1. Patient Characteristics

Patient demographic and clinical characteristics are reported in Table 1. Key attributes of the sample include that participants most commonly reported having experienced pain for between one and 5 years, many had pain in multiple locations, and most reported pain that was always present. A meaningful proportion (> 13%) had a compensation case regarding their pain, and just under 30% had attended a specialist pain clinic. Some significant differences were found based on location. For example, regional patients were older and were less likely to complete education beyond high school. Outer regional and remote patients were also more likely to be male, less likely to be working, and to have pain of varying intensity that was always present.

TABLE 1.

Demographic and clinical characteristics of participants.

	Overall	Major city	Inner regional	Outer regional and remote
n	1567	968	401	198
Age (mean, SD)	46.5 (14.5)	44.7 (14.8)	49.4 (13.7)**	48.9 (13.4)**
Sex (female; number, %)	1217 (77.7%)	774 (80%)	302 (75.3%)	141 (71.2%)*
Aboriginal and Torres Strait Islander (number, %)	34 (2.7%)	13 (1.7%)	14 (4%)	7 (4%)
State (number, %)
New South Wales	575 (36.7%)	366 (37.8%)	168 (41.9%)	41 (20.7%)
Queensland	406 (25.9%)	249 (25.7%)	80 (24.2%)	77 (38.9%)
Victoria	278 (17.7%)	156 (16.1%)	100 (24.9%)	22 (11.1%)
Western Australia	127 (8.1%)	91 (9.4%)	15 (3.7%)	21 (10.6%)
South Australia	88 (5.6%)	60 (6.2%)	17 (4.2%)	11 (5.6%)
Northern Territory	11 (0.7%)	0 (0%)	0 (0%)	11 (5.6%)
Australian Capital Territory	45 (2.9%)	45 (4.6%)	0 (0%)	0 (0%)
Tasmania	37 (2.4%)	1 (0.1%)	21 (5.2%)	15 (7.6%)
Education (number, %)
High school or less	372 (24.5%)	200 (21.2%)	110 (28.5%)**	62 (33.3%)**
Trade certificate or diploma	502 (33.1%)	291 (30.8%)	145 (37.4%)	66 (35.5%)
Undergraduate degree	312 (20.6%)	229 (24.3%)	54 (14%)*	29 (15.6%)
Postgraduate degree	329 (21.7%)	222 (23.6%)	78 (20.2%)	29 (15.6%)
Employment (number, %)
Full‐time/Part‐time work	668 (43.2%)	451 (47.0%)	149 (37.8%)	68 (35.2%)**
Disability support pension	219 (14.2%)	121 (12.6%)	77 (19.5%)*	21 (10.9%)
Unemployed	188 (12.2%)	111 (11.6%)	43 (10.9%)	34 (17.6%)
Other	470 (30.4%)	275 (28.7%)	125 (31.7%)	70 (36.3%)
Relationship Status (number, %)
Married/De facto	805 (52.5%)	476 (49.6%)	221 (54.5%)	108 (55.3%)
Separated/Divorced	280 (18.0%)	156 (16.2%)	83 (21.0%)	41 (21.0%)
Other	449 (29.3%)	315 (33.3%)	88 (22.4%)**	46 (23.5%)*
Pain Duration (number, %)
Less than 1 year	160 (11.1%)	113 (12.5%)	33 (8.9%)	14 (7.9%)
One to 5 years	569 (39.3%)	369 (41.0%)	134 (36.2%)	66 (37.3%)
6–10 years	268 (18.5%)	163 (18.1%)	70 (18.9%)	35 (19.8%)
More than 10 years	449 (31%)	254 (28.3%)	133 (35.8%)*	62 (35%)
Pain Location (number, %)
Head/face/mouth	459 (30.6%)	288 (31.1%)	120 (31.1%)	51 (27.3%)
Neck/upper back/shoulder	763 (50.9%)	452 (48.8%)	216 (56.0%)	95 (50.8%)
Arms/forearms/hands	611 (40.8%)	345 (37.3%)	176 (45.6%)*	90 (48.1%)*
Lower back/Upper back	1096 (73.1%)	651 (70.3%)	303 (78.5%)*	142 (75.9%)
Buttocks/Hips	816 (54.4%)	511 (55.2%)	204 (52.8%)	101 (54.0%)
Legs/knees/feet	847 (56.5%)	486 (52.5%)	238 (61.7%)*	123 (65.8%)**
Pain presence (number, %)
Always present (same intensity)	74 (6.3%)	42 (5.8%)	24 (7.7%)	8 (5.4%)
Always present (intensity varies)	888 (75.4%)	520 (72.4%)	240 (76.9%)	128 (87.1%)**
Often present (pain free periods < 6 h)	154 (13.1%)	109 (15.2%)	37 (11.9%)	8 (5.4%)*
Occasionally present (present < 1 h at least once a day)	50 (4.2%)	38 (5.3%)	9 (2.9%)	3 (2.0%)
Rarely present (pain occurs every few days or weeks)	11 (0.9%)	9 (1.3%)	2 (0.6%)	0 (0%)
Compensation Status (number, %)
Yes, ongoing	88 (6.3%)	55 (8.8%)	21 (8.4%)	12 (10.9%)
Yes, resolved	99 (7.1%)	55 (8.8%)	38 (15.3%)	6 (5.4%)
Attended Specialist Pain Clinic (number, %)	333 (28.3%)	212 (29.5%)	80 (25.6%)	41 (27.9%)

Note: Percentages are calculated based on the numbers of participants providing data for each question. Inner Regional, Outer Regional and Remote patients were compared to Major City participants on demographic and clinical characteristics. Significant differences are indicated.

^* p < 0.01.

^** p < 0.001.

3.2. Patient Attrition and Adherence

A total of 1132/1567 (72%) completed the treatment, and there were no differences in completion rates based on patient location (ps > 0.624). A total of 1137/1567 (72%) provided data at post‐treatment, and 740/1567 (47%) provided data at 3‐month follow‐up. There were no differences in the proportions of participants providing data across the location groups at either post‐treatment (ps > 0.231) or follow‐up (ps > 0.092).

3.3. Patient Satisfaction

Patient satisfaction data is reported in Table 2. Most respondents were either ‘very satisfied’ (38%; 95% CI: 35, 40) or ‘satisfied’ (31%; 95% CI: 38, 42) with the intervention overall. There were no significant differences between patients in major cities and regional locations in terms of overall satisfaction (ps > 0.625).

TABLE 2.

Participant Satisfaction and self‐reported impacts on confidence to manage.

	Overall	Major city	Inner regional	Outer regional and remote
n	1567	968	401	198
Overall satisfaction
Very satisfied	38% [35, 39]	36% [32, 43]	39% [33, 46]	43% [34, 53]
Satisfied	31% [29, 34]	32% [29, 35]	31% [26, 37]	28% [21, 37]
Neutral	18% [16, 21]	19% [16, 22]	18% [13, 23]	15% [9, 25]
Dissatisfied	7% [4, 10]	8% [5, 12]	5% [2, 10]	4% [1, 8]
Very dissatisfied	4% [2, 6]	3% [1, 5]	5% [2, 10]	7% [3, 15]
Recommend
Yes	85% [81, 88]	84% [79, 88]	88% [82, 92]	84% [71, 92]
Worth time
Yes	83.9% [79.1, 87.8]	85% [78, 89]	82% [75, 87]	81% [72, 87]
Confidence to manage pain on day‐to‐day activities
Greatly increased	17% [15, 20]	17% [14, 19]	18% [14, 24]	19% [12, 28]
Increased	47% [44, 50]	47% [44, 51]	47% [41, 53]	47% [38, 56]
No change/Decreased	28% [25, 31]	30% [26, 33]	27% [22, 34]	23% [15, 33]
Confidence to manage stress and anxiety
Greatly increased	19% [17, 21]	18% [16, 21]	23% [18, 29]	17% [11, 25]
Increased	44% [41, 47]	44% [40, 48]	44% [37, 50]	47% [38, 55]
No change/Decreased	28% [25, 30]	30% [27, 34]	24% [19, 30]	20% [13, 30]
Confidence to manage low mood and depression
Greatly increased	19% [16, 21]	17% [15, 20]	20% [13, 28]	23% [14, 33]
Increased	43% [40, 46]	42% [39, 45]	44% [37, 50]	44% [35, 52]
No change/Decreased	31% [29, 34]	33% [30, 37]	29% [24, 35]	25% [17, 34]

Note: Participants could indicate their confidence had “Decreased” and “Greatly decreased”. However, less than 2% of participants indicated this and consequently these response options were collapsed with “No Change”. Inner Regional and Outer Regional and Remote patients were compared to Major City participants on demographic and clinical characteristics. Significant differences are indicated.

3.4. Patient Reported Confidence to Manage Pain

Patient‐reported improvements are reported in Table 2. Most patients reported improvements in their confidence to manage pain in their day‐to‐day activities, low mood and depression, and stress and anxiety.

3.5. Clinical Effectiveness

The proportions of patients making clinical improvements (≥ 30% from baseline) and major clinical improvements (≥ 50% from baseline) are reported in Table 3 and displayed Figure 1.

TABLE 3.

Proportions meeting criteria for clinically significant (≥ 30%) and major clinically significant (≥ 50%) at post‐treatment and 3‐month follow‐up.

	N	Pre‐treatment	Clinical improvement (≥ 30%)				Major clinical improvement (≥ 50%)
			Pre → Post		Pre → 3MFU		Pre → Post		Pre → 3MFU
		Mean (SE)	%	p	%	p	%	p	%	p
Pain Disability (BPI‐I)
Overall	1567	46.1 (0.423)	32% [29, 34]	< 0.001	37% [34, 39]	< 0.001	14% [13, 16]	< 0.001	19% [16, 21]	< 0.001
Major city	968	44.0 (0.459)	31% [28, 34]	—	38% [33, 42]	—	15% [13, 18]	—	20% [17, 23]	—
Inner regional	401	46.1 (0.704)	34% [28, 39]	0.274	37% [30, 46]	0.901	14% [10, 19]	0.735	18% [13, 24]	0.423
Outer regional and remote	198	48.4 (0.985)	31% [23, 43]	0.992	29% [19, 39]	0.094	13% [7, 20]	0.475	12% [7, 20]	0.039
Depression (PHQ‐9)
Overall	1567	12.1 (0.197)	44% [39, 49]	< 0.001	42% [37, 47]	0.004	23% [20, 27]	< 0.001	21% [18, 24]	< 0.001
Major city	968	11.9 (0.208)	43% [38, 49]	—	40% [35, 46]	—	23% [19, 27]	—	21% [16, 26]	—
Inner regional	401	11.9 (0.201)	47% [41, 54]	0.227	45% [35, 55]	0.331	23% [19, 29]	0.833	23% [16, 32]	0.554
Outer regional and remote	198	12.4 (0.455)	42% [32, 52]	0.795	44% [33, 55]	0.512	27% [20, 35]	0.233	21% [12, 32]	0.996
Anxiety (GAD‐7)
Overall	1567	8.7 (0.168)	43% [39, 47]	0.002	42% [38, 45]	< 0.001	25% [22, 28]	< 0.001	24% [20, 28]	< 0.001
Major city	968	8.7 (0.175)	42% [37, 47]	—	42% [38, 46]	—	23% [19, 27]	—	24% [20, 28]	—
Inner regional	401	8.6 (0.279)	44% [37, 51]	0.488	42% [35, 48]	0.994	27% [21, 34]	0.138	24% [19, 30]	0.988
Outer regional and remote	198	8.8 (0.384)	48% [38, 57]	0.209	43% [31, 55]	0.845	30% [23, 43]	0.041	25% [14, 39]	0.805
Average pain intensity (WBPQ)
Overall	1567	5.6 (0.049)	23% [21, 26]	< 0.001	28% [25, 31]	< 0.001	6% [5, 8]	< 0.001	10% [8, 12]	< 0.001
Major city	968	5.5 (0.054)	23% [20, 26]	—	30% [26, 33]	—	7% [5, 9]	—	11% [9, 13]	—
Inner regional	401	5.8 (0.078)	24% [19, 29]	0.822	27% [22, 33]	0.339	6% [4, 10]	0.607	9% [6, 14]	0.406
Outer regional and remote	198	5.7 (0.116)	23% [17, 31]	0.922	25% [19, 33]	0.237	4% [2, 10]	0.303	8% [4, 15]	0.335

Note: Statistically significant effects at p < 0.01 and 0.001 are presented in bold for easy identification.

FIGURE 1.

Proportions of patients across regions reporting clinical improvements (≥ 30% from baseline to post‐treatment) in each outcome domain.

3.5.1. Pain‐Related Disability

A significant proportion of patients made clinical improvements (32% [95% CI: 29, 34]) and major clinical improvements (14% [95% CI: 13, 16]) in pain‐related disability by post‐treatment (ps < 0.001). These improvements were maintained to the 3‐month follow‐up (ps < 0.001). Inner regional, outer regional and remote patients reported similar improvements to patients in major cities (ps ≥ 0.039).

3.5.2. Depression Symptoms

A significant proportion of patients made clinical improvements (44% [95% CI: 39, 49]) and major clinical improvements (23% [95% CI: 20, 27]) in depression symptoms by post‐treatment (ps ≤ 0.004). No differences were identified based on region (ps ≥ 0.233).

3.5.3. Anxiety Symptoms

A significant proportion of patients made clinical improvements (43% [95% CI: 39, 47]) and major clinical improvements (25% [95% CI: 22, 28]) in anxiety symptoms by post‐treatment (ps < 0.001). No differences were identified based on patient location (ps ≥ 0.233).

3.5.4. Average Pain Intensity

A significant proportion of patients made clinical improvements (23% [95% CI: 21, 26]) and major clinical improvements (6% [95% CI: 5, 8]) in average pain intensity by post‐treatment (ps < 0.001), which were maintained at 3‐month follow‐up (ps < 0.001) and with no differences observed between regions (ps ≥ 0.237).

4. Discussion

The aim of the current study was to report the outcomes of an internet‐delivered PMP when offered as routine care to a large and representative sample of Australians in regional and remote parts of the country with chronic pain. High levels of treatment satisfaction and treatment completion were observed, with 72% of patients completing the treatment and 69% reporting being satisfied or very satisfied overall. Evidence of meaningful clinical improvements (≥ 30% improvement) were also 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. No marked differences in clinical outcomes were observed between patients in major cities and regional locations. These findings highlight the potential of internet‐delivered psychological PMPs for Australians living in regional and remote locations [16].

The results observed in the current study are similar to those observed in randomised controlled trials of patients recruited through a university research clinic [17, 18, 25]. They also appear similar to those reported for face‐to‐face psychological pain management programmes in routine care, although direct comparison is complicated by differing methods [36]. The model of funding by the Australian government to offer digital psychological services “direct‐to‐the‐public” and at no cost to patients has reduced a further possible barrier to care [19, 20]. Reflecting the benefits of this treatment approach, several specialist pain services have also recently started to use these programmes as a part of their services [22, 37]. For example, a regional Australian persistent pain management service recently reported similarly positive outcomes for their patients (n = 653) after 6 years of delivering the same internet‐delivered PMP [22]. However, referral to specialist services is usually reserved for those most affected by chronic pain. Thus, there is specific additional value in the “direct‐to‐the‐public” delivery of internet‐delivered PMPs by government‐funded digital psychology services, which are accessible to all Australians irrespective of severity of pain, level of mobility and location.

A surprising finding was that similar proportions of patients had accessed (28%) specialist pain services in regional and metropolitan locations. Regional patients are believed to face greater barriers accessing specialist pain services, but these findings do not clearly fit with that argument. It is unclear whether the level of access observed in the current study is representative of regional Australians with chronic pain or is a characteristic of regional patients accessing the MindSpot Clinic. However, one possible explanation is that there is less competition for referrals to the specialist clinics that are provided at the base hospitals at large regional centres because of the lower population density. We had a similar surprising finding in a study of regional differences in accessing treatment from MindSpot for anxiety and depression, with a higher proportion of regional and remote patients reporting previous specialist care [38]. The rates are much higher than were observed in a recent community health survey of a specific region in Victoria, which found 6% of patients with chronic pain had accessed specialist services [8]. However, that study collected no data on the duration or severity of patients' pain, making direct comparison difficult. Nevertheless, travel can be a significant barrier to accessing psychologically based PMPs offered by specialist services [12]. This is because many of the most effective programs require repeat attendance at a service (e.g., once or twice a week) over numerous weeks (e.g., 4–10 weeks) [7], which can be a major barrier for rural patients [8, 10, 22]. Thus, even where regional patients can access specialist services, internet‐delivered PMPs have potential for increasing access to psychological pain management because they remove the need to repeatedly attend clinics face‐to‐face.

There were several significant differences between patients in major cities and those in regional locations, including that regional patients were slightly older, slightly more likely to have a completed high school and slightly less likely to be employed. However, past research shows basic demographic or clinical characteristics have not significantly affected the likelihood of deriving benefit from internet‐delivered PMPs [19, 20, 39]. Thus, a broad range of patients appear to benefit from these programmes. Future studies exploring when and how these programs can be best used by general practitioners and medical specialists are needed. Our anecdotal experience is that comprehensive medical assessment, care planning and coordination, and a ‘warm referral’ improves patients' ability to engage and benefit from these programmes. Future research could also explore the potential of such programmes to support primary care doctors in opioid management and de‐prescribing initiatives [40, 41].

The current study has several limitations. First, as a study using routine care data, there was no control group, and patients were often receiving care from other sources, including medication prescribers. Nevertheless, the effectiveness over control conditions has already been established [16] and chronic pain patients rarely improve spontaneously without care [42]. Second, there were only a relatively small number of patients from remote and very remote (n = 22) locations, and it is unclear whether patients in very remote locations faced additional difficulties in accessing and using internet‐delivered PMPs. Further data should become available as more patients use these services and good‐quality internet reaches the most remote parts of Australia via satellite services. MindSpot does offer ‘low‐tech’ workbook and teletherapy services to patients who might experience internet or technological issues with access, and the efficacy and acceptability of such low‐tech approaches are also well established [26].

With these limitations in mind, the current study provides novel data concerning the effectiveness and acceptability of internet‐delivered PMPs when provided as a routine service to regional and remote Australians. The current study found high levels of treatment completion, satisfaction and clinical outcomes in patients in regional and remote parts of Australia. Thus, the current study highlights the utility of internet‐delivered PMPs in reducing one significant barrier to accessing specialist face–to‐face care—geographical isolation.

Author Contributions

Blake F. Dear: conceptualization, investigation, writing – original draft, methodology, visualization, writing – review and editing, formal analysis, data curation. Lauren Staples: conceptualization, investigation, writing – review and editing, data curation, writing – original draft. Olav Nielssen: conceptualization, investigation, writing – review and editing, methodology, writing – original draft. Nickolai Titov: conceptualization, investigation, writing – original draft, writing – review and editing, methodology, supervision.

Disclosure

Professors Dear and Titov are authors and developers of the Pain Course but derive no financial benefit or royalties from it or its use. B.F.D. is supported by a National Health and Medical Research Council Emerging Leader Fellowship.

Ethics Statement

Approval for the current study was provided by the Macquarie University Medical Sciences Human Research Ethics Committee (520221101840066).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data is available for validation purposes subject to appropriate Australian Human Research Ethics Committee approval and the establishment of an institutional data sharing agreement.