Taal , L. A. ( 1998 ). Th e psychological aspects of burn injuries . Maastricht : Shaker Publishing B.V . Terman , G. and Bonica , J. ( 2001 ). Spinal mechanisms and their modulation . Bonica \200 \231s management of pain (3rd edn). Philadelphia, PA : Lippincott Williams & Wilkins . Online supplementary materials Video 54.1 Hypnosis for procedural pain management: \200 \234Favorite Place \200\235. Reproduced with permission from Leora Kuttner (dir.), No Fears No Tears , Copyright 1985. Trautmann , E. and Kroner-Herwig , B. ( 2010 ). A randomized controlled trial of Internet-b ased self-help training for recurrent headache in childhood and adolescence . Behav Res Th er , 48 , 28 \200\22337. Video 54.2 Hypnosis for procedural pain management: \200\234Th e Magic Glove \200\235. Rep roduced with permission from Leora Kuttner (dir.), No Fears No Tears , Copyright 1985. Trautmann , E. , Lackschewitz , H. , and Kroner-Herwig , B. ( 2006 ). Psychological treatme nt of recurrent headache in children and adolescents \200\224a meta- analysis . Cephalalgia , 26 , 1411 \200\2231426. Uddin , L. Q. , Supekar , K. S. , Ryali , S. , and Menon , V. ( 2011 ). Dynamic reconfi gur ation of structural and functional connectivity across core neurocognitive brain networks w ith development . J Neurosci , 31 , 18578 \200\22318589. Video 54.3 Hypnosis for acute pain management: Focussed breathing. Reproduced with permissi on from Leora Kuttner (dir.), No Fears No Tears , Copyright 1985. Uman , L. S. , Chambers , C. T. , McGrath , P. J. , and Kisely , S. ( 2006 ). Psychological interventions for needle-related procedural pain and distress in children and adolescents . Cochrane Database Syst Rev , 4 , CD005179 . Video 54.4 Hypnosis for persistent pain management: Dissociation Imagery. Reproduced with p ermission from Leora Kuttner (dir.), No Fears No Tears , Copyright 1985. CHAPTER 55 New information and communication technologies for pain Jennifer Stinson and Lin dsay Jibb Summary Th e rapid growth in the amount and availability of information and communication t echnology (ICT) in the last decade means that several new tools have become available to mo nitor and manage chronic pain. Th ese tools include the Internet (and associated social sup port networks), mobile phones, and telemedicine and they are being used to enable self-mana gement by people suff ering from persistent pain. Th e benefi ts of ICT-based pain therapie s are many and include improved treatment accessibility and satisfaction, as well as potent ial decreases in therapy cost. ICT therapies for people in pain represent exciting treatmen t possibilities. Future, rigorous research into the design and eff ectiveness of these ther apies will shed more light on how ICT might improve the quality of life for people with chr onic pain. Smartphone applications (apps) for the management of chronic pain are reviewed. Future dire ctions for theory, research, and clinical practice are also described. Chronic pain self-management Chronic pain is common in adults (Johannes et al., 2010 ) as w ell as children and adolescents (King et al., 2011 ) and can negatively impact all aspects of life including physical, emotional, social, and role functioning (Law et al., 2012 ; Pal ermo, 2000 ; Reid et al., 2011 ). Chronic pain may include varying amounts of disability an d may be independent of the amount of tissue damage and perceived severity of injury (Hugue t and Miro, 2008 ; Melzack and Wall 1965 ). In the likely absence of a cure or total pain r elief, the prevention of pain-related disability and the improve- ment of quality of life t hrough better chronic pain self-manage- ment are critical (Ritterband et al., 2003 ). Self- management can be defined as \200\230the individual \200\231s ability to manage the sympto ms, treatment, physical, and psychological consequences and life- style changes inherent in living with a chronic illness \200\231 (Barlow et al., 2002 ). Introduction Over the past decade there has been tremendous growth in the development and e valuation of ICT to deliver health care inter- ventions including those for the treatment o f chronic pain. Results from a 2010 telephone survey of 3001 American adults showed that 80 % of Internet users accessed health informa- tion online and 14% accessed information speci fi c to managing chronic pain (Fox, 2011 ). From a public health perspective, there is grea t potential for self-administered treatments to improve the health of individuals who suff er from chronic pain but are unable to access services. ICT-based programs off er an inno- vative approach to improve the availability, accessibility, and acceptability of these prog rams. Th is chapter will review ICT for pain by: defi ning chronic pain self-management, di scussing barriers to the provision of pain self-management and psycho- educational interven tions, and discussing methods by which ICT can overcome these barriers. Th e theories, proc esses, and content elements of ICT-based chronic pain programs are defi ned and described. Th e evidence, where available, from treatment inter- vention trials and the advantages and disadvantages of telehealth, internet-based programs, and mobile-health (m-health) or Self-management interventions that provide individuals with knowledge about pain, strategie s to manage pain (cognitive- behavioral therapies or CBT), and social support are needed to promote optimal health outcomes. Studies in adult chronic ill- nesses (Foster et al., 2007 ; Lorig and Holman, 1993 ; Smith et al., 2005 ) have shown that comprehensive interactive face-to-face psycho-educational interventions lead to symptom reduction and improved qualit y of life compared with care that is strictly medication focused. Th e proposed mechanism o f eff ect for this phenomenon is presumed to be enhanced self-effi cacy (i.e. belief in one \200\231s ability to successfully perform a behavior) and empow- erment over disease and s ymptom management (Marks et al., 2005a , 2005b ). For example, Lefort and colleagues (1998) found that a 12-h community-based, chronic pain psycho-educational program led to signifi cant short-term improvements in pain, independence, vitality, aspects of role functioning, life satisfaction, SECTION 7 psychosocial interventions 570 self-effi cacy and resourcefulness compared to a wait-list control group in adults with chr onic pain. (Griffi ths et al., 2006 ; Ritterband et al., 2003 ). Using ICT to deliver health intervent ions dramatically reduces geographic constraints, provides opportunities for access regardl ess of language spoken and travel constraints (fi nancial or due to physical disability) an d pro- vides more immediate access to information that can help patients feel less isolated and more in control of managing their chronic condition (Griffi ths et al., 2006 ; Nguyen et al., 2004 ). Variations in pain-related disability exist in young people and adults with chronic pain. H owever, the majority of the variance is related to several physical, psychological, and soc ial variables (Bargiel-Matusiewicz and Krzyszkowska, 2009 ; Lynch et al., 2007 ). Th us, in tervening in the pain experiences of young people and adults with chronic pain requires a b road framework that compre- hensively addresses the physical and psychosocial precipitants, as well as modifi ers and consequences, of chronic pain (Rapoff and Lindsley, 2000 ). Th e most successful interventions in improving pain and associated impairments in adults with chronic health conditions (including pain) are based on CBT (LeFort et al., 1998 ). CBT inc orporate normalization of the patient \200\231s experience through education about the cond ition and its impact, training in specifi c strategies, including managing disease-related and other stressors, and guidance on developing and implementing a long-term plan for self- managing the condition (Palermo et al., 2010 ). Research into ICT-based psycho-educational and disease self- management interventions for a dults has rapidly increased over the past decade, with results from systematic and meta-ana lytic reviews suggesting excellent effi cacy for symptom reduction, knowledge attainment, a nd improved health behaviors across a wide range of chronic conditions including chronic pa in (Cuijpers et al., 2008 ; Lorig et al., 2008 ; Murray et al., 2005 ; Nguyen et al., 2004 ; Palmqvist et al., 2007 ; Spek et al., 2007 ; Wantland et al., 2004 ). However, there is l ess empirical data on the availability and eff ectiveness of ICT-based psycho-educational a nd disease self-management interventions for children and adolescents with chronic health c onditions (Cushing and Steele, 2010 ; Lelieveld et al., 2010 ; March et al., 2009 ; Palermo et al., 2010 ; Ritterband et al., 2003 ; Runge et al., 2006 ; Stinson et al., 2009 ). In t he following sections, the evidence from treatment inter- vention trials and the advantages and disadvantages of telehealth, Internet-based programs, and m-health (including smartpho ne apps) for management of chronic pain will be described. Barriers to the provision of pain psychosocial interventions Th ere is a solid empirical fo undation supporting CBT interven- tions to equip individuals with the necessary coping skil ls to reduce chronic pain and pain-related disability (Barlow et al., 1999 ; Jensen, 2010 ; Lineker et al., 1996 ; Stinson et al., 2012 ). Historically, bar- riers to accessing compr ehensive chronic pain-specifi c education and cognitive behavioral coping skills training h ave included: (1) limited access to services in many geographic areas (including rural and remote regions), (2) language barriers (programs off ered only in English), (3) and long-wa it times (Elgar and McGrath et al., 2003 ; Peng et al., 2006 ; Stinson et al., 2008 ; Stins on et al., 2010 ); (4) limited availability of trained professionals such as psychologists, particularly in non-urban centers; (5) time restrictions limiting the amount of content re viewed during regular chronic pain clinic or primary care visits; and (6) additional costs (direct and indirect) including costs of CBT and time off work and/or school associated wit h these therapies (Barlow and Ellard, 2006 ; Barlow et al., 1999 ; Elgar and McGrath, 2003 ; Lineker et al., 1996 ; Stinson et al., 2012 ). Th eoretical frameworks for ICT-based pain self-management programs Murray and colleagues ( 2005) have developed a theoretical pathway to explain changes in health outcomes mediated b y ICT (primarily Internet-based programs). According to this pathway, ICT work by combining information with peer, decision-making, and behav- ioural change supports to allow interna lization and interpretation of the information by the user. A combination of enhanced self- effi - cacy with motivation and knowledge, enables users to change their health behaviors l eading to changes in clinical outcomes (Murray et al., 2005 ). Ritterband and colleagues (2009) have built upon this postulated pathway of change by inclu ding characteristics of the end-users (i.e. demographic, disease, cognitive and physiologic al factors; personality traits; beliefs and attitudes; self-effi cacy and skills), the envi ronment, and the Web-based program (see Figure 55.1 ) (Ritterband et al., 2009 ). While thi s model was based on Internet- based programs, the key concepts are applicable to other ICT s as well. Th e model purports that program users are infl uenced by environmental factors (i.e. family, friends, signifi cant others, employers/school, health care system, community , and societal infl uences) which aff ect website use and adherence. Website use and adhere nce is also infl uenced by the type of support provided (e.g. email, phone, face-to-face) a nd characteristics of the web- site (e.g. appearance, behavioral prescriptions (e.g. contra cts, prompts), content, burden (e.g. diffi culty of use, length), delivery (e.g. animations , audio, illustrations, text, testimonials), message (e.g. source and style), participation (e.g. interaction, reinforce- ment, testing) and assessment (e.g. personalized or tailorin g)). Finally, website use leads to changes in behavior that results in symptom improvement through various mechanisms of change such as gaining knowledge, changing attitudes and beli efs, motiva- tion, and skill building. New technologies as an intervention medium to overcome barriers to pain care With emerging ICT (e.g. telehealth, Internet, smartphone apps), new media for the delivery of health inte rventions are now availa- ble (Ritterband et al., 2003 ). For example, the Internet has eme rged as one of the top health information resources and modes of social communication, espe cially for youths and young adults, and con- tinues to be increasingly integrated into the provision of health care services (Drotar et al., 2006 ; Gray et al., 2005 ; Griffi ths et al., 2006 ). In developed countries, the vast majority of people have Internet access at ho me, work, school, or through the use of mobile tech- nology (Fox, 2011 ; Klasnja and Pratt, 2012 ). ICT provides patients, families, and health care professionals with unparalleled o pportu- nities to: (1) learn, inform, and communicate with one another; (2) receive meaning ful social support; (3) fulfi l the rising demand for expedient access to evidence-based he alth information; and (4) achieve greater involvement in health care decision-making CHAPTER 55 new information and communication technologies for pain 571 Disease Demographics Traits Cognitive Factors Beliefs and Attitudes Physiological Factors S kills E-Mail Phone Face-to-Face Appearance \200 Color Usage \200 Layout \200 Organization \200 Screen Size User Characteristics Support Personal Professional Community Healthcare System Media/Policy/Culture Behavioral Prescriptions \200 Contracts \200 Written Instructions \200 Prompts Environment Website Use Burdens \200 Di \203culty of Use \200 Length Website For Exsample: \200 Knowledge/Information \200 Motivation \200 Beliefs and attitudes \200 Skill Building Content \200 Accurate \200 Clear \200 Simple Mechanisms of Change Delivery \200 Animations \200 Audio \200 Illustrations \200 Text \200 Video \200 Vignetters/Testimonials Problem-Speci \201c Dependent Variables Behavior Change Message \200 Source \200 Style Symptom Improvement Treatment Maintenance Participation \200 Interaction \200 Reinforcement \200 Testing Assessment \200 Personalization \200 Tailoring Figure 55.1 Model of Internet interventions. Reproduced from Lee M. Ritterband et al., A be havior change model for internet interventions, Annals of Behavioral Medicine , Volume 38, No. 1, pp. 18 \200\22327, Copyright Th e Society of Behavioral Medicine 2009, with kind permission from Springer Science and Business Media, http://www.springer.com/medicine/journ al/12160. Internet-based chronic pain interventions Improvements in Internet access and broadband spe eds have led to an increase in Web-based treatments for chronic pain. Th erapeutic Internet -based interventions are treatments based on eff ective face-to-face interventions (e.g. ps ycho-educational and CBT) that are transformed for delivery via the Internet with the goal of improved health outcomes (symptom reduction (pain and pain- related disability; decrease d anxiety and depression) and improved health-related quality of life). Usually, Internet-b ased interventions are highly structured, self-guided or partly self-guided (i.e. mini- mal therapist support through regular brief telephone and or email contact), tailored to the u ser \200\231s needs and interactive (Ritterband et al., 2003 ). While this is a burgeoning fi eld, the Internet remains a relatively new medium for delivery of psychosocial health in ter- ventions. Formal evaluations of the impact of Internet health interventions on health outcomes, level of resource utilization and user satisfaction have lagged far behind interv ention development (Danaher and Seeley, 2009 ; Nguyen et al., 2004 ). Th e literature on Internet-based chronic pain interventions is rapidly growing with studie s on feasibility and utility, as well as evidence of effi cacy in improving clinical health outcomes being conducted (Lorig et al., 2008 , Macea et al., 2010 ). Macea and col- league s recently conducted a meta-analysis of the effi cacy of Web- based self-guided cognitive-b ehavioral interventions (4 \200\2237 weeks in length) with minimal therapist involvement (e mails and/or tele- phone contact) for chronic pain. Th e primary outcome in this anal- ysis was pain intensity. Eleven RCTs, including 2953 participants (67.5% women with mean age 41 .32 (range: 7 \200\22391) years), with ten diff erent pain-related disorders (low back pain and arthritis typi- cally) were included. Th e pooled eff ect size (standardized mean dif- ference between intervention and wait-list control group means) from a random eff ects mod el was 0.28 (95% confi dence interval: 0.14, 0.42). Internet-based interventions resulted i n signifi cant changes favoring the experimental group in variables including medication us e, health care visits, return to work capacity and pain reduction. In summary, the authors showed small treatment eff ects SECTION 7 psychosocial interventions 572 Social support in the age of the Internet Social support is a multidimensional concept, whi ch describes the formal and informal relationships developed to provide for the needs of in dividuals. Social support has been identifi ed as a key factor in aiding patients in managi ng painful conditions and cop- ing with related diagnoses (Rodham et al., 2009 ). Social su pport may take the form of peer education and peer networks fostering identity, empathy, an d empowerment (Polomano et al., 2007 ); mak- ing it an important factor in establishing eff ective self-management behaviors. for improvement of pain, greater improvements in pain-related conditions such as work disab ility and that CBT interventions are eff ective. All studies in this review used wait-list controls instead of placebo control, thus placebo eff ects remain to be examined in future trials. More recently, Bender and colleagues conducted a systematic review of 17 RCTs of Internet-b ased pain interventions; however, this review incorporated both acute and chronic pain cond itions (Bender et al., 2011 ). Th e 17 studies included interventions pro- viding either CB T (n = 11), moderated peer support programs (n = 3), or clinical visit preparation/follow-u p support (n = 3) to 2503 individuals in pain. Most Internet-based CBT trials (72.2%) used wait-list control conditions and three used compa- rable Internet-based control conditions. Interventions consisted of structured, self-administered therapy programs off ered in week ly modules that ranged in length from 6 to 20 weeks. All interventions included support fro m a clinical or research staff person via telephone, email, asynchronous or synchronous mes sage boards. Minimal support typically included providing feedback on weekly reports, remin ders to complete program activities and administrative or technical assistance. Seven of el even studies evaluated outcomes in adults and four evaluated outcomes in children and adole scents. Th e majority of studies showed improvements in pain (n = 7; 77.8%), activity limit ation (n = 4; 57.1%) and costs associated with treatment (n = 3; 100%), whereas eff ects on depression (n = 2, 28.6%) and anxiety (n = 2, 50%) were less consistent. Several positive health outcomes from social support have been identifi ed in people with c hronic pain. For instance, von Weiss and colleagues (2002) found that in children with pain ful rheumatic diseases, high levels of social support predicted lower levels of depression regardless of the level of daily hassle perceived to be due to the disease. Supportive soci al networks may also result in facili- tating self-management behaviors and smoother transi tions from pediatric to adult health care for adolescents with chronic pain- ful conditions (Stinson et al., 2008 ; van Staa et al., 2011 ). Engaging in supportive and understanding social networks also results in improvements in long-term functional disability and pain in adults with rheumatoid arthritis (Evers et al., 2003 ). In addition, in adults with chroni c pain, supportive social interactions resulted in reduc- tions in negative mood feelings a nd improved perceived abilities to cope with their diagnosis (Feldman et al., 1999 ). Modern social networking In recent years, the advent of the Internet and associated technol ogies has resulted in new means by which people may engage in socially supportive networks. Technology-based social networks have been used to connect people with members of existing communities, to build new communities and as modalities to disseminate and transfer knowle dge (Henderson et al., 2012 ; Polomano et al., 2007 ; Scanfeld et al., 2010 ; Subrahmanyam et al., 2008 ). At present, social network- ing is amongst the most common reasons people a ccess the Internet (Henderson et al., 2012 ). Technology-based social networking may take t he form of electronic peer feedback generated from thoughts and experiences published on pe rsonal blogs and short Twitter mes- sages or through more interactive discussion forums, on line support groups and listservs (Barak et al., 2009 ). In addition, a review and meta-analysis of computerized CBT programs for pain, aimed specif i cally at children and adoles- cents was conducted by Velleman and colleagues (2010) . Fou r studies met the inclusion criteria and all demonstrated 50% reduc- tion in pain compared to control groups that was maintained out to 3 months. Meta-analysis results suggested a po oled medium eff ect size of \210\2220.41 for reduction of pain intensity post-treatment wi th mean odds ratio of 0.63 for achieving clinically signifi cant reductions in pain. Th ese three systematic reviews provide grow- ing evidence that Internet-based interventions redu ce pain and pain-related disability. However, evidence on other important outcomes such as emotional functioning and cost-eff ectiveness compared to traditional face-to-face therapie s remains to be determined. While there are many advantages of Internet-based pain thera- pies; the current evidence su ggests several limitations as well. For instance, given the self-guided nature and relative anonym- ity of this medium high trial dropout rates compared to tradi- tional face-to-face therapies have been observed (Bender et al., 2011 ). However, adding human support via bri ef telephone/email contact with a therapist, or lay peers, and/or including social net- wor king opportunities for intervention participants has improved motivation and adherence to o nline health care services, thereby optimizing the achievement of desired outcomes (Nguyen et al., 2004 ; Palmqvist et al., 2007 ; Rosser et al., 2011 ; Spek et al., 2007 ; Stinson e t al., 2009 ). It is important that future studies collect information on reasons for dropo ut to inform the development of strategies to improve the adherence and effi cacy of these interven- tions. In addition, motivational interviewing regarding readiness to change pain behaviors represents another promising method to help reduce dropout rates (Duff and Latchf ord, 2010 ; Vong et al., 2011 ). Th e advantages of technology-based social networking opportu- nities for individuals with pain are many. Participating in blogging is postulated to act as an adjunct to other psycho logical and behav- ioural therapies by enabling self-refl ection, debate and knowledge- exc hange (Barak et al., 2009 ; Tan, 2008 ). Furthermore, the skills required to engage in onli ne networking are relatively easy to learn and, in the case of children and young adults wh o have lived their entire lives in the age of the Internet (Henderson et al., 2012 ), are t ypically already possessed. Networks established via ICT have the added advantage of increa sing accessibility to social support for people with pain. Online communication may act as a means to create social support networks, which would otherwise be diffi cult to build for persons with stigmatizing health conditions (Bargh et al., 2002 ; Henderson et al., 2012 ) . Virtual communities can also facilitate interactions between people with chronic pain con ditions. Peer \200\223peer interactions may be problematic for those with rare medical pres entations or those living in more remote communities. Research suggests that people with ch ronic and life-limiting health CHAPTER 55 new information and communication technologies for pain 573 m-Health technologies and pain Mobile devices such as cellular phones and personal digital assist- ants (PDAs) represent another novel pain modality for monitor- ing and managing pai n. In addition, the widespread use of mobile devices (85% of surveyed Americans) with incre asing technical capabilities (Raine, 2010 ) increases the number of people electronic healt h interventions can reach. At present, several diff erent mobile technology applications ar e being developed and tested for use in health care (Klasnja and Pratt, 2012 ). conditions desire the ability to make social connections and seek social support from their peers with the same condition (Bender et al., 2011 ; Kearney et al., 2009 ; Stinson et al. , 2008 ). ICT may cir- cumvent this issue and increase accessibility to social support net- works for all people with painful health conditions. Online social networking for people with pain Th e limited number of studies (n = 2) examin ing peer social support in adults with chronic pain show preliminary but positive eff ects on pain outcomes. Th ese studies include a 2002 investigation by Lorig and colleagues into the use of an email-based listserv to con- nect people with pain. Peer support was provided in a second study through the use of an Internet-based asynchronous discussion forum (Lori g et al., 2008 ). Chronic pain conditions in these stud- ies were recurrent lower back pain (Lorig et al., 2002 ) and arthritis (Lorig et al., 2008 ). Both of the interventions inclu ded group mod- eration by either peers or health care providers and in both cases, study sa mple sizes were large (range: 580 \200\223855). Peer support pro- vided by the e-mail based listserv resulted in signifi cant reductions in pain intensity, disability, and distress i n the intervention group (Lorig et al., 2002 ). Use of the peer moderated discussion forum by people with arthritis resulted in signifi cant reductions in pain intensity, distress, a ctivity limitation, and improvements in health status (Lorig et al., 2008 ). However, neith er study was able to show a reduction in health care utilization. In addition, clinically s ignifi - cant changes in health outcomes were not described in either study. A third study examined the eff ectiveness of using email-based peer support by adults with chronic low ba ck pain to enhance the use of complementary and alternative medicine (CAM) modalities (Bruc e et al., 2005 ). Th is study showed that participants in the intervention group did not di ff er from those in the control group, suggesting that peer support may be ineff ective in enhancing the use of CAM therapies for pain. Th e most basic of the mobile technology interventions is text messaging (short messaging s ervice or SMS), a service allowing messages of 160 characters to be sent between mobile pho nes. Because the vast majority of mobile phones are capable of sending and receiving SMS, t his service does not suff er from the potential drawbacks of more expensive devices (e.g. i Phones, BlackBerrys, devices with Android-based operating systems) and is commonly used in the developing world (Klasnja and Pratt, 2012 ). Potential health intervention uses of SMS technology include: (1) the log- ging of symptom data, (2) communication with health care p rovid- ers and (3) the ability for patients to receive remote reminders to engage in health behaviors (Klasnja and Pratt, 2012 ). A more complex use of mobile technologies for health condi- tion management comes in the fo rm of automated clinical deci- sion support systems (CDSSs). Th e number of CDSS has increa sed greatly in the last two decades and CDSSs currently under develop- ment vary in their p urpose and their intended user-groups (Moxey et al., 2010 ). Some are intended to provide h ealth care profession- als with evidence-based advice on how to proceed with patient care ( Garg et al., 2005 ; Traft on et al., 2010 ). Others are designed in a \200\230shared-care \200\231 tradition and are intended to inform manage- ment strategies through direct use by patients (Gibson et al., 2010 ; Kearney et al., 2009 ). Because of the technical programmi ng intri- cacies of these systems, they are typically available only on mobile devices that support more complex platforms, such as the iPhone or Android-operating system phones. At this time however, only a few evidence-based mobile technology-based interventions for pain management exist. Despite increasing interest in the prevalence and eff ectiveness of social support networki ng by people with pain, very little is known about how this group uses the most common soci al networking sites (although pain-related Facebook groups and Twitter handles do exist at present). Facebook, Twitter, and MySpace are some of the most widely accessed websites in u se today. Facebook alone reports over 800 million members, with 400 million logging on to t he site daily (Facebook, 2012 ). Social support networks for people with health issues have been established on these widely-used com- munication platforms oft en by patients or thei r family and friends (as opposed to health care providers; Bender et al., 2011 ). Created g roups are typically informally moderated by more active group members and lack formal hiera rchical organization. Recently, a review of 111 smartphone apps for the management of pain due to a wide variety of conditions was conducted (Rosser and Eccleston, 2011 ). Apps were targeted at a range of health conditions known to cause pain with the most common conditions targeted being heada che or migraine (39%), followed by back pain (16%). Th e content of apps available at the t ime of review varied with 54% including education related to pain and its management, 24% i nclud- ing pain diary capabilities, and 17% including relaxation or medita- tion leading ca pabilities. Importantly, 86% of the apps did not report the involvement of health care prof essionals in content development and none have undergone rigorous evaluation using RCTs. In its early stages, Internet-based social networking appears to be a promising avenue to e licit accessible social support for people with pain; it is, however, not without inherent limitations. For instance, the majority of current social support networks are unmoderated and operate with little or no input from clinical or research experts. Given the sensitive nature of the information, opinions, and beliefs being expressed through these networks, mo nitoring by health care professionals or disease-specifi c organizations is warranted. In a ddition, support group websites should clearly present authorship details and disclaimers r elated to use. Health care professionals must also engage in conversations with patients ab out the benefi ts and drawbacks of participating Internet-based social support groups. m-Health technologies under development A mobile phone-delivered, and Web-based chronic pai n intervention A mobile phone-based intervention for people with chronic wide- spread pain has recently been developed and is in the pre-trial stages of eff ectiveness testing (Krist jansdottir et al., 2011 ). Th is intervention involves the remote delivery of CBT using SMS . Th e SECTION 7 psychosocial interventions 574 study involved six participants (23 \200\22348 years) with chronic wide- spread pain who co mpleted multidimensional pain diary entries for 4 weeks on phones. A therapist then remotel y logged on to a secure website, viewed the diary entries, and provided individual- ized fe edback aimed at stimulating patient self-management of the current pain situation. Th is in tervention received high par- ticipant acceptability and usability ratings. In addition, co mpli- ance with diary entries was high (78 \200\22394% of entries completed) and technical problems with the intervention were infrequent and minor. Despite the rapid adoption of these therapies, a technological divide does still exist in t erms of age-related diff erences in technol- ogy confi dence, skill, and use and the unequa l provision of costly infrastructure (broadband computing) in diff erent communities. Th e extent to which these interventions can be independent of any human support (lay person, tr ained non-health care professionals, health care professionals) is not known. Th ere is evi dence that self- guided or minimal human involvement is associated with greater patient dro pout compared to face-to-face therapy. Determination of the minimum amount of support requi red to improve outcomes and the most appropriate person to provide that support is needed. In developing mobile phone-based pain management interven- tions, researchers and developer s should seek the expertise of health care professionals in the design and implementation o f mobile pain management programs to help ensure usefulness and safety. Rigorous testing of these interventions (i.e. via randomized control- led trials or RCTs) is also needed to de termine their eff ectiveness. Successful evidence-based development of m-health interventio ns for people with pain may result in accessible care and improved outcomes, making researc h exploration in this area important. Th e essential ingredients that are needed in ICT-based pro- grammes are also largely unkno wn and should be determined by conducting dismantling studies. We need to determine what ty pes of patients are best served by these programs and when in the pain trajectory, programs are the most eff ective. In addition, the cost eff ectiveness of these programs compared t o traditional approaches needs to be determined. Th e cost of the development of these prog rams can be reduced by developing a core set of pain coping skills that can be used across all types of chronic pain con- ditions. Clinicians and policy makers will need to rethink h ealth care processes around chronic pain management to ensure funding to support the sustai nability of these ICT-based therapies. Finally, we need to ensure data security, privacy, a nd confi dentiality of per- sonal health information. Telemedicine/telehealth Telemedicine or telehealth refers to telecommunication systems in t he broadest sense and includes the use of technology to help deliver and support health ser vices (e.g. call centers, cell phones, video-conferencing, and web-based platforms). Teleme dicine methods have been proposed as a means to improve access to pain management programmi ng provided that appropriate thera- pists and remuneration policies are in place (MacDonald et al., 2011 ). A recent systematic review of telehealth for pain manage- ment found that only a limited number of RCT examinations of telemedicine versus traditional therapies exis t (McGeary et al., 2012 ). However, based on currently available literature, there is good preliminary evidence to believe that telemedicine is an eff ective and viable means of mana ging pain (McGeary et al., 2012 ). Th e costing of telemedicine methods for pain management in adults with chronic pain has also been compared to traditional face-to-face therapies i n a RCT (Pronovost et al., 2009 ). Results showed that direct patient costs were signifi ca ntly lower in the telemedicine group than the face-to-face group and that more participants in the telemedicine group were satisfi ed with their consultation. In terms of research, standards on the reporting and evaluation of ICT have been recently e stablished and will provide important guidance for future studies (Eysenbach and CONSORT-EH EALTH Group, 2011 ). Multicentred RCTs of high quality are needed to compare ICT-based trea tments with active placebos as well as face- to-face CBT. Conducted trials should include t he measurement of broader biopsychosocial outcomes and move beyond simple pain intensity ex aminations. Dismantling studies can help determine the optimal length of interventions, spe cifi c treatment compo- nents which are eff ective, and whether social support or therapist involvement would improve outcomes. Finally, strategies to reduce dropout rates (e.g. moti vational interviewing and minimal online support) need to be evaluated. Conclusion ICT-based pain treatments are an innovative way to improve the access and availa bility of psycho-educational pain therapies for individuals with chronic pain. Th ere is gr owing evidence that ICT treatments not only reduce pain but also pain-related disability in various types of chronic pain conditions and in both pediatric and adult populations. We c an continue to harness the potential of these mediums by ensuring that we explore the needs and perceptions of people in pain regarding ICT-based pain treatments \200\224including wh en and under what circumstances the Internet is preferred to face-to-face therapies. Th is will help to tailor pain management eff orts to individual preferences and enhance complian ce and acceptability of these programs. Moreover, well-designed stud- ies with placebo cont rol groups that include diverse patient groups are needed to strengthen the growing evidenc e base concerning ICT-based interventions for people with pain. Finally, we need to ensure that these programs are publically available and that when they off er therapist involvemen t that this is remunerated by our health care system. Future directions for theory, research, and clinical practice Th ere is great excitement an d opportunity associated with new ICT for the management of long-term health conditions suc h as chronic pain. While there is enthusiasm, there are a number of theoretical, research a nd clinical issues that need further consideration. First, consensus and standards on metho ds of development and met- rics for evaluation of ICT-based health care treatments need to be developed. Th ere is currently little guidance on how to develop or translate therapy fr om traditional human face-to-face to ICT-based delivery system. To this end, user-centered designs must be the start- ing point. Th e needs and perspectives of people in pain regardi ng ICT-based therapies (i.e. when and under what conditions ICT therapy is preferred to fac e-to-face) needs to be the fi rst step guid- ing development of these interventions. CHAPTER 55 new information and communication technologies for pain 575 References Barak , A. , Klein , B. , and Proudfoot , J. G. ( 2009 ). Defi ning internet-sup ported Garg , A. X. , Adhikari , N. K. , McDonald , H. , Rosas-Arellano , M. P. , Devereaux , P. J . , Beyene , J. , et al . ( 2005 ). Eff ects of computerized clinical decision support syst ems on practitioner performance and patient outcomes: a systematic review . JAMA , 293 (10) , 1223 \200\2231238. therapeutic interventions . Ann Behav Med , 38 (1), 4 \200\22317. Bargh , J. A. , McKenna , K. 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