Introduction
Telemedicine (the use of telecommunication and information technologies [ITs] to deliver patient care at a distance) has great potential to play a practical, cost-effective, and meaningful role in chronic pain management. Chronic pain is one of the highest impact problems in health care, with more than 100 million American adults affected, which is more than those affected by heart disease, cancer, and diabetes combined. Pain care, as a whole, costs the United States upward of $635 billion each year in specialty visits, interventional procedures, surgery, and lost productivity. Chronic pain is the number one cause of long-term disability in the United States, with indirect costs (reduced or missed work productivity) accounting for more than 50% of this burden. In 2016 approximately 20% of US adults had chronic pain, and 8% had high-impact chronic pain limiting at least one major life activity. Furthermore, up to 80% of postoperative patients do not have adequate pain management. Persistent pain syndromes destroy an individual’s quality of life—including engagement in physical activity and with society—as well as increase risks for other serious noncommunicable diseases, such as obesity, cardiovascular disease, and mental health disorders, including addiction. Inappropriate and dangerous opioid prescribing and misuse of opioids has been associated with 130 US deaths per day from opioid overdose, and an economic burden of $78.5 billion per year. There are approximately 2.3 million people with opioid use disorder in the United States, and 5 to 8 million medical opioid users still suffering with chronic pain. Globally, chronic pain is one of the leading causes of disability. Low back pain is the leading cause of years lost to disability in high-income, high-middle-income, and middle-income countries, and a top cause of years lost to disability in all quintiles of the sociodemographic index. Neck pain, osteoarthritis, opioid use disorder, and tension headaches are chronic pain–related disorders within the top 30 global culprits of years lost to disability.
To identify why in-person nonpharmacological treatments are poorly implemented in chronic pain practices, Becker et al. determined barriers as seen from pain patients, nurses, and primary care providers’ perspectives. For patients, high costs, low motivation, and transportation issues were the main barriers to care. For providers, the main barriers included inability to promote nonpharmacological therapy once opioid therapy was initiated, and patients’ skepticism about efficacy of these approaches. It will take a seismic shift in mindset to overcome these barriers, on the part of both chronic pain patients and the many providers who treat them. With the use of telerehabilitation for pain management, however, at least some of these barriers, including transportation, motivation, and cost, may be overcome. According to Pew Research Center data, 81% of American adults now own a smartphone, making the internet a ubiquitous tool to deliver cognitive behavioral and other nonpharmacological, integrative pain management therapies directly to patients.
With burgeoning telerehabilitation options, such as pain apps and trackers, virtual pain programs, and internet-based tools, patients may be empowered to participate more in lifestyle and behavior changes, as well as access behavioral-psychological, nonpharmacological pain therapies not often found in conventional pain care clinics. Patient engagement in Zoom multidisciplinary pain programs and other telerehabilitation platforms can enable these mobility-impaired, often isolated individuals to find evidence-based self-management therapeutic options as well as social connection—a key ingredient to successful pain management programs and long-term patient engagement. There is an extremely high prevalence of serious comorbid mood disorders with chronic pain, with as much as 50% to 70% of chronic pain patients showing signs of significant depression or anxiety. In fact, the presence of a persistent pain syndrome is a leading risk factor for suicide in these patients. With remote access to providers who offer helpful psychological and even pharmacological (i.e., medication-assisted therapy [MAT], for addiction therapy) support via telerehabilitation, patients with comorbid chronic pain, mental health, and opioid use disorders no longer need their access to care be limited by location, time constraints, or physical handicaps. The field of telerehabilitation for pain management is still emerging, however, and there is much work to be done.
The National Pain Strategy recommends a comprehensive, biopsychosocial approach to pain care, tailored to individual patient needs. This requires providers treating the same patient to have a consistent message: after red flags and treatable medical causes for pain are ruled out or addressed, the emphasis should be on education and pain coping strategies, which can be delivered via telerehabilitation. Multidisciplinary, functional restoration pain rehabilitation models that encourage activity engagement despite pain, improve cognitive coping strategies, and address underlying mental health issues are the gold standard approach to chronic pain care. Unfortunately, due to health care systems’ incentivization of pharmacological care and procedures over self-care and education, and because access to multidisciplinary pain programs has been historically limited for the majority of chronic pain patients, including the most vulnerable, low-income patients with few resources, the problem of chronic pain and its cost is not going away any time soon. With the COVID-19 pandemic, which forced isolation and restrictions on helpful resources such as live group therapies, physical treatments, and access to pain management providers, this problem is further highlighted. However the pandemic also brings hope for the newly expanded role of telerehabilitation to improve access to evidence-based cognitive behavioral and integrative pain management therapies.
Telerehabilitation in Pain Management
Pain management providers may be better positioned than ever to deliver the most significant part of multidisciplinary pain care directly to patients’ homes, with the ease and flexibility offered by technology. Telerehabilitation, with multiple platforms available for chronic pain management, provides global access to internet-based pain programs, mobile health pain apps for symptom tracking and stress management, and even new pain therapies, such as virtual reality (VR) programs. Virtual consultations with pain doctors, psychologists, and other mental and behavioral health experts are encouraged, particularly during the age of COVID-19. Mobile app and internet-delivered psychological therapies with the most evidence, such as cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), mindfulness meditation, and stress management, have already shown great promise with telerehabilitation. Individual consultations or group sessions, interdisciplinary team conferences, support groups, pain education workshops and programs, pain apps and software, and integrative mind-body treatments can all be offered virtually via the internet.
Overcoming Geography/Physical Limitations to Pain Care
Pain rehabilitation programs inclusive of psychological and behavioral pain treatments are often confined to big cities and academic centers or small community centers invested in integrative or alternative pain care, so their influence cannot extend to the masses of chronic pain sufferers globally. With only 8000 to 9000 pain medicine specialists in the United States, who are mainly congregated in large cities, there is the added obstacle of geography in providing pain management expertise to remote areas. Clearly, patients residing in more remote regions may take advantage of telerehabilitation to access pain care. Boston’s MGH SCOPE (Safer/Competent Opioid Prescribing Education) telemedicine study involved a 13-month study of 238 virtual evaluations of pain patients from Martha’s Vineyard, a small island off the Massachusetts mainland only accessible by ferry. This study demonstrated that it is possible and feasible to maintain a telerehabilitation pain program with acceptable patient satisfaction. The inability to travel to pain clinics and pain care providers due to illness, inclement weather, or other external factors can be overcome by telerehabilitation. There is also access for the pain patients with debilitating physical impairments who previously required a support network or insurance coverage for transportation to and from numerous specialty appointments and treatments. This is pertinent for the most disabled, mobility-impaired patients with cumulative medical problems.
Evolution of Telerehabilitation for Pain Management
Telehealth delivery of pain care, including internet and mobile app pain programs, has been appreciated and studied since the 1990s, but many online programs are not standardized or evidence-based, and many are undergoing active development. Prior to COVID-19, telerehabilitation was not implemented in most outpatient pain clinics. There was not enough incentive to provide telerehabilitation routinely, as it was not covered by insurance in the same way in-person visits were in the United States. With the March 2020 Medicare ruling opening access to virtual visits in almost every field of nonessential specialty care, this suddenly changed. Telemedicine as a platform for health care delivery has been rapidly transformed during the public health crisis, from a poorly utilized intervention into a mainstream form of health care delivery.
In this chapter, some of the more recent programs and reviews that can be found in the expansive, burgeoning field of telerehabilitation for pain management will be highlighted. With implementation already underway, the wider vision of a more comprehensive, integrative pain care model—a model in which elements of pain psychology, mind-body strategies, and lifestyle medicine can be delivered remotely through platforms such as Zoom, online pain programs, pain apps, and VR—may become the norm rather than the exception. The level of participation, engagement, and expectation on the part of patients, as well as providers, must change for this to be successfully accomplished, which cannot happen overnight. We have included numerous international studies in this chapter, which is perhaps a reflection of how the role of telemedicine has been appreciated outside the United States for many years. Virtual pain care has great potential to change the way we think about and treat chronic pain, but there are also real practical obstacles and inherent inequities in this type of care delivery that must not be overlooked.
Chronic pain management should involve evidence-based pain psychology, which can be delivered virtually. Treating the person as an individual, influenced by unique biopsychosocial determinants of pain, rather than only structural pathologies to be targeted by external physical interventions, is consistent with evidence-based pain psychology strategies such as CBT and the more recent “third wave” psychological therapy, ACT. CBT encourages cognitive and behavioral change techniques, focusing on changing maladaptive thoughts and behaviors with a goal-oriented, problem-solving approach. ACT focuses on the role of acceptance and mindfulness rather than cognitive change, increasing psychological flexibility to foster moment-to-moment awareness, acceptance, and a commitment to values and direction. Both pain interventions can improve quality of life, pain acceptance, function, and self-efficacy, and reduce pain, emotional burden, and distress. Unfortunately, these interventions are not always offered. Perhaps access to interdisciplinary, psychologically informed pain care is still limited, in part, because not all insurers or stakeholders have been assured of the economic success of such models. Evidence for long-term successful outcomes is also not assured. Results from a 13-year follow-up study from Mayo Clinic on patients who finished extended pain rehabilitation programs with multidisciplinary therapies showed that 68% still had functional impairments and difficulty returning to daily life, and 53% of the patients had deteriorated 3 years after a multidisciplinary pain management program. The attrition rates are likely related to multiple factors, such as absence of long-term provider-patient engagement, worsening chronic illness, and decreased patient motivation over time. In a study on an internet-based booster program to support patients after discharge from interdisciplinary pain centers, findings suggested there could be small but real benefits.
Telerehabilitation for chronic pain is a promising and cost-effective method of delivering psychological care. With telerehabilitation, direct access to evidence-based pain education and pain psychology, counseling, and pain coping strategies can be delivered by providers on an ongoing, long-term basis without the requirement of physical face-to-face encounters. Allowing patients the flexibility to access care at their own pace and from the comfort of their home is a huge perk of this technology. For the past decade, researchers from around the world have been investigating delivery of internet-based chronic pain prevention and treatment programs based on pain psychology. In a systemic review of three technology-enhanced psychological treatment modalities, including telephone, interactive voice response, and internet (n = 9890), evidence suggested that across modalities, technology-assisted psychological interventions are efficacious for improving self-management of chronic pain in adults.
A large number of trials for various mental health and physical conditions have been developed, with internet-delivered CBT taking the early lead. In the Cooperative Pain Education and Self-management (COPES) trial, 125 VA patients with chronic back pain were treated with either interactive voice response-based-CBT (IVR-CBT) or individual CBT sessions. IVR is the use of a phone’s touch-tone keypad to provide responses to automated scripts. The pain intensity scale measured by the numeric rating scale (NRS) showed a reduction with IVR (−0.77) similar to in-person care (−0.84), with a 95% confidence interval (CI) for the difference between groups, indicating noninferiority for the IVR form of delivery. There were improvements in physical function, sleep quality, and physical quality of life at 3 months relative to baseline, with no advantage for either treatment, and treatment dropout was a little lower in IVR-CBT (patients completed on average 2.3% more sessions).
For the past two decades, a range of health domains, including chronic pain and mood disorders, have been targeted with eHealth interventions based on CBT principles. These programs are currently seeing wider applications for children and adults, with the type of available help ranging from text-based, educational websites to custom-built software applications. In several systematic reviews of internet-based interventions for chronic pain, small but significant improvements in pain experience and reductions in functional disability were reported. Online programs for pain have progressed from uncontrolled case studies and feasibility trials to many randomized clinical trials. While early applications of “self-management” tools focused on biofeedback, more recent approaches attempt to teach patients a variety of pain coping skills and strategies, including self-monitoring, goal setting, relaxation training, physical exercise, attention and emotional control, belief reappraisal, and self-efficacy (planning, coping, and pacing). In an online Chronic Pain Management Program studied in 2012, self-directed, web-based pain education, CBT skills, and social networking were incorporated into an interactive learning environment. Of 305 adult participants, 162 chronic pain patients were randomly assigned unsupervised access to the program for approximately 6 weeks, while 143 were assigned to the wait-listed control group with treatment as usual. A comprehensive assessment was administered before the study and approximately 7 and 14 weeks thereafter. All recruitment, data collection, and participant involvement took place online. The program resulted in increased pain knowledge and decreased perceived pain magnitude (severity, interference, and emotional burden), disability, and catastrophizing.
Internet delivery of ACT for chronic pain is an area of growing interest, with expanding evidence for long-term benefit and cost-effectiveness. Telerehabilitation may be used to enhance delivery of ACT, either in isolation or as a complement to traditional face-to-face delivery. Telerehabilitation interventions can provide opportunities for tracking, forming, and reinforcing through reminders and feedback, which is a cornerstone process in ACT: psychological flexibility. Participants are encouraged to engage in experiential exercises and metaphors that may be particularly relevant to their in-the-moment perception of pain. Willingness to experience pain with a moment-to-moment awareness, consistent with mindfulness, is another key feature of ACT. Perhaps there is no one better to ask about the experience of providing ACT concepts online than Dr. Joe Tatta, founder of the Healing Pain Podcast and the Integrative Pain Science Institute, who has built a career treating chronic pain and educating providers who treat chronic pain via Zoom. He has a worldwide following with well-received provider training programs featuring ACT, functional nutrition, and other internet-based educational programs for chronic pain.
Herbert et al. showed, in a noninferiority trial of US veterans with chronic pain (n = 128), that ACT delivered via video teleconferencing was noninferior to in-person delivery of ACT for the primary outcome of pain interference and several secondary measures at posttreatment and at 6-month follow-up. A three-arm randomized controlled trial (RCT) compared an internet-guided self-help ACT intervention (“Living with Pain”) with an internet-based control arm (i.e., expressive writing) and a wait-list group. Results showed that participants in the ACT arm improved on several domains of chronic pain disability, including psychological flexibility and pain catastrophizing, compared to both control groups. In another three-arm German RCT (n = 302), a guided online ACT-based program (“ACTonPain”), which included e-coaches (psychologists) providing feedback 2 days after each module, showed significantly less pain interference and higher pain acceptance at posttreatment and at 6-month-follow-up compared with the other groups. Patient guidance involved regular feedback, explanations, motivation, and reminders to adhere to treatment. Guidance seems to improve treatment effects and can be cost-effective, but more evidence is needed. This general consensus is in line with a 2014 systemic review on the impact of guidance on internet-delivered mental health interventions. In theory, blended therapies, which include technology-enhanced booster sessions or evidence-based apps with in-person therapy, are ideal.
In a 2015 metaanalysis involving 22 RTCs of internet interventions for chronic pain, there were overall small-to-moderate effect sizes, with these sizes comparable with those seen for reviews of psychological pain care strategies in general. In general, systemic reviews of internet-delivered CBT, ACT, and mind-body pain therapies suggest beneficial and comparable outcomes to their in-person delivery counterparts, with good patient satisfaction. In Andersson’s metaanalysis of 13 controlled trials (n = 1053) comparing in-person to internet-delivered CBT, participants consented to being randomized to either ICBT or conventional face-to-face CBT (n = 6 individual format, n = 7 group format) for a variety of mental health conditions, including depression, anxiety, panic disorder, and phobias. The two treatment formats were equally effective in addressing many of these conditions. This metaanalysis mirrored findings by Cuijpers et al. who found no differences between guided self-help and face-to-face therapies.
As Dr. Kurt Kroenke, a leader of opioid reduction risk strategies, aptly states:
Telehealth is not only useful for monitoring and adjusting analgesics but also for the delivery of nonpharmacological therapies such as pain self-management, cognitive-behavioral therapy, mindfulness-based therapy, and motivational interviewing for exercise. Also, pain is frequently comorbid with other symptoms such as depression, insomnia and fatigue. Several studies in patients with cancer have documented the effectiveness of telecare management of pain along with other symptoms. This multisymptom approach might not only improve outcomes in individual patients with pain who suffer from other comorbid symptoms but also increase the cost-effectiveness of a telehealth service designed to cover multiple symptoms.
Pain Apps/Trackers
Technology-assisted self-management treatments have shown significant benefits in the chronic pain population. In the first large Cochrane review of technological interventions for pain, there were 15 studies involving 2000 participants. Reviews identify small-to-moderate reductions in pain, disability, and distress in intervention groups compared with any control, including active, standard care, or wait-list control, with little difference between remote and in-person therapies (see Fig. 13.1 ). A 2019 network metaanalysis review of 30 RCTs (5394 participants) involving “eHealth” modalities aimed to determine which were most effective for reducing pain interference in chronic pain patients. These included internet-based and telephone-supported interventions, interactive voice response, VR (a three-dimensional [3D] computer-generated environment an individual may explore, interact with, and manipulate), videoconferencing (the use of high-quality real-time video and audio connection via online internet networks), and mobile phone apps (mobile-based or mobile-enhanced programs). This review found that that mobile apps and VR for pain were two of the most effective interventions; however, there was a bias of underrepresentation of many modalities.
There has been significant work in the field of pain apps and trackers, along with telephone, interactive voice response, and website interventions. There is a growing number of pain apps, and, although many are not evidence-based, there is a push from industry and other stakeholders to advance these technologies further, with gamification and other motivators to improve patient adherence.
There is a growing market for pain apps that can deliver pain symptom tracking and monitoring, as well as self-management coping strategies, including relaxation therapy, yoga, and guided imagery. From a New Zealand systemic review of 939 pain apps available through 2018, using the search term, “pain management,” in both Google Play and App stores, 19 apps met the review’s inclusion criteria, with meditation and guided relaxation most frequently included in self-management strategies. Only three apps ( Curable, PainScale-Pain Diary and Coach , and SuperBetter ) met the largest number of criteria to foster self-management of pain, according to the review, with self-monitoring of symptoms (n = 11) and self-tailoring of strategies (n = 9) frequently featured. Although two apps ( Headspace and SuperBetter ) have been shown to improve health outcomes, none of the included apps have been evaluated in people with persistent pain. Another notable app is “WebMAP Mobile,” created by Dr. Tonya Palermo and her team at Seattle Children’s Research Institute for adolescents with chronic pain, which includes CBT skills for coping and activity engagement. “Solution for Kids in Pain” (SKIP) is a self-proclaimed “knowledge mobilization network” based at Dalhousie University and co-led by Children’s Healthcare Canada. The web-based program includes some of the evidence-based pain apps available commercially, including “Symple,” “Liv,” CareClinic,” “Migraine Buddy,” and “Pain Coach.” The more one searches, the more apps there seem to be, not to mention the innumerable websites and webpages available for chronic pain. These can be loosely organized into the following subsets: mindfulness/meditation (e.g., “Calm,” “Headspace,” or “Yoga for Beginners”), stress and mental health, distraction, biofeedback, and pain education.
Another randomized trial of an internet-delivered Pain Tracker Self-Manager (PTSM), utilizing Butler and Moseley’s pain model, ACT metaphors, and verbal/visual cues, showed significant reductions of pain intensity and interference, perceived disability, catastrophizing and fear.
With digital medicine constantly evolving into an ever more user-friendly, accessible platform, along with the ubiquity of mobile phones and internet culture, there is a growing potential to educate patients, provide more counseling on nonpharmacological, noninterventional pain therapies, and promote self-management for chronic pain. Providers have access to evidence-based electronic health record systems that already allow for electronic administration of pain assessments and outcome measures, as well as email and telerehabilitation virtual visit communication with patients. Several web-based systems, such as Collaborative Health Outcomes Information Registry (CHOIR), deliver multidisciplinary pain history intakes, which may help providers with their evaluations.
However, as the industry of eHealth becomes more commercialized in the private sector, a concern is raised regarding the loss of quality in the heterogeneity. Quantity does not mean quality, and there in turn may be a lack of standardized, evidence-based resources that health care providers will be confident enough in to start prescribing routinely to patients. Furthermore, adherence and compliance issues are existing challenges. Will telerehabilitation self-management apps and educational websites be able to engage patients consistently enough and in a personalized manner in order to foster sustainable practice?
Digital therapies have already shown to be effective for outcomes associated with some of the most common, noncommunicable, high-morbidity disease states in the Western world, including diabetes type 2, hypertension, and insomnia. In a recent, large-scale longitudinal cohort study by Baily et al. , 10, 264 adult participants with chronic knee and back pain used a 12-week digital care mobile app program for pain education, sensor-guided exercise therapy, and behavioral health support with one-on-one remote health coaching. Participants experienced a 68.45% improvement in visual analogue scale (VAS) pain between baseline and 12 weeks, and although 78.6% of completers achieved minimally important changes in pain, the level of engagement correlated with improvement in pain, and secondary depression and anxiety scores decreased by 57.9% and 58.3%, respectively. Furthermore, work productivity increased by 61.5%. This bodes well for the applicability and feasibility of further pain app development for self-management strategies, including self-monitoring and relaxation therapies.
Virtual Reality in Pain Management
In the past few decades, VR technology has emerged from science fiction to become a multibillion-dollar industry with promising applications in entertainment, business, and medicine. VR is most commonly composed of a simulated 3D image or environment, visualized by equipment such as a head-mounted display, sometimes with a screen for each eye to create the perception of depth of field. The environment can be interacted with by using electronic equipment such as gloves or a handheld controller or joystick with or without additional motion sensors. Other forms of VR may include a camera capturing the user and using software to integrate them into a virtually rendered environment displayed on a screen where they can see themselves in a simulated environment and, by tracking their movements, they may interact with rendered objects onscreen. The underlying technology behind VR hardware has been a perpetually limiting factor in the realism and fidelity of the simulated environments. Recent advances, however, have led to an exponential growth in the adaption of the technology within the gaming entertainment industry over the last several years. In the future, the user interface and experience may be achieved directly via neural implants. Many major technology companies, including Apple, Facebook, Google, Nintendo, and Sony, are actively innovating in this rapidly growing sector of the entertainment industry.
The promise of VR has long been recognized by the medical community as a potential means to improve patient experience and outcomes. By the year 2000, VR was found to reduce pain scores for burn patients during physical therapy (PT) and was hypothesized to serve as an effective distraction from pain. For example, David Patterson and Hunter Hoffman’s “Snow World” VR program ( Fig. 13.2 ) has been shown to reduce the acute pain in pediatric burn victims by 35% to 50%. There is a growing body of evidence supporting the use of VR as an adjunct therapy for reducing acute pain in pediatric and adult patients during medical procedures and in the inpatient setting. There may also be a role for VR in patients with chronic pain. Studies with fibromyalgia and complex regional pain syndrome patients have shown reduction in pain scores. Studies investigating chronic musculoskeletal pain, such as assessing and improving reduced neck range of motion in chronic neck pain, and pain relief through distraction in the chronic pain population, are promising.
