Effectiveness and acceptability of remotely delivered psychotherapies for management of chronic non-cancer pain: A systematic review and network meta-analysis of randomized controlled trials

Abstract

Background: Psychotherapeutic interventions, including cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT), have shown benefits in managing chronic non-cancer pain (CNCP). This systematic review and network meta-analysis (NMA) assessed the effectiveness and acceptability of remote psychotherapies for CNCP. Methods: We searched databases for trials comparing remote psychotherapies (and their combinations with other treatments) with usual care and active interventions. Reviewers independently screened studies, extracted data, and assessed risk of bias. We conducted a frequentist random-effects NMA across outcomes at post-treatment, first follow-up (≤ 6 months), and second follow-up (6–12 months), with certainty of evidence evaluated using CINeMA. When interventions were disconnected in networks, we ran component NMA. Results: Sixty-six trials (8,993 participants) were included. At post-treatment, moderate certainty evidence showed that compared to usual care, remote ACT (r-ACT) and remote CBT (r-CBT) probably result in slight pain reductions (mean difference [MD]: –0.59, 95% confidence interval [CI]: –0.81 to –0.37 and MD: –0.36, 95% CI: –0.50 to –0.23, respectively; on 0-10 visual analogue scale), slight quality of life improvements (MD: 0.06, 95% CI: 0.02 to 0.10 and MD: 0.05, 95% CI: 0.03 to 0.08, respectively; on 0-1 EuroQol- 5 dimension), slight depression reductions (MD: –1.75, 95% CI: –2.46 to –1.05 and MD: –1.80, 95% CI: –2.32 to –1.28, respectively; on 0-27 patient health questionnaire-9), and slight anxiety reductions (MD: –0.84, 95% CI: –1.64 to –0.03 and MD: –1.41, 95% CI: –1.93 to –0.89, respectively; on 0-21 general anxiety disorder-7). Benefits at follow-ups were limited. The dropout rates may increase with r-ACT (risk difference [RD]: 7.33% more patients, 95% CI: 2.4% to 13.73%) and r-CBT (RD: 6.13% more patients, 95% CI: 2.4% to 10.80%) compared to usual care (low certainty). Conclusion: r-ACT and r-CBT offer slight benefits for CNCP. Future research should enhance patient engagement and assess long-term effects.