The present study evaluated the efficacy of a clinician-guided Internet-delivered cognitive behaviour therapy (iCBT) program, the Pain Course, to reduce disability, anxiety, and depression associated with chronic pain. Sixty-three adults with chronic pain were randomised to either a Treatment Group or waitlist Control Group. Treatment consisted of 5 iCBT-based lessons, homework tasks, additional resources, weekly e-mail or telephone contact from a Clinical Psychologist, and automated e-mails. Twenty-nine of 31 Treatment Group participants completed the 5 lessons during the 8-week program, and posttreatment and 3-month follow-up data were collected from 30/31 and 29/31 participants, respectively. Treatment Group participants obtained significantly greater improvements than Control Group participants in levels of disability, anxiety, depression, and average pain levels at posttreatment. These improvements corresponded to small to large between-groups effect sizes (Cohen's d) at posttreatment for disability (d = .88), anxiety (d = .38), depression (d = .66), and average pain (d = .64), respectively. These outcomes were sustained at follow-up and participants rated the program as highly acceptable. Overall, the clinician spent a total mean time of 81.54 minutes (SD 30.91 minutes) contacting participants during the program. The results appear better than those reported in iCBT studies to date and provide support for the potential of clinician-guided iCBT in the treatment of disability, anxiety, and depression for people with chronic pain.

Individuals with chronic pain demonstrate attentional biases (ABs) towards pain-related stimuli. However, the clinical importance of these biases is yet to be determined and a sound theoretical model for explaining the role of ABs in the development and maintenance of pain is lacking. Within this article, we (1) systematically review prospective and experimental research exploring ABs and pain outcomes in light of current theoretical models and (2) propose a theoretical framework for understanding AB in pain. Across prospective research, an attentional pattern of vigilance-avoidance was observed. Interventions targeting ABs were less consistent; however, there were promising findings among studies that found attentional training effects, particularly for laboratory research. The proposed Threat Interpretation Model suggests a relationship between threat, interpretation, and stimuli in determining attentional processes, which while tentative generates important testable predictions regarding the role of attention in pain and builds on previous theoretical and empirical work in this area.

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Potential applications of attention bias modification (ABM) for acute and chronic pain patients are investigated. In study 1, 54 acute back pain patients (46 of whom completed the study) were recruited at their initial physiotherapy session and randomised to receive 1 session of ABM or placebo. Patients were followed up 3 months later. Participants who were randomised to receive ABM reported less average (P=0.001) and current pain (P=0.008) and experienced pain for fewer days (P=0.01) than those who received placebo. In study 2, 34 chronic pain patients were recruited and randomly assigned to receive either 4 sessions of ABM (n=22) or placebo (n=12), followed by 8 sessions of cognitive behavioural treatment (CBT). After ABM, there was a significant group-by-time effect for disability. By 6-month follow-up, differences had emerged between the 2 training groups, such that the ABM group had shown greater reductions in anxiety sensitivity and disability than the placebo group. Although the results of these studies show that there is potential in the application of ABM to pain conditions, the mechanisms of treatment could not be established. Neither group showed an initial bias towards the word stimuli or a training effect, and only in the acute pain group were changes in biases related to outcome. Nonetheless, the fact that 2 independent samples showed a positive effect of ABM on clinical outcomes suggests that ABM is worthy of future study as an intervention for pain patients.