Hybrid in-person and internet-based pain management programs; an opportunity for improved patient experience and outcomes

Pain Management Programs (PMPs) are multidisciplinary group-based interventions that aim to improve function and quality of life in people with chronic pain. Essential elements include education about chronic pain, cognitive behavioral therapy (CBT), and goal directed rehabilitation. Designed as face-to-face interventions, their widespread introduction has been limited by constraints of cost, geographical distance, and insufficient service capacities, creating a treatment gap [1], particularly in large and sparsely populated regions. This has driven research into internet-based models of delivery [2,3].

We will consider a range of PMP interventions that are delivered using the internet (internet-based PMPs), including those delivered using videoconferencing technology (VC-PMP) and remotely delivered PMPs. We adopt the terminology used in Cochrane Reviews where remote-delivery is defined as neither physical presence nor active involvement of clinicians, except for limited and defined on-line contact [4,5]. On this basis, VC-PMPs are defined as internet-based, but not remote, treatment [4,5]. We discuss the implications of current evidence for hybrid programs that could combine different modalities of internet-based and in-person delivery.

1. Evidence for internet-based PMPs

Before the COVID Pandemic, a good body of literature existed for self-directed remotely delivered programs in which participants independently complete a set of sessions encompassing all the components of a CBT-based PMP [3]. A Cochrane Review in 2014 concluded that there is considerable heterogeneity in studies of remotely delivered psychological therapies for chronic pain and uncertainty in estimates of effect size [4]. The pandemic widened the treatment gap for PMPs, as it did for most treatments, leading to a shift in our mind-set with respect to telemedicine. Videoconferencing was encouraged as a means of continuing treatment, and internet-based interventions were rapidly implemented. At this time, a systematic review found only three papers on VC-PMP, concluding that extensive research is necessary [6]. Despite this, in many chronic pain services, clinicians designed programs that stayed faithful to the in-person version using VC technology [7–11], rather than promoting remotely delivered programs. In this time of crisis, our behavior as health professionals, and as researchers, became intuitive rather than evidence based. This was not all bad; intuitive thinking can lead to innovation, and evidence from a second Cochrane Review in 2023 supported this intuitive thinking [5,12]. This review included 32 trials, rather than the previous 15, and showed that participants of remote psychological programs gain small benefits for pain intensity and functional disability but these were not maintained at follow‐up [4,5].

There is now a growing body of literature on VC-PMP. Currently, most of the publications are observational studies done during the COVID Pandemic with contemporaneous data collection pre and post intervention. This real-life data has inherent weaknesses: data quality (including data completion) issues, difficulty in controlling sample sizes and real-time changes to treatment driven by feedback from participants or staff. In these studies, patient outcomes collected immediately after VC-PMPs have been compared with in-person PMP data from the same services [7,9–11]. In two services, the outcomes were comparable in all measured domains [7,9], and, in one of them, they were maintained six months later [9]. In the other services, face-to-face outcomes were better [10,11]. In one service, where three program types (high intensity, low intensity, and pre-neuromodulation) were offered, participants in the high intensity VC-PMP achieved greater overall improvement [11].

The differences between in-person and VC-PMP outcomes in these studies are not merely related to the shortcomings of real-life data collection or the medium of delivery (e.g., screen fatigue) but could also be related to the pandemic. Collecting real-life data in a crisis is different from doing so in stable times. Rapid implementation amplifies the usual problems with real-life data collection. It also means that the therapists are on a learning curve themselves [8]. During the COVID pandemic, there were difficulties with accessing gym space, equipment, social activities, and implementation of physical movement goals, as well as additional reasons for psychological distress such as fear and bereavement, which also affected staff [8,11].

Hale et al. have published a randomized controlled trial (RCT) of an interactive VC-delivered program, compared with an in-person program, for patients with chronic non-cancer pain. This trial was designed and begun prior to the COVID pandemic and continued during the pandemic period [2]. Inescapably, both the participants and the staff were exposed to pandemic effects during the study. The results show non-inferiority of the VC intervention for all outcomes, maintained at six months post-program. This finding draws us to the conclusion that a thoughtfully designed VC intervention, with clinicians who have had specific training and preparation for its delivery, is likely to be as effective as its face-to-face version, at least in research settings.

Could some elements of a program be delivered with no input from a clinician? A series of studies of a remote online program (Pain Course) reported no difference in outcomes with or without very limited clinician contact (maximum 120 minutes for the entire program in this series of studies) or even with a paper guide book only [3,13]. This suggest that clinician contact, that is limited in scope and time, contributes negligibly to effect size. Remote internet-based PMPs with minimal clinician guidance have small benefits that are not maintained at follow up [5]. Other systematic reviews have included studies of online programs with less stringent limitations on clinician contact time and allowing live, interactive guidance (termed “synchronous”). The results suggest that clinician guidance, especially when synchronous, may result in better outcomes [14–16].

2. Acceptability and patient preferences

Although the RCT by Hale et al. was done in a setting where there is need for more accessible pain services, potentially eligible participants were more likely to turn it down due to preference for an in-person program [2], as opposed to a preference for VC. Most participants of VC-PMPs during the COVID pandemic appreciated being offered them but favored in-person interventions [8–10,17,18]. VC-PMPs had equal or higher attrition rates [7], and lower opt-in rates, even when no in-person treatment was available [8–10]. The reasons for this preference are likely to be multifactorial. Technical difficulties and poor digital skills remain a common reason for dropouts from internet-based programs [15]. In PMPs, personal interactions are important to patients and are also an active part of the behavior change process [9]. This is categorically lost in remotely delivered programs, although VC allows limited opportunities for group interaction [8,17].

Are some PMP components less suited to internet-based delivery? In papers that have reported real-life data during the COVID pandemic, VC-delivered movement-based sessions were more difficult to incorporate into programs [7,8,18]. In addition, physiotherapy direct access is commonly expressed as a reason for in-person program preference [9]. In a qualitative investigation of acceptability of VC-PMP, participants perceived that they had missed out on direct access to the therapy team and in-person physical therapy [17]. In a feasibility trial of a combined VC program of mindfulness with exercise classes, participants’ main suggestions for change were more exercise education, individualized exercise instruction and slower pace of exercise [19]. In contrast, online delivery of pain education and mindfulness sessions have been reported as particularly acceptable by patients [18]. Furthermore, at least in research settings, VC-delivered psychological interventions for chronic pain are as effective as in-person delivery [20].

3. Conclusions

To improve the accessibility of PMPs, a reasonable undertaking would be to offer patients a choice of remotely delivered, VC-based or in-person programs in a process of shared decision making, on the basis that all of these are better, at least in the short term, than staying on a waiting list. However, the logistics of providing all these choices are difficult for most services and could drown any cost reduction for the healthcare provider.

The question of a blended approach or hybrid design for PMPs inevitably arises. Hybrid PMPs may be a blend of in-person and video-conferencing sessions combined with on-line resources accessed remotely (and independently) by participants.

Firm RCT evidence is awaited for hybrid PMPs. Designing these in a clinical setting would be premature at this stage and should be done as a research endeavor. To aid researchers in their design of experimental hybrid programs, it is possible to make a number of reasonable inferences from the literature. Firstly, for many people, at least some elements of a PMP (e.g., pain education) can be delivered online. Secondly, psychology-oriented sessions are likely to be suitable for interactive VC delivery. Thirdly, physical activity sessions are probably best delivered in-person. To make clinically useful conclusions, researchers should also consider the longevity of the treatment effects, the risk of participant selection bias and participants’ social interactions during the program.

In the future implementation of hybrid PMPs, clinicians and researchers must bear in mind the needs of the service users. Decisions on which elements are delivered online, and in what form (remote or VC-based), should be tailored to the populations served by the pain management services. In doing so, the problems of digital literacy and digital poverty must not be ignored. We are otherwise in danger of replacing a treatment gap created by geographical distance and health services’ capacity issues with a treatment gap related to digital poverty. This would compound the difficulties in equitable access to healthcare in disabled, elderly, and financially vulnerable people who are a significant proportion of the chronic pain patient population.

Funding Statement

This paper was not funded.

Author contributions

Roxaneh Zarnegar and Gregory Booth both contributed to the conceptualization, writing – original draft and writing – review and editing. Both authors have agreed on the submitted version of the manuscript.

Disclosure statement

Gregory Booth is funded by the NIHR Doctoral Fellowship (NIHR303240). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.