Online pain management programs for chronic, widespread musculoskeletal conditions: a systematic review with meta-analysis
Open accessAbstract
Face-to-face pain management programs demonstrate positive clinical outcomes in the chronic pain population by improving pain intensity and attitudes, depression, and functional disability scores. The effects of this modality carried out online is less known, particularly in subgroups of chronic pain. This systematic review assessed the effects of online pain management programs in chronic, widespread musculoskeletal conditions on pain measurements (intensity, interference, coping, and catastrophizing), health-related quality of life, depression, and anxiety scores immediately post-intervention. Five electronic databases (Embase, Medline, CINAHL, Scopus, and PEDro) were searched with 3546 studies identified. Eighteen randomized controlled trials fulfilled the inclusion criteria. Included studies had moderate methodological quality (using the Effective Public Health Practice Project (EPHPP) quality assessment tool) but high risk of bias (using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2)). There were significant improvements in pain intensity (11 studies, 1397 participants, SMD -0.30, 95% CI -0.50 to -0.10, p = 0.004), health-related quality of life (eight studies, 1054 participants, SMD 0.41, 95% CI 0.08 to 0.75, p = 0.02), and depression (nine studies, 1283 participants, SMD -0.32, 95% CI -0.55 to -0.08, p = 0.008). However, effect sizes were small and did not meet their respective measure's minimal clinically important change score. Guided interventions (regular interaction with an instructor) appeared to be superior to self-completed interventions. Future research should standardize outcome measures for assessing pain, use active control groups, and analyze other outcome measures such as cost and long-term effects. This study was registered with Prospero on August 15, 2021 (CRD42021267565).
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Guided internet-based ACT treatment has improved outcomes and higher rates of session completion compared to unguided treatment.
“Improved outcomes and higher rates of session completion have been reported in guided internet-based ACT treatment compared to unguided treatment.37,38”
From Design and implementation of online acceptance and commitment therapy with enhanced therapist support for chronic low back pain (ACT for PAIN) (2025) · cites this paper as [38]
The Main findings and clinical implications section reports that a trial comparing guided with self-completed internet-based ACT found no difference in pain interference or acceptance, contrary to the claimed improvement for guided ACT. Although the Self-completed versus guided section suggests guided online pain interventions may be more effective overall, the Completion rates section does not compare session completion for guided versus unguided ACT. (LLM, conf=0.84)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredTreatment completion and engagement appear to be enhanced with therapist-guided involvement, which may also improve patient engagement.
“In this growing body of research, treatment completion and engagement appear to be enhanced with therapist-guided involvement which may also improve patient engagement.”
From Design and implementation of online acceptance and commitment therapy with enhanced therapist support for chronic low back pain (ACT for PAIN) (2025) · cites this paper as [38]
The 'Self-completed versus guided' section reports that guided interventions appear more effective for clinical outcomes, but does not compare treatment completion or patient engagement. The 'Completion rates' section reports rates across studies without linking them to therapist guidance. Searches for therapist-guided completion and engagement found no passage establishing the claimed relationship; page numbers were not available in our copy. (LLM, conf=0.75)
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“the biopsychosocial model to varying extents.(45,46,53,55) Their programs included education about the condition, symptom management, behavioral coping skills, and social/lifestyle skills.”
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Nicholl, B. I., Sandal, L. F., Stochkendahl, M. J., McCallum, M., Suresh, N., Vasseljen, O., Hartvigsen, J., Mork, P. J., Kjær, P., Søgaard, K., et al. (2017) · Journal of Medical Internet Research · doi:10.2196/jmir.7290 · Cited by 180 · see citing works
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“Intervention group completion rates ranged from 49% to 100%, while the control groups ranged from 63% to 100% completion.(44,48) Overall, completion rates varied, but were comparable between online pain management and control groups.”
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“Another trial proposed measuring outcomes at 3, 6, 9, and 12 months but in their published paper, results (which were significant improvements in healthrelated quality of life) were only reported for 3 and 9 months.(51) The authors did not state reasons for non- reporting on 6- and 12- month results.”
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“Completion rates Completion rates (defined as finishing all or a predetermined percentage of modules) were reported across six studies.(44,45,48,52,53,58) Intervention group completion rates ranged from 49% to 100%, while the control groups ranged from 63% to 100% completion.”
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“After registering our protocol on PROSPERO, we were made aware of some of the challenges in using the GRADE approach for public health systematic reviews.(61) This led us to the EPHPP quality assessment tool, which is used for assessments of public health articles.”
MethodInternet-Delivered Exposure Therapy for Fibromyalgia: A Randomized Controlled Trial
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“In the fibromyalgia population, one study reported higher incidence of adverse events in the intervention group (34% versus 6% in the control group).(46) Their adverse events included increased pain (most common), sleep disturbance, increased fatigue, migraine, swelling, and weight loss.”
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Nikoloudakis, I., Vandelanotte, C., Rebar, A. L., Schöeppe, S., Alley, S., Duncan, M. J., & Short, C. E. (2016) · American Journal of Men s Health · doi:10.1177/1557988316650625 · Cited by 70 · cited 1× · see citing works
“There is some research to suggest that women may have higher health literacy and women with long- term illnesses were more likely to use the internet for health information than men.(68,69) Therefore, we are unable to generalize our findings to males with chronic widespread musculoskeletal conditions.”
BackgroundDavies, L. M., Hinman, R. S., Russell, T. G., Lawford, B. J., Bennell, K. L., Billings, M., Cooper-Oguz, C., Finnan, K., Gallagher, S., Gilbertson, D. K., et al. (2021) · Journal of physiotherapy · doi:10.1016/j.jphys.2021.09.001 · Cited by 64 · cited 1× · see citing works
“Remote delivery of healthcare is increasingly accepted and adopted.(16,17) The global COVID19 pandemic greatly expedited the uptake of these services.”
BackgroundOnline teletherapy for chronic pain: A systematic review
Mariano, T. Y., Wan, L., Edwards, R. R., & Jamison, R. N. (2021) · Journal of Telemedicine and Telecare · doi:10.1177/1357633x19871746 · Cited by 52 · cited 1× · see citing works
“Moderate quality studies indicate the potential of online cognitive behavioral therapy to improve pain in a mixed chronic pain population.(23) In site- specific populations, such as adults with chronic back pain, three systematic reviews reported minimal evidence for online interventions in reducing pain and disabilit…”
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“Using helpfulness rating scales, majority of participants in two studies rated their online pain management intervention as helpful (one used 0– 10 rating scale and one used a 4- item Likert scale).(41,47) Two studies measured satisfaction with one reporting a 7.”
Zuidema, R., van Dulmen, S., der Sanden, M. W. G. N., Meek, I., van den Ende, C. H. M., Fransen, J., & van Gaal, B. G. I. (2018) · Journal of Medical Internet Research · doi:10.2196/12463 · Cited by 46 · see citing works
Lalloo, C., Harris, L., Hundert, A. S., Berard, R. A., Cafazzo, J. A., Connelly, M. A., Feldman, B. M., Houghton, K. M., Huber, A. M., Laxer, R. M., et al. (2020) · Lara D. Veeken · doi:10.1093/rheumatology/keaa178 · Cited by 46 · cited 1× · see citing works
“6 respectively).(49) The other study used a modified Client Satisfaction Questionnaire reporting higher general satisfaction (91%) and helpfulness (78%) for the online intervention compared with the standard care control group (73% and 44% respectively).”
MethodRomm, M. J., Ahn, S., Fiebert, I. M., & Cahalin, L. P. (2020) · Pain Practice · doi:10.1111/papr.12962 · Cited by 45 · see citing works
Stinson, J., Lalloo, C., Hundert, A. S., Campillo, S., Cellucci, T., Dancey, P., Duffy, C. M., Ellsworth, J. E., Feldman, B. M., Huber, A. M., et al. (2020) · Journal of Medical Internet Research · doi:10.2196/16234 · Cited by 41 · cited 1× · see citing works
“Two studies of juvenile idiopathic arthritis participants used the Medical Issues, Exercise, Pain, and Social Support Questionnaire (MEPS).(53,54) Both studies reported improvements in disease knowledge following online pain management, although only one was significant (p = 0.”
BackgroundConnelly, M. A., Schanberg, L., Ardoin, S., Blakley, M., Carrasco, R., Chira, P., Hayward, K., Ibarra, M., Kimura, Y., Kingsbury, D., et al. (2018) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsy066 · Cited by 34 · cited 2× · see citing works
“Other outcomes Adverse events Three studies reported on adverse events experienced during their study.(43,46,58) In arthritic conditions, adverse events included infections, arthritis flares (some requiring specialized treatment) and suicidal thoughts that were low in incidence and comparable between groups.”
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“These findings are supported by another systematic review of a mix of face- to- face and remotely delivered psychoeducation (education and psychotherapeutic approaches such as cognitive behavioral therapy) for fibromyalgia and found significant reduction in both pain intensity and depression.(66) However, our prelimin…”
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“Using helpfulness rating scales, majority of participants in two studies rated their online pain management intervention as helpful (one used 0– 10 rating scale and one used a 4- item Likert scale).(41,47) Two studies measured satisfaction with one reporting a 7.”
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Cited by
Sorted by citations
Bartels, S. L., Pelika, A., Taygar, A. S., & Wicksell, R. K. (2024) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2024.101976 · Cited by 20 · see citing works
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Lee, J. W. K., Mowat, R. M., Blamires, J., & Foster, M. (2025) · Journal of Advanced Nursing · doi:10.1111/jan.16716 · Cited by 3 · see citing works
“This observation is concordant with the findings from Chew et al. (2023), which concluded that web interventions with guided support (regular interaction with healthcare staff) are superior to unguided web interventions.”
Chew, M. T., İlhan, E., Nicholson, L. L., Kobayashi, S., & Chan, C. L. (2024) · Disability and Rehabilitation · doi:10.1080/09638288.2024.2351180 · Cited by 3 · see citing works
“Online pain management programs are easily accessible and significantly improve pain intensity, health-related quality of life and depression in chronic, widespread musculoskeletal conditions [11].”
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“37,38 Without guidance and ongoing motivation, it can be easy for participants to disengage.”
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“To date, there are no empirically tested, online, asynchronous pain management programs utilising the biopsychosocial approach for hEDS/HSD (Chew et al. 2023).”
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“This was exemplified in a recently published systematic review with meta-analysis on outcomes of web-based pain management for chronic widespread musculoskeletal conditions where the investigators found clinically significant improvements but failed to show a clinically relevant change [39].”
Foustoukos, T. L., Leclercq, I., Blanchard, M., & Hügle, T. (2025) · Interactive Journal of Medical Research · doi:10.2196/67523 · Cited by 1 · see citing works
“All 3 are included in most of the current fibromyalgia mHealth applications on the market, several of those with proven efficacy in randomized controlled trials, although the underlying therapeutic content is not openly accessible [75].”
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Telerrehabilitación en patología musculoesquelética de miembro superior e inferior
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Perspectives on Online Resources for People Experiencing Pain: A Qualitative Study
Wilson, M., Katz, J. R., Chase, M. D., Bindler, R. J., Rangel, T. L., Penders, R. A., Kohlmeier, P. S., & Lewis, J. (2024) · Pain Management Nursing · doi:10.1016/j.pmn.2024.07.006
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“Despite their potential, existing online pain management programs often suffer from low retention rates, a problem that is exacerbated by a lack of feedback, social interaction, and engaging content [12].”
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Exercise for Health: The Use of Digital Tools from Activity Tracking Through to Guided Delivery
Buist, B. D., Wright, K. E., Kramer, B., Borges, N., Petrofes, A. M., & Furzer, B. J. (2026) · Springer eBooks · doi:10.1007/978-3-032-32552-5_10
- Authors
- Chew, M. T., Chan, C., Kobayashi, S., Cheng, H. Y., Wong, T. M., & Nicholson, L. L.
- Affiliations
- The University of Sydney (AU)
- Hong Kong Polytechnic University (HK)
- Corresponding author
- Chew, Min Tze
- Venue
- Pain Practice
- Publisher
- Wiley
- Published
- 2023-04-13
- Volume
- 23
- Issue
- 6
- Pages
- 664-683
- ISSN
- 1530-7085 (ISSN-L)
- 1533-2500
- OpenAlex
- W4365444013
- Cited by
- 18
- References
- 67
- Citations by year
- 2026: 5 · 2025: 5 · 2024: 8
- FWCI
- 0.65
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Pain Practice (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- PolyU Institutional Research Archive (Hong Kong Polytechnic University) (submittedVersion, cc-by-nc)
- Funders
- Australian Government
- Macquarie University
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Keywords
- chronic widespread pain, musculoskeletal pain, pain intensity, health-related quality of life, depression, anxiety, pain catastrophizing, pain coping, guided intervention, self-guided intervention, telemedicine
- MeSH terms
- Chronic Disease, Depression, Humans, Quality of Life, Chronic Pain, Pain Management
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