Support For Rheumatic Conditions: Understanding Internet-Based Therapy For Chronic Pain

Published 06/24/2022

Rheumatic conditions, such as rheumatoid arthritis and lupus, are often characterized by chronic pain, fatigue, difficulty with movement, and decreased mental health. Rheumatic conditions are autoimmune and inflammatory diseases that lead to your immune system attacking your joints, muscles, organs, and bones. These diseases are typically chronic and require ongoing pain and symptom management. Because of this, cognitive behavioral therapy can be a huge asset when managing the mental and physical symptoms of patients with rheumatic conditions.

How Can Cognitive Behavioral Therapy Help Rheumatic Conditions?

One of the greatest patient difficulties with rheumatic conditions is adjusting to a new normal.These adjustment problems can lead to a lower quality of daily life and an increased incidence of conditions such as anxiety, depression, and insomnia. One review showed that almost39% of patients with rheumatoid arthritis experience depression worldwide. When patients have difficulty adjusting to their condition, adherence to treatment plans can significantly decrease. This means that people are much less likely to participate in treatment for symptoms of their condition, such as doing physical therapy exercises, making necessary environmental changes, and seeking consistent mental health care. When treatment adherence decreases, symptoms often dramatically worsen, and medical costs for those affected increase.

One of the main goals of cognitive-behavioral therapy for those with rheumatic conditions is to help patients learn how to manage symptoms of chronic pain independently. This helps increase independence, accept new daily needs, reduce disease-specific dysfunctional beliefs, and improve mental health. While living with rheumatic conditions can be challenging—and it is normal to feel overwhelmed and uncomfortable—cognitive behavioral therapy can provide huge mental health benefits and increase the quality of everyday life. Patients learn strategies to take control of their health and self-monitor their condition, allowing them to catch warning signs early and seek assistanceas needed.

Cognitive-behavioral therapy has shown great promise with bodily conditions such as fibromyalgia, chronic pain, and rheumatoid arthritis. Patients can significantly reduce unhealthy beliefs about living with chronic conditions and modify behavioral and environmental factors to minimize discomfort best. Despite its proven positive effects for people living with rheumatic conditions, patients face several barriers when seeking this type of treatment. These barriers include high financial costs, time constraints, discomfort and anxiety related to medical settings, lack of accessibility, and stigmas related to seeking psychological treatment.

Is Internet-Based Cognitive Behavioral TherapyAsas Effective As Face-to-Face Cognitive Behavioral Therapy?

Internet-based cognitive-behavioral therapy (ICBT) has a high potential to provide evidence-based therapeutic intervention to patients with rheumatic conditions without the barriers seen with traditional cognitive behavioral therapy (CBT).

For one, internet-based therapies can be completed within the home in a self-paced manner. For people with busy schedules or families at home, this flexibility allows participants to reduce the stress associated with the time commitment of traditional therapy. This is especially relevant for people with rheumatic conditions because travel may be difficult, and the cost of traditional therapy may feel like an additional burden on top of other necessary medical costs. Communicating remotely with therapists can be an added benefit for those who feel unease in medical settings or interacting directly with providers.

In previous research studies, ICBT has been linked to a significant reduction in symptoms of certain psychological outcomes such as depressive moods and anxiety symptoms, as well as disease-specific symptoms such as pain, fatigue, and headaches. Daily life quality in patients who completed ICBT programs was also significantly improved compared to groups that did not complete the internet-based program. Participants in the programs were especially happy with the ease of online programs and flexibility in terms of time commitment.

What Does Internet-Based Cognitive Behavioral Therapy Consist Of?

Internet-based cognitive therapy typically consists of modules with a recommended time per module. For example, some programs assign one module per week, with a certain number of assignments and assessments corresponding with each lesson. The online environment is created on a secure server, and patient information is kept confidential from those other than the guiding therapist and the participant.

The modules are often disease or condition-specific but generally cover psychoeducation, exercises to reduce symptoms, self-management techniques, relaxation exercises, and relapse prevention. Online programs can be guided by overseeing therapists or completely independent, but preliminary research has indicated that guided programs tend to have better outcomes for participants. Some training also has periodic live sessions with the therapist or with the other participants. Those in the program can continually reach out to their therapist with questions, thoughts, or concerns. Internet-based therapy has shown promise for the self-management of rheumatic conditions. Still, there is a lack of research specifically for patient populations with a high disease burden (i.e.,those with severe symptoms or a drastic reduction in quality of everyday life).

Can Internet-Based Cognitive Behavioral Therapy Help Adults With Rheumatic Conditions?

Unlike face-to-face therapy, which is often individualized, online cognitive behavioral therapy usually consists of a broad range of modules to provide effective treatment to the widest audience possible. When designing an ICBT program for people with rheumatic conditions, it is important to understand the most prevalent needs of this specific population.

For rheumatic conditions, the fear-avoidance (FA) model has been used to conceptualize the best way to develop an effective ICBT program. In this model, the most important categories for the management of chronic pain and other rheumatic symptoms include:

  • Catastrophizing
  • Pain-related fear
  • Low self-efficacy

When people with rheumatic conditions engage in pain avoidance behavior, this can increase physical symptoms and impact rheumatic conditions' impact on daily activities. When participating in ICBT, patients have shown significant improvements in their physical symptoms and psychological well-being and a reduction in the impact of their condition on everyday activities.

To better understand how ICBT impacts patients with rheumatic conditions, a systematic review of previous programs was performed by researchers to see how the therapeutic interventions impacted physical and psychological outcomes. Psychological outcomes included depression, anxiety, self-efficacy, and catastrophizing, while physical outcomes includedpain intensity and fatigue markers. Researchers looked at quality of life indicators when measuring the impact on daily life.

Systematic Review OfICBT For Patients With Rheumatic Conditions

How Were Studies Identified?

Researchers used databases such as PsycINFO, Embase, Emcare, Cochrane Library, Web of Science, and PubMed to find studies to include in the systematic review. They looked for studies using keywords such as "cognitive-behavioral therapy," "chronic pain," and "internet." Once studies were identified, they were screened for inclusion based on the following criteria:

  1. Study participants were over 18 years of age
  2. A randomized controlled trial (RCT) design was used
  3. The study was published in English
  4. A full-text article was available
  5. The intervention was internet-based
  6. The intervention used CBT principles
  7. A therapist guided the intervention
  8. The data was original
  9. Psychological and physical outcomes were included

What Data Were Collected FromEach Study?

From each study, participant data consisted of:

  • Mean age and sex
  • Country of data collection
  • Number of patients
  • Type of rheumatic disease
  • Number of completers and dropouts
  • Reasons for dropouts
  • Type of control conditions
  • Completer and intent-to-treat analyses

In addition to this, intervention data were collected to ensure there was standardization between the studies analyzed. This includes the goals of the intervention, duration of the intervention, types of therapists guiding the program, frequency of therapist contact with participants, mode of contact between participants and therapists, results, and any adverse outcomes.

What Were TheResults Of The Study?

After filtering the studies for inclusion criteria, eight studies conducted between 2008 and 2018were identified for the analysis. Two of these studies were conducted in a hospital setting, universities ran two, and the settings of the other studies were not disclosed. The participants of the studies had a combination of rheumatic conditions, including rheumatoid arthritis, osteoarthritis, fibromyalgia, and other arthritic conditions.

All of the interventions aimed to improve patients' ability to manage their condition and use cognitive, behavioral, and emotional strategies to improve their daily quality of life. Improvement of daily life was broken down into the following categories:

  1. Reducing avoidance behaviors through exposure
  2. Reducing patient distress
  3. Improving mental health
  4. Improving physical health
  5. Developing psychological flexibility
  6. Improving self-efficacy

For each module, there were associated themes so patients could complete each unit individually at their own pace.The length of studies varied between six to ten weeks, and the most commonly mentioned elements of the interventions were psychoeducation, self-monitoring, relaxation, problem-solving, cognitive restructuring, physical exercise, and relapse prevention, among others.

A therapist or an otherwise-trained moderator guided each intervention, and some of the interventions also encouraged patient-to-patient online communication.

Overall, internet-based cognitive behavioral therapy was shown to have a significant effect on the psychological well-being of participants when compared to groups who did not complete the online treatment. This includes depression, anxiety, or self-efficacy measures, depending on the study. One study also found a significant reduction in pain catastrophizing for those who completed the online program.

For physical symptoms, four out of seven studies found that the online therapy helped patients reduce pain severity, and one study showed participants had a significant reduction of fatigue. For daily life measures, two out of three relevant studies showed a significant improvement in the participants' quality of life, and three out of four studies showed participants experiencing much less of an impact on their daily life from their rheumatic condition.

What's Next?

As more research emerges specifically using therapist-guided internet-based cognitive behavioral therapy to support those living with rheumatic conditions, the benefits become more and more apparent. While future studies will continue to enhance our understanding of which components are most important in these study designs, people living with rheumatic conditions should consider internet-based cognitive behavioral therapy as a legitimate avenue to decrease psychological and physical symptoms and improve the quality of everyday life.

If you believe internet-based cognitive behavioral therapy could benefit you, consider reaching out to an experienced mental health provider at BetterHelp. BetterHelp is an online therapy platform that connects individuals seeking mental health care with therapists who know how to use evidence-based methodsto help them take control of their health and move towards their wellness goals.