Self-help interventions for persistent physical symptoms: a systematic review of behaviour change components and their potential effects

Figures & data

Figure 1. PRISMA flow diagram illustrating the identification, screening and inclusion of studies.

Figure 2. Risk of bias assessment based on five domains and overall bias as defined by the revised Cochrane risk-of-bias tool for randomised trials (n = 51).

Table 1. Characteristics of included RCTs and intervention descriptions.

Type of PPS	Recruitment setting	Main inclusion criteria	Sample size	Females %	Age, y (SD)	Duration of symptoms/disorder, y (SD)	Intervention description	Methodological approach	Mode of delivery	Duration	Guidance	Control condition(s)	Follow-up points extracted
Amirova et al. (2017); UK
Fibromyalgia	Regional support groups	Diagnosis according to ACR criteria	IG: 67, ACG: 66, PCG: 58	93.7	48.1 (11.1)/50.5 (10.8)/49.0 (10.1)	11.6 (7.0)/14.1 (9.6)/11.0 (6.77)	The Mitchell Method Relaxation Technique including daily auditory guided imagery, muscular relaxation and breathing exercises guided by an audio recording (5 min 20 sec).	Mind-body theory	Online including written instructions and an guided audio recording	1 month	None	Attention control group, WL	Post treatment, 1 m FU
Andersson et al. (2002); Sweden
Tinnitus	General population and patient associations	≥6 mo tinnitus plus seen a general practitioner or ear, nose and throat physician	IG: 53, PCG: 64	46.0/48.0	48.5 (12.3)/47.2 (15.0)	6.2 (5.6)/6.4 (6.8)	Self-help programme including 10 components presented in six modules on a weekly basis, including homework and weeekly reports.	CBT	Website and e-mail	6 weeks	Participants received an encouraging e-mail when submittng a weekly report.	WL	Post treatment
Andersson et al. (2003); Sweden
Headache (migraine and tension type)	General population	Diagnosis according to IHS criteria	IG: 24, ACG: 20	81.8	40.3 (n.r.)	0.5–1 y: 4.5%/1–5 y: 31.8%/6–10 y: 11.4%/ > 10 y: 52.3%	Self-help programme with six weekly treatment modules, including information, applied relaxation and exercises. Weekly report cards for the exercises were used.	CBT	Website and e-mail	6 weeks	Weekly telephone support by therapist to forster adherence (lasting on average 10 min).	Self-help programme without telephone support	Post treatment
Berman et al. (2009); US
Chronic pain	Community settings	≥55 y plus ≥1 d/mo with functional impairment or average pain ≥3 (0–10)	IG: 52, PCG: 37	87.2	65.8 (range 55–91)	n.r.	Intervention including self-help content and exercises covering abdominal breathing, relaxation, expressive writing, creative visual expression and positive thinking delivered in six modules.	Mind-body theory	Website and e-mail	6 weeks	None	WL	Post treatment
Buhrman et al. (2004); Sweden
Chronic back pain	General population	≥3 mo pain plus been in contact with a physician	IG: 22, PCG: 29	62.7	43.5 (10.3)/45.0 (10.7)	8.8 (6.8)/10.5 (11.2)	Self-help intervention including psychological components, streching and physical exercises.	CBT	Website and telephone support	6 weeks	Weekly telephone support by CBT trained therapists (graduate students) to review homework, answer questions, provide reminders and maintain motivation. Supervision provided by clinical psychologist and physiotherapist.	WL	Post treatment
Buhrman et al. (2015); Sweden
Chronic pain with comorbid depression or anxiety	Specialised care and general population	Medical investigation(s), ≥ 3 mo pain plus depression >10 points (MADRS-S)	IG: 28, ACG: 24	85.0	50.7 (12.7)	3 mo–1 y: 12%/1–5 y: 21%/5–10 y: 13%/ > 10 y: 54%	Treatment programme including information, assignments and exercises. The first and the last part of the programme was the same for all participants, whereas parts of the programme focusing on behavioural activation and content about worry and insomnia were individualised. The full programme consisted of eight sections.	CBT	Website and e-mail	8 weeks	Weekly written feedback was given by CBT trained therapists (graduate students) and included positive reinforcement and replies to inquiries. Supervision provided by clinical psychologist.	Moderated online discussion forum	Post treatment
Carpenter et al. (2012); US
Chronic low back pain	General population	≥6 mo pain plus pain ≥4 (0–10)	IG: 70, PCG:71	83.0	42.5 (10.3)	8.6 (7.8)	Online ‘Wellness workbook’ consisting of a mind/body treatment rationale, pain education and CBT tecniques, including cognitive restructuring, stress management, relaxation training, mindfulness and values-based behavioural activation. Content was presented in six chapters, each taking 1–1.5 h to complete.	Enhanced CBT	Website	3 weeks	None	WL	Post treatment
Chalder et al. (1997); UK
Chronic fatigue	General practice	Fatigue ≥4 for >6 mo	IG: 70, PCG:80	74.7	36.0 (10.1)/35.0 (7.5)	n.r.	Self-help booklet, including information about fatigue, diary-keeping, cognitive and behavioural techniques and sleep management.	CBT	Booklet	n.r.	The self-help booklet was initiated by a nurse in general practice.	TAU	Post treatment
Chhabra et al. (2018); India
Chronic low back pain	Specialised care	Pain ≥5 (NPRS) for >12 weeks plus undergoing treatment	IG: 45, PCG: 48	n.r.	41.4 (14.2)/41.0 (14.2)	1.9 (1.8)/2.3 (2.1)	‘Snapcare’ app providing daily activity goals based on patient health status, activity of daily living and daily activity progress.	n.r.	App	12 weeks	None	TAU	Post treatment
Chiauzzi et al. (2010); US
Chronic back pain	General population, specialised care and patient associations	Pain ≥10 days/mo for ≥3 mo	IG: 104, ACG: 105	67.7	46.1 (12.0)	n.r.	Online self-management tailored through a recommendation engine that matched self-reported user chracteristics with lessons, interactive tools, personalised assessments and articles. Content presented in two weekly session (8 sessions in total), each taking at least 20 min to complete.	CBT	Website	Primary intervention: 4 weeks, booster period: 5 website visits per month during FU	None	Text-based back pain guide	Post treatment, 3 m FU, 6 m FU
Devineni and Blanchard (2005); US
Chronic headache (migraine and tension type)	General population	≥1 y pain plus self-reported medical diagnosis	IG: 39, PCG: 47	88.0/79.0	43.6 (12.0)/41.0 (11.8)	n.r.	Online behavioural regimen composed of progressive relaxation, limited biofeedback with autogenic training and stress management.	Mind-body theory	Website	4 weeks	None	WL	Post treatment
Dowd et al. (2015); Ireland
Chronic pain	Individuals with pain listed on a research database	≥6 mo pain	IG: 62, ACG: 62	90.3	44.5 (12.3)	10.8 (9.0)	Online ‘Mindfulness in action’, including a psychoeducation component, a mindfulness practice focus and a cognitive and behavioural change component. Content was presented in 12 sessions, each taking approx. 20 min to complete.	Mindful-ness	Online programme, audio recordings and e-mail	6 weeks	None	Written pain management psychoeducation delivered by e-mails	Post treatment, 6 m FU
Friedberg et al. (2016)/Meng and Friedberg (2017); US
Chronic fatigue syndrome	Specialised care and patient associations	≥6 mo fatigue plus 4 secondary symptoms	IG: 44, ACG: 45, PCG: 48	88.3	47.0 (10.8)/48.0 (12.4)/50.0 (11.3)	13.7 (7.0)/12.6 (8.5)/17.3 (10.7)	Fatigue self-management booklet (also available as audio CD) paired with relaxation audio CD, daily paper diary and step counter.	CBT	Booklet, audio CDs, paper diary and step counter	12 weeks	None	Fatigue self-management booklet (also available as audio CD), relaxation audio CD, daily online web diaries and actigraphs, TAU	Post treatment, 12 m FU
Friesen et al. (2017); Canada
Fibromyalgia	General population, general practice and patient associations	Prior diagnosed by physician, > 3 mo pain plus depression ≥5 (PHQ-9) or anxiety ≥5 (GAD-7)	IG: 30, PCG: 30	95.0	48.0 (11.0)	16.0 (10.0)	Online pain course consisting of lessons, homework assignments and additional resources.	CBT	Website and automated weekly e-mails	8 weeks	Weekly telephone contact (5–10 min) with therapist (doctorate-level graduate student trained in chronic pain) to summarise content, answer questions, reinforce progress and encourage practice. Supervision provided by registered psychologist.	WL	Post treatment
Gallagher et al. (2013); Australia
Chronic pain	Specialised care	>3 mo pain related impairment	IG: 40, ACG: 39	60.8	42.0 (11.0)/45.0 (11.0)	2.1 (1.6)/2.6 (1.7)	Booklet with metaphors and stories to help understand the biology of pain. Content presented in 80 pages divided in 11 sections.	Psycho-education	Booklet	3 weeks	None	Booklet with advice about managing pain	Post treatment, 3 m FU
Geraghty et al. (2018); UK
Low back pain	General practice	Current pain plus consulted general practitioner within 6 mo	IG: 29, ACG:30, PCG: 28	61.4	59.3 (10.4)/54.5 (13.7)/60.3 (16.3)	<1 y: 45.8%/1–5 y: 32.6%/6–10 y: 10.8%/ > 10 y: 10.8%	Online ‘SupportBack’ intervention focusing on self-regulatory processes, including goal setting, self-monitoring and tailored feedback to support physical activity. Content presented in 6 sessions.	n.r.	Website and e-mail	6 weeks	Three phone calls by senior physio-therapist (15–30 min, 1 h total) to support and encourage participants to use the SupportBack intervention.	Online SupportBack intervention without physio-therapist support, TAU	Post treatment
Hagatun et al. (2018); Norway
Insomnia	General population	Diagnosis according to DSM-IV criteria	IG: 95, ACG: 86	67.0	44.9 (13.0)	<1 y: 15.0%/1–5 y: 22.0%/6–10 y: 34.0%/ > 10 y: 28%	Online ‘SHUTi’ intervention, including sleep hygiene, sleep restriction, stimulus control and cognitive restructuring. Content presented in six modules and includes personalised treatment recommendations.	CBT	Website	9 weeks	None	Patient education website	Post treatement
Hesser et al. (2012); Sweden^a
Tinnitus	General population	>6 mo tinnitus, prior diagnosed by physician plus tinnitus distress ≥38 (THI)	IG: 35, ACG1: 32 ACG2: 32	43.4	48.5 (14.7)	0.8 (0.7)	Online treatment including text- and picture-based self-help material, exercises and homework. Content presented in eight modules.	ACT	Website	8 weeks	Asynchronous online communication with CBT/ACT trained therapist (psychologist or psychology students). Mean time spent per participant each week was 9 min, including response to messages and administration. Supervision was provided.	CBT with therapist feedback, online discussion forum	Post treatment
Hunt et al. (2015); US
Irritable bowel syndrome	Specialised care and patient associations	Prior diagnosed by physician plus meeting Rome III IBS criteria	IG: 32, PCG: 28	83.3	36.0 (15.7)/36.0 (12.6)	n.r.	Workbook for irritable bowel syndrome, including psychoeducation, relaxation training, cognitive model, avoidance behaviour and exposure. Content presented in 9 chapters.	CBT	Booklet or link to online version	6 weeks	None	WL	Post treatment
Irvine et al. (2015); US
Low back pain	General population	Pain within past 3 mo plus no impairment	IG: 199, ACG: 199, PCG: 199	60.0	n.r.	n.r.	Online FitBack intervention providing low back pain education and behavioural strategies to manage current pain and future pain episodes.	CBT	Website and e-mail	8 weeks	None	8 e-mails with links to 6 websites ith information about low back pain, TAU	Post treatment, 4 m FU
Janse et al. (2016); The Netherlands
Chronic fatigue	Specialised care	≥6 mo severe fatigue plus impairment 450–700 (SIP8) and/or <4 secondary symptoms	IG: 50, PCG: 50	68.0	median (range): 37.0 (18.0-63.0)/31.0 (18.0–62.0)	median (range): 5.5 (1.0–61.0)/4.0 (0.5-26.0)	Booklet with self-instructions based on the assumptions that fatigue-related cognitions and behaviour perpetuate fatigue. Content presented in 13 modules.	CBT	Booklet and e-mail	6 months	Cognitive behavioural therapists responded to fortnightly e-mails of the patients explaning certain aspects of the treatment relevant for the individual patient or suggesting how to proceed with the treatment. Supervision was provided.	WL	Post treatment
Jasper et al. (2014)/Conrad et al. (2015); Germany^b
Chronic tinnitus	General population, specialised care and patient associations	≥6 mo tinnitus plus tinnitus distress ≥18 (THI) or ≥8 (Mini-TQ)	IG: 41, ACG: 44	37.6	51.3 (9.8)/52.1 (9.0)	9.2 (7.9)/8.0 (7.1)	Online treatment combining CBT techniques with relaxation exercises. Content presented in 12 mandatory and 6 optional modules, each including general information, suggestions for exercising, worksheets and solutions for common problems.	CBT	Website	10 weeks	Weekly e-mail communication with therapist (clinical psychologist). Therapist spent max 10 min per week per patient. Supervision was provided.	Discussion forum	Post treatment
Jernelöv et al. (2012); Sweden
Insomnia	General population	Diagnosis according to AASM research criteria	IG: 44, ACG: 45, PCG: 44	82.0	47.9 (13.9)	11.8 (12.0)	Self-help intervention with two parts. The first part consists of psychoeducation about sleep and insomnia. The second part presents techniques, e.g., relaxation and visualisation techniques, sleep restriction and stimulus control, cognitive restructuring techniques, and sleep hygiene.	CBT	Booklet, CD, digital treatment guide and sleep diary	6 weeks	Weekly telephone contact with therapist (graduate student) following a structured guide (each call max. 15 min). Supervision provided experienced clinician.	Self-help booklet and CD without therapist support, WL	Post treatment, 3 m FU
Johnston et al. (2010); New Zealand
Chronic pain	Specialised care	Referred to a pain clinic	IG: 12, PCG: 12	62.5	Median (range): 43.0 (20.0–84.0)	n.r.	Self-help workbook ‘Living beyond your pain’ focusing on relationship with pain, values, thoughts, mindfulness and committed actions, including exercises. Content presented in eight chapters.	ACT	Booklet	6 weeks	None	WL	Post treatment
Kaldo et al. (2007); Sweden
Tinnitus	General population and specialised care	≥6 mo tinnitus, prior medical examination by specialist plus tinnitus distress ≥10 (TRQ)	IG: 34, PCG: 38	48.6	45.9 (13.0)/48.5 (15.7)	8.6 (8.4)/12.4 (11.7)	Self-help book, including introduction, treatment tools, evaluation and maintenance, with focus on tinnitus, noise sensitivity and hearing impairments.	CBT	Booklet	6 weeks	Brief weekly telephone calls by therapist (graduate student) focusing on treatment progress and advice on how to move on. Mean time spent per patient was 107 min. Supervision provided by clinical psychologists.	WL	Post treatment
Knoop et al. (2008); The Netherlands
Chronic fatigue syndrome	Specialised care	Diagnosis according to CDC criteria	IG: 85, PCG: 86	79.3	37.6 (10.0)/38.5 (10.6)	Median (range): 6.0 (1.0–35.0)/8.0 (1.0–35.0)	Self-instruction booklet containing information about chronic fatigue syndrome and weekly assignments.	CBT	Booklet	At least 16 weeks	Patients e-mailed or phoned a cognitive behavioural therapist fortnightly to report on progress and received a response.	WL	Post treatment
Lee et al. (2014); Taiwan
Bladder pain syndrome/interstitial cystitis	Specialised care	IC/BPS	IG: 40, PCG: 40	n.r.	46.5 (10.2)/49.5 (11.8)	n.r.	Online web service asking patients to check and follow diets and lifestyles suggested by physicians and providing a Q/A SMS application for management of symptom flares.	n.r.	Website and SMS application	8 weeks	None	TAU	Post treatment
Lee et al. (2018); Taiwan
Bladder pain syndrome/interstitial cystitis	Specialised care	Diagnosis of IC/BPS according to AUA	IG: 30, PCG: 30	100.0	42.9 (10.4)/46.3 (14.2)	n.r.	Online service providing 21 video clips for weekly health education and symptom flare management and weekly check for diets and lifestyles.	n.r.	App and reminders (via e-mail, SMS, voice call, or social network apps)	8 weeks	None	TAU	Post treatment
Lin et al. (2017); Germany
Chronic pain	Specialised care	≥6 mo pain plus interference ≥2 (0–10)	IG: 100, ACG: 101, PCG: 101	84.1	41.7 (13.1)	9.5 (10.1)	Online ‘ACTonPain’ programme comprising modules focusing on information, assignments, relevant metaphors, and mindfulness exercises. Content presented in eight modules, each taking approx. an hour to complete.	ACT	Website and e-mail feedback	8 weeks	Personalised and standardised e-mail feedback from e-coaches (psychologists). Time spent on guiding per participant averaged 105 min. Supervision provided by psychological psychotherapist.	ACTonPain programme without e-coaching, WL	Post treatment, 6 m FU
Ljotsson et al. (2010); Sweden
Irritable bowel syndrome	Specialised care	Prior diagnosed by physician plus meeting Rome III IBS criteria	IG: 43, ACG: 43	84.7	34.6 (9.4)	6.3 (7.3)	Self-help manual based on exposure and mindfulness exercises with guidance. The manual was divided into five steps: (1) A rationale for the treatment and instructions on mindfulness, (2–4) Presentation of a psychological model of IBS and continued mindfulness exercises, (5) Exposure exercises and finally, relapse prevention.	Enhanced CBT	Website and closed online discussion forum	10 weeks	Asynchronous correspondence with CBT trained therapist (graduatestudent) providing weekly feedback. Time spent per participant averaged 165 min. Supervision provided by psychologist.	Online discussion forum and permission to contact student therapist for general support	Post treatment
Lorenz et al. (2019); Switzerland, Austria & Germany
Insomnia	General population and specialised care	Insomnia severity ≥8 (ISI)	IG: 29, PCG: 27	69.6	41.7 (17.3)/44.0 (20.1)	n.r.	Online treatment ‘mementor somnium’ focusing on psychoeducation, sleep restriction, relaxation, sleep hygiene, cognitive restructuring and changing sleep-related behaviours. Content presented in six sessions with guidance by an animated sleep coach.	CBT	Website	6 weeks	None	WL	Post treatment
Lorig et al. (2008); US^c
Arthritis and Fibromyalgia	General population	Diagnosed with osteoarthritis, rheumatoid arthritis or fibromyalgia	IG: 433, PCG: 422	89.8/90.5	52.2 (10.9)/52.5 (12.2)	n.r.	Online arthritis self-management programme consisting of interactive instructions, bulletin board discussions, tools such as exercise logs, medication diaries and tailored exercise programmes and arthritis helpbook containing all of the programme content. Participants were expected to spend 3–6 h each week on programme content.	CBT	Website, booklet and e-mail	6 weeks	Trained online peer moderaters reminding participants to log on, modelling action planning and problem solving, offering encouragement and posting to the bulletin boards.	TAU	12 m FU
Malouff et al. (2010); Australia
Tinnitus	General population, specialised care and patient associations	Tinnitus	IG: 84, PCG: 78	49.0/39.7	57.3 (13.7)/57.8 (13.3)	n.r.	Self-help book ‘Tinnitus: A self-Management Guide for the Ringing in Your Ears’ focusing on tinnitus education, cognitive reappraisal and restructuring, relaxation exercises, stress management tecniques, attention control techniques, use of self-instruction and lifestyle changes.	CBT	Booklet	2 months	None	WL	Post treatment
Menzies et al. (2006); US
Fibromyalgia	Specialised care	Diagnosis of fibromyalgia plus functional impairment >20 (FIQ)	IG: 24, PCG: 24	97.9	49.6 (10.5)	n.r.	Gudied imagery involving guided imagery audiotapes adressing familiarity with relaxation and imagery, the signal breath relaxation and imagery of a pleasant scene and reinforcement of the signal breath conditioning for relaxation. Tapes were practiced daily for two weeks.	Guided imagery	Audiotapes	Primary intervene-tion: 6 weeks; Follow-up period (4 weeks): Use of any of the tapes once a day	None	TAU	Post treatment, 10 weeks FU
Mulet et al. (2007); US
Masticatory myofascial pain and forward head posture	Specialised care and general population	Meet research diagnostic criteria for TMD, > 6 mo pain plus pain >4 (0–10)	IG: 20, ACG: 22	95.2	24.2 (10.0)	5.4 (3.9)	Self-care programme including counselling, patient education, reassurance about symptoms and encouragement to rest the masticatory muscles combined with Rocabado's 6 × 6 exercise programme, including 6 exercises to be performed 6 times a day repeated 6 times each.	n.r.	Written explanations and instructions	4 weeks	Treatment initiated by a physical therapist who conducted treatment review after 1 week.	Self-care programme without Rocabado's 6 × 6 exercises	Post treatment
Oerlemans et al. (2011); The Netherlands
Irritable bowel syndrome	General practice and patient associations	≥3 mo IBS according to ICPC or Rome III criteria	IG: 38, PCG: 38	91.9/76.9	35.9 (11.7)/40.6 (15.5)	n.r.	Digital diaries three times daily assessing quality of sleep, severity of complaints, intended activities for the day (mornings), severity of complaints, accomplished activities, cognitions and feelings (afternoons) and severity of complaints, satisfaction with activity level and achievements of the day (evenings).	CBT	Personal digital assistant (PDA)	4 weeks	Based on diaries and following a standardised protocol, situational feedback from psychologists was provided via SMS. Supervision provided by psychologist/senior researcher.	TAU	Post treatment, 3 m FU
Onieva Zafra et al. (2013); Spain
Fibromyalgia	Patient associations	≥3 y fibromyalgia diagnosis	IG: 30, PCG: 30	96.4	51.6 (6.3)	>3 y: 7.3%/>5 y: 29.1%/>10 y: 4.8%/>15 y: 21.8%	Music therapy (classical music mixed with salsa music) in two phases, each with initial face-to-face music therapy and with subsequent CDs for self-administration.	Music therapy	CD	4 weeks	Intervention phases initiated by 1 h face-to-face sessionwith researcher.	TAU	Post treatment
Peters et al. (2017); The Netherlands & Belgium
Chronic musculoskeletal pain	General population and patient associations	>3 mo pain	IG: 117, ACG: 116, PCG: 51	85.0	48.6 (12.0)	12.8 (10.1)	‘Happy despite pain’ intervention, including self-compassion exercises, ‘three good things’ exercises, savouring techniques, writing about and imagining the ‘best possible self’ and maintenance plan. Content presented in eight modules.	Positive psychology	Website and telephone and e-mail support	8 weeks	Forthnightly semi-structured telephone calls by graduate/newly graduated psychology students (mean duration of each call 15–20 min) and, forthnightly semistandardised e-mails to encourage to continue the programme and share any problems encountered.	iCBT including relaxation, stretching exercises, cognitive restructuring, coping techniques, body scan exercises and relapse prevention, WL	Post treatment
Rantonen et al. (2014)/Rantonen et al. (2016); Finland^d
Low back pain	Worksite	Pain intensity 10–34 (0–100) plus ≥2 weeks pain/y or ≥2 recurrent episodes/y	IG: 90, ACG: 92, PCG: 83	21.0/34.0/24.0	45.0 (8.0)/43.0 (7.0)/45.0 (8.0)	12.0 (9.0)/11.0 (7.0)/14.0 (9.0)	‘Back book’ based on a biopsychosocial model, focusing on LBP attitudes, inappropriate LBP behaviour, coping, avoiding LBP re-exacerbation and emphasing the importance of getting back to normal activities.	Psycho-education	Booklet	n.r.	Initial 20 min face-to-face book presentation and advice by occupational health nurse trained in LBP.	‘Back book’ without advice, natural course control group	Post treatment, 6 m FU, 12 m FU, 24 m FU
Riva et al. (2014); Switzerland
Chronic back pain	Specialised care	≥3 mo pain	IG: 27, ACG: 24	50.0/51.9	44.0 (13.6)/51.0 (14.1)	7.9 (7.2)/9.3 (8.7)	The ‘ONESELF website’ containing static features including a library, a first aid section and a frequently asked questions section and interactive features including a virtual gym, a testimonials and commentaries section, a weekly action plan and a quiz game.	n.r.	Website and SMS reminders	8 weeks	None	Static features of ‘ONESELF website’	Post treatment
Robinson et al. (2006); UK
Irritable bowel syndrome	General practice	Prior or current diagnosis of IBS and attending general practitioner	IG: 139, ACG: 141, PCG: 140	89.0	40.0 (14.4)	6.0 (7.2)	Self-help guide book containing information about lifestyle, diet and pharmacological and alternative therapies based on up-to-date evidence and patients’ anecdotal experiences.	n.r.	Booklet	n.r.	One group meeting (2 h) facilitated by trial coordinator.	Self-help guide book without group meeting, TAU	12 m FU
Sanders et al. (2007); US
Irritable bowel syndrome	Specialised care	Prior diagnosed by physician using Rome II IBS criteria	IG:17, PCG: 11	71.4/88.9	56.9 (14.6)/41.8 (10.3)	16.3 (15.0)/15.0 (12.7)	Self-help book ‘Breaking the bonds of irritable bowel syndrome’ containing review of the digestive system, diagnostic medical tests, diet, medical and psychological treatments and describing several exercises to assist identification of foods, situations, emotions and thoughts influencing IBS and providing CBT techniques to deal with difficult situations. Content presented in 5 modules.	CBT	Booklet and work sheets sent by e-mail	10 weeks	None	WL	Post treatment
Ström et al. (2000); Sweden
Headache	General population	≥6 mo pain plus headache frequency ≥1/week	IG: 20, PCG: 25	68.9	41.5 (range 23–62)/39.2 (23–61)	0.5–1 y: 6.7%/1–5 y: 35.6%/ > 5 y: 55.6%	Internet headache treatment based on applied relaxation, autogenic training and problem-solving training. Participants registered the frequency and duration of practising relaxation, and the results were reported once each week.	n.r.	Website and e-mail	6 weeks	None	WL	Post treatment
Townsend et al. (2001); US
Temporo-mandibular disorder	General population	Pain in the past year plus 1 of 5 secondary symptoms	IG: 14, ACG: 10	100.0	35.4 (9.5)/38.9 (8.2)	7.5 (0.8)/9.5 (2.5)	Self-help manual incorporating treatment rationale, awareness-training exercises, including deep breathing and progressive relaxation training, habit detection procedures, the use of competing responses to prevent or interrupt the target behaviour and relapse prevention. Content presented in 7 lessons.	Mind-body theory	Written materials and audiotape	App. 10 weeks	Weekly therapist (advanced graduate student) contact via e-mail or telephone (mean telephone contacts 9/mean length each 4 min) to answer questions and assist with problem solving.	Waiting list condition with weekly telephone contact to monitor pain levels and ensuring intervention enrolment	Post treatment
Trompetter et al. (2015); The Netherlands
Chronic pain	General population and online patient platforms	Pain ≥3 days/week for ≥6 mo plus pain intensity ≥4 (0–10)	IG: 82, ACG: 79, PCG: 77	76.8/75.9/75.3	52.9 (13.3)/52.3 (11.8)/53.2 (12.0)	>5 y: 58.5%/69.6%/61.0%	‘Living with pain’ intervention, including experiential exercises, metaphors and mindfulness exercises to be practised daily. Content presented in nine modules.	ACT	Website and e-mail	9–12 weeks	Structured e-mail counselling once a week provided by recently graduated psychology students to guide, encourage and support the process. Supervision by a registered cognitive behavioural therapist.	Expressive writing with structured e-mail correspondence once a week, WL	Post treatment, 6 m FU
Tummers et al. (2012); The Netherlands
Chronic fatigue syndrome	Community health centre	Diagnosis according to CDC criteria	IG: 62, PCG: 61	78.0	36.3 (12.1)/36.4 (13.6)	median (range): 4.0 (0.5–38.7)/5.0 (0.5–52.1)	Self-instruction material with information and assignments including establishment of treatment goals, precipitation and perpetuating factors, reducing the focus on fatigue, establishing a sleep routine, establishing an adequate activity pattern, illness beliefs, plan for work resumption, modifying expectations to social environment, increasing mental and social activities and relapse prevention. Content presented in 15 chapters.	CBT	Booklet	20 weeks	Forthnightly e-mail correspondance with psychiatric nurse trained in coaching. Supervision by a cognitive behavioural therapist.	WL	Post treatment
Vallejo et al. (2015); Spain^b
Fibromyalgia	Specialised care	Diagnosis according to ACR criteria	IG: 20, PCG: 20	100.0	51.6 (9.9)	8.7 (7.3)	Programme, including psychoeducation, relaxation training, emotional training, adjusting daily activities, insomnia and sexual dysfunctions, problem solving, cognitive restructuring attentional control, illness behaviours, cognitive processing and memory, and relapse prevention. Content presented in 10 sessions.	CBT	App	10 weeks	Digital messaging with therapist (junior therapist) to verify understanding of main topics, reinforce weekly schedule and resolve any problems. Supervision by a cognitive behavioural therapist.	WL	Post treatment
van Ittersum et al. (2014); Belgium
Fibromyalgia	Specialised care	Diagnosis according to ACR criteria	IG: 53, ACG: 52	93.0	46.5 (9.3)	median (range): 8.5 (1.0–30.0)/8.0 (0.1–25.0)	Pain neuroscience education using a cognitive approach to restructure thoughts and reconceptualise pain, including explanations and illustrations about pain physiology, mechanisms of central sensitisation, and tips and tricks on how to incorporate the information in daily life.	Psycho-education	Booklet	6 weeks	One telephone call from therapist (researcher) to provide opportunity for clarification, verify understanding and providing further information, patient allowed to ask questions twice by telephone or e-mail contact.	Written relaxation education, including exercises and instructions	Post treatment, 6 m FU
Vincent and Lewycky (2009); Canada
Chronic insomnia	Specialised care and general population	≥ 6 mo insomnia ≥4 nights/week plus daytime impairment	IG: 59, PCG: 59	66.9	n.r.	n.r.	Online treatment programme including psychoeducation, sleep hygiene, stimulus control, relaxation training, sleep restriction, hypnotic medication tapering and introduction to cognitive therapy. Content presented in five modules.	CBT	Website	5 weeks	None	WL	Post treatment, 1 m FU
Williams et al. (2010); US
Fibromyalgia	General practice and specialised care	Diagnosis according to ACR criteria	IG: 59, PCG: 59	95.0	50.5 (11.5)	9.4 (6.5)	Online ‘Living well with fibromyalgia’ behavioural self-management intervention, including educational lectures on fibromyalgia, educational, behavioural and cognitive skills to help with symptom management and behavioural and cognitive skills to facilitate adaptive life style changes. Content presented in 13 modules.	CBT	Website	6 months	None	TAU	Post treatment
Wilson et al. (2015); US
Persistent pain	General practice and general population	>3 mo pain plus current prescription(s) for opioids	IG: 57, PCG: 57	78.0	49.3 (11.6)		Online ‘Chronic pain management program’ consisting of learning modules related to cognitive, behavioural, social and emotional determinants and regulation and including exercises, relaxation and self-monitoring.	CBT	Online programme	8 weeks	None	TAU	Post treatment

AASM = American Academy of Sleep Medicine, ACG = active control group, ACR = American College of Rheumatology, ACT = acceptance and commitment therapy, AUA = American Urological Association, BPS = Bladder Pain Syndrome, CBT = cognitive behavioural therapy, CDC = Centers for Disease Control and Prevention, CFS =Chronic Fatigue Syndrome, DSM-IV = Diagnostic and Statistical Manual for Mental Disorders, fourth edition, FIQ = Fibromyalgia Impact Questionnaire, FU = follow-up, GAD = Generalised Anxiety Disorder, HIS = International Headache Society, IBS = Irritable Bowel Syndrome, IC = Interstitial Cystitis, ICPC = International Classification of Primary Care, IG = intervention group, ISI = Insomnia Severity Index, LBP = low back pain, n.r. = not reported, MADRS-S = Montgomery Åsberg Depression Rating Scale, Mini-TQ = Mini-Tinnitus Questionnaire, NPRS = Numeric Pain Rating Scale, PCG = passive control group, PHQ = Patient Health Questionnaire, SIP = Sickness Impact Profile, TAU = treatment as usual, THI = Tinnitus Handicap Inventory, TMD = Temporomandibular Disorder, TRQ = Tinnitus Reaction Questionnaire, WL = waitlist.

^a Two active interventions were compared with a less intensive ACG. Only data for the primary intervention compared with the less intensive ACG were retrieved.

^b One study arm assigned to group CBT was excluded from the review.

^c Only data on patients with fibromyalgia was retrieved.

^d Outcome measures based on registerdata were retrieved at 12 months FU or 24 month FU.

Figure 3. Standardised mean difference (95% CI) of the effect of the primary interventions compared with passive control groups on symptom burden at post-treatment (n = 32).^a

Figure 4. Standardised mean difference (95% CI) of the effect of the primary interventions compared with passive control groups on quality of life at post-treatment (n = 33).

Figure 5. Proportion of studies (95% CI) favouring the intervention (SMD > 0) and proportion of interventions (95% CI) with effect (SMD ≥ 0.2) at post-treatment, ≤3 month follow-up and >3 month follow-up according to risk of bias distribution. SMD = standardised mean difference.

Figure 6. Frequency of behaviour change techniques applied in studies comparing the primary intervention with an active control group (n = 23) and/or a passive control group (n = 38).

Table 2. Effect (SMD> = 0.2) of interventions and index of potential of BCTs (95% BCI) applied in each symptom cluster in studies with passive control groups (n = 38)^a,b,c.

	Symptom burden					Anxiety					Depression					Quality of life
	Effect, n	All, n	Index of potential	95% BCI	p	Effect, n	All, n	Index of potential	95% BCI	p	Effect, n	All, n	Index of potential	95% BCI	p	Effect, n	All, n	Index of potential	95% BCI	p
Post treatment
Problem solving	11	14	0.79	(0.53;0.94)	0.057	5	9	0.56	(0.25;0.83)	1.000	8	11	0.73	(0.43;0.92)	0.227	12	16	0.75	(0.51;0.91)	0.077
Goal setting (outcome)	10	12	0.83	(0.56;0.96)	0.04	5	7	0.71	(0.35;0.94)	0.453	5	7	0.71	(0.35;0.94)	0.453	13	13	1.00	(0.82;1.00)	<0.001
Action planning	9	14	0.64	(0.38;0.85)	0.424	4	8	0.50	(0.20;0.80)	1.000	6	9	0.67	(0.35;0.90)	0.508	13	16	0.81	(0.58;0.94)	0.021
Feedback on behaviour	6	9	0.67	(0.34;0.90)	0.508						3	5	0.60	(0.21;0.91)	1.000	7	10	0.7	(0.39;0.91)	0.344
Self-monitoring of behaviour	18	24	0.75	(0.56;0.89)	0.023	5	10	0.50	(0.22;0.78)	1.000	7	13	0.54	(0.28;0.78)	1.000	19	24	0.79	(0.60;0.92)	0.006
Self-monitoring of outcome(s) of behaviour	6	8	0.75	(0.41;0.94)	0.289						4	5	0.80	(0.37;0.98)	0.375	7	9	0.78	(0.46;0.95)	0.180
Feedback on outcome(s) of behaviour	3	5	0.60	(0.21;0.91)	1.000											3	5	0.60	(0.21;0.91)	1.000
Social support (unspecified)	10	17	0.59	(0.36;0.79)	0.629	5	7	0.71	(0.35;0.94)	0.453	6	10	0.60	(0.31;0.85)	0.754	13	18	0.72	(0.49;0.89)	0.097
Instruction on how to perform behaviour	23	31	0.74	(0.57;0.87)	0.011	7	14	0.50	(0.26;0.74)	1.000	12	18	0.67	(0.44;0.85)	0.238	25	32	0.78	(0.62;0.90)	0.002
Information about health consequences	20	24	0.83	(0.65;0.94)	0.002	5	10	0.5	(0.22;0.78)	1.000	8	12	0.67	(0.39;0.88)	0.389	20	26	0.77	(0.58;0.90)	0.009
Information about social consequences	14	17	0.82	(0.60;0.95)	0.013	4	7	0.57	(0.23;0.86)	1.000	6	9	0.67	(0.35;0.90)	0.508	16	19	0.84	(0.64;0.95)	0.004
Information about emotional consequences	16	19	0.84	(0.64;0.95)	0.004	5	8	0.63	(0.29;0.88)	0.727	6	10	0.60	(0.31;0.85)	0.754	17	20	0.85	(0.65;0.96)	0.003
Demonstration of the behaviour	7	9	0.78	(0.46;0.95)	0.180	3	5	0.6	(0.21;0.91)	1.000	4	5	0.8	(0.37;0.98)	0.375	8	9	0.89	(0.59;0.99)	0.039
Social comparison																5	5	1.00	(0.62;1.00)	0.063
Prompts/cues	10	16	0.63	(0.38;0.83)	0.454	3	5	0.60	(0.21;0.91)	1.000	4	7	0.57	(0.23;0.86)	1.000	10	16	0.63	(0.38;0.83)	0.454
Associative learning	5	6	0.83	(0.44;0.98)	0.219											6	6	1.00	(0.67;1.00)	0.031
Behavioural practice/rehearsal	16	25	0.64	(0.44;0.80)	0.230	7	13	0.54	(0.28;0.78)	1.00	10	16	0.63	(0.38;0.83)	0.454	21	26	0.81	(0.63;0.92)	0.002
Graded tasks	3	7	0.43	(0.14;0.77)	1.000											6	8	0.75	(0.41;0.94)	0.289
Credible source	13	19	0.68	(0.46;0.86)	0.167	5	8	0.63	(0.29;0.88)	0.727	7	11	0.64	(0.35;0.86)	0.549	14	19	0.74	(0.52;0.89)	0.064
Reduce negative emotions	8	9	0.89	(0.59;0.99)	0.039											8	10	0.80	(0.50;0.96)	0.109
Self-regulation of attention	11	18	0.61	(0.38;0.81)	0.481	5	8	0.63	(0.29;0.88)	0.727	6	9	0.67	(0.35;0.90)	0.508	15	18	0.83	(0.62;0.95)	0.008
Distraction	4	5	0.8	(0.37;0.98)	0.375											6	7	0.86	(0.50;0.98)	0.125
Adding objects to the environment	8	10	0.80	(0.50;0.96)	0.109	0	6	0	(0;0.33)	0.031	4	8	0.50	(0.20;0.80)	1.000	9	10	0.90	(0.62;0.99)	0.021
Body changes	16	22	0.73	(0.52;0.88)	0.052	4	11	0.36	(0.14;0.65)	0.549	8	14	0.57	(0.32;0.80)	0.791	18	24	0.75	(0.56;0.89)	0.023
Framing/reframing	16	21	0.76	(0.55;0.90)	0.027	7	13	0.54	(0.28;0.78)	1.00	10	15	0.67	(0.42;0.86)	0.302	20	23	0.87	(0.69;0.96)	<0.001
Valued self-identity																5	5	1.00	(0.62;1.00)	0.063
> 3-month follow-up
Self-monitoring of behaviour																4	5	0.8	(0.37;0.98)	0.375
Instruction on how to perform behaviour	3	5	0.6	(0.21;0.91)	1.000											4	5	0.8	(0.37;0.98)	0.375
Information about health consequences	3	5	0.6	(0.21;0.91)	1.000											4	5	0.8	(0.37;0.98)	0.375

BCT = behavioural change technique, BCI = Bayesian credible interval.

^a Only results for BCTs applied in at least five studies within an outcome cluster are included in the table.

^b A two-sided test for binomial random variables was used (alpha level p < 0.05).

^c Note that the 95% BCI and the p-value from the exact test do not always correspond. In the interpretation, the p-value was prioritised.

Table 3. Effect (SMD> = 0.2) of interventions and index of potential of BCTs (95% BCI) applied in each symptom cluster in studies with active control groups (n = 21)^a,b,c,d.

	Symptom burden					Anxiety					Depression					Quality of life
	Effect, n	All, n	Index of potential	(95% BCI)	p	Effect, n	All, n	Index of potential	(95% BCI)	p	Effect, n	All, n	Index of potential	(95% BCI)	p	Effect, n	All, n	Index of potential	(95% BCI)	p
Post treatment
Problem solving	5	5	1.00	(0.62;1.00)	0.063						5	5	1.00	(0.62;1.00)	0.063	6	6	1.00	(0.67;1.00)	0.031
Goal setting (outcome)																4	5	0.8	(0.37;0.98)	0.375
Action planning	3	5	0.60	(0.21;0.91)	1.000						5	5	1.00	(0.62;1.00)	0.063
Feedback on behaviour	4	5	0.80	(0.37;0.98)	0.375						4	5	0.80	(0.37;0.98)	0.375	5	5	1.00	(0.62;1.00)	0.063
Self-monitoring of behaviour	4	7	0.57	(0.26;0.86)	1.000											4	6	0.67	(0.28;0.92)	0.688
Social support (unspecified)	3	5	0.60	(0.21;0.91)	1.000											5	7	0.71	(0.35;0.94)	0.453
Instruction on how to perform behaviour	3	5	0.60	(0.21;0.91)	1.000						4	5	0.80	(0.37;0.98)	0.375	5	7	0.71	(0.35;0.94)	0.453
Information about health consequences																5	5	1.00	(0.62;1.00)	0.063
Information about emotional consequences																3	5	0.60	(0.21;0.91)	1.000
Demonstration of the behaviour	2	6	0.33	(0.08;0.71)	0.688
Prompts/cues	3	6	0.50	(0.17;0.83)	1.000											4	5	0.80	(0.37;0.98)	0.375
Behavioural practice/rehearsal	5	10	0.50	(0.22;0.78)	1.000	4	5	0.80	0.37;0.98	0.375	5	6	0.83	(0.44;0.98)	0.219	7	9	0.78	(0.46;0.95)	0.180
Credible source	5	7	0.71	(0.35;0.94)	0.453						4	5	0.80	(0.37;0.98)	0.375	6	8	0.75	(0.41;0.94)	0.289
Reduce negative emotions																4	5	0.80	(0.37;0.98)	0.375
Self-regulation of attention	3	6	0.50	(0.17;0.83)	1.000						4	5	0.80	(0.37;0.98)	0.375	6	8	0.75	(0.41;0.94)	0.289
Body changes	3	6	0.50	(0.17;0.83)	1.000											3	5	0.60	(0.21;0.91)	1.000
Framing/reframing	4	5	0.80	(0.37;0.98)	0.375						4	5	0.80	(0.37;0.98)	0.375	6	7	0.86	(0.50;0.98)	0.125

BCT = behavioural change technique.

^a Only results for BCTs applied in at least five studies within an outcome cluster are included in the table.

^b In two studies (Andersson et al., 2003 & Friedberg et al., 2016), the applied BCTs were used in both the intervention and the active control condition, i.e., these studies did not contribute to the analyses of potentially effective BCTs.

^c A two-sided test for binomial random variables was used (alpha level p < 0.05).

^d Note that the 95% BCI and the p-value from the exact test do not always correspond. In the interpretation, the p-value was prioritised.

Table 4. Definitions (Michie & Atkins, 2014) and examples of behaviour change techniques with potential effect.

BCT	BCT number	BCT cluster	Definition	Examples extracted from included studies	Index of potential according to PCG or ACG
Problem solving	1.2	Goals and planning	Analyse, or prompt the person to analyse, factors influencing the behaviour and generate or select strategies that include overcoming barriers and/or increasing facilitators (includes ‘Relapse Prevention’ and ‘Coping Planning’).	Included was a problem-solving section in which subjects were presented with different methods aimed to be useful in the identification of problems, coping with problems in general, and coping with headache-related problems (Andersson 2003). In the last module, participants were encouraged to develop individualised plans with the purpose of maintaining the skills acquired during treatment (Hesser et al., 2012).	ACG
Goal setting (outcome)	1.3	Goals and planning	Set or agree on a goal defined in terms of a positive outcome of wanted behaviour.	Patients started with formulating their personal goals for therapy. Achievement of these goals should, when attained imply that the patient was recovered (i.e., no longer severely fatigued and no longer disabled by the fatigue) (Janse et al., 2016).	PCG
Action planning	1.4	Goals and planning	Prompt detailed planning of performance of the behaviour (must include at least one of context, frequency, duration and intensity). Context may be environmental (physical or social) or internal (physical, emotional or cognitive) (includes ‘Implementation Intentions’).	Sleep restriction instructions include setting a sleep window to number of hours slept during the previous 4–7 nights based on sleep diary recordings (no lowest limit given), fixating the wake-up time, and increasing the scheduled time in bed with 15 min contingent on sleep efficiency exceeding 85% during the last 4–7 days (Jernelöv et al., 2012).	PCG
Self-monitoring of behaviour	2.3	Feedback and monitoring	Establish a method for the person to monitor and record their behaviour(s) as part of a behaviour change strategy.	Participants are asked to write down everything they have done to reduce/manage their pain and record their behaviours and sensations during increased pain situations (functional analysis) for a week (Lin et al., 2017).	PCG
Instruction on how to perform the behaviour	4.1	Shaping knowledge	Advise or agree on how to perform the behaviour (includes ‘Skills training’).	Each session included a prerecorded presentation designed to build skills associated with mindfulness and instructions on how to cultivate and sustain positive emotional experiences, particularly within social relationships (Dowd et al., 2015).	PCG
Information about health consequences	5.1	Natural consequences	Provide information (e.g., written, verbal, visual) about health consequences of performing the behaviour.	Information regarding headache and the role of psychological factors was provided (Andersson et al., 2003).	PCG
Information about social and environmental consequences	5.3	Natural consequences	Provide information (e.g., written, verbal, visual) about social and environmental consequences of performing the behaviour.	Explain that sometimes people unnecessarily avoid or refrain from all kinds of activities because of their complaints. This so-called avoidance behaviour can aggravate the complaints by causing stress and a vicious circle develops (Oerlemans et al., 2011).	PCG
Information about emotional consequences	5.6	Natural consequences	Provide information (e.g., written, verbal, visual) about emotional consequences of performing the behaviour.	Information about tinnitus, the distress it can lead to, and the aims and methods of CBT for tinnitus (Kaldo et al., 2007).	PCG
Demonstration of the behaviour	6.1	Comparison of behaviour	Provide an observable sample of the performance of the behaviour, directly in person or indirectly e.g., via film, pictures, for the person to aspire to or imitate (includes ‘Modelling’).	Videos used gain-framed messaging delivered by an animated whiteboard-style coach and behaviourally focused live-action instructional videos on ergonomics and exercises (Irvine et al., 2015).	PCG
Associative learning	7.8	Associations	Present a neutral stimulus jointly with a stimulus that already elicits the behaviour repeatedly until the neutral stimulus elicits that behaviour (includes ‘Classical/Pavlovian Conditioning’).	The goal of this technique is to enable you to achieve relaxation in response to a self-produced cue (e.g., saying the word relax) (Malouff et al., 2010).	PCG
Behavioural practice/rehearsal	8.1	Repetition and substitution	Prompt practice or rehearsal of the performance of the behaviour one or more times in a context or at a time when the performance may not be necessary, in order to increase habit and skill.	It encourages readers to practice each of the three different approaches to relaxation and to pick the one (or two) that work best and use them daily (Hunt et al., 2015).	PCG
Reduce negative emotions	11.2	Regulation	Advise on ways of reducing negative emotions to facilitate performance of the behaviour (includes ‘Stress Management’).	The Learning Center content includes (…) methods for managing negative emotions such as anger, fear and depression (Lorig et al., 2008).	PCG
Self-regulation of attention	11.5^a	Regulation	Attention is brought to a direct experience of events in the mind and body by fostering a non-elaborative awareness of thoughts, feelings and sensations as they arise, i.e., rather than getting caught up in ruminative, elaborative thought streams. Includes mental imagery in which neural perceptions are employed to foster change in emotional or physical experience or to transform the imagery content. Includes mindfulness, imagery and visualisation.	The mindfulness instructions included exercises to be practiced daily, aimed at bringing the participant into immediate awareness of current GI symptoms, thoughts, feelings and behavioural impulses (Ljotsson et al., 2010).	PCG
Adding objects to the environment	12.5	Antecedents	Add objects to the environment in order to facilitate performance of the behaviour.	Module 3 presented relaxation training and provided MP3 files for paced breathing, progressive muscle relaxation, imagery-induced relaxation and selfhypnosis (Vincent and Lewycky, 2009).	PCG
Body changes	12.6	Antecedents	Alter body structure, functioning or support directly to facilitate behaviour change.	Applied relaxation: Tension and relaxation of different muscle groups; relaxation through controlled breathing; establishing a relaxation routine in everyday life (Jasper et al., 2014).	PCG
Framing/reframing	13.2	Identity	Suggest the deliberate adoption of a perspective or new perspective on behaviour (e.g., its purpose) in order to change cognitions or emotions about performing the behaviour (includes ‘Cognitive structuring’).	In an adaptive dialogue, different typical thoughts that insomnia patients often have are discussed. The aim is to identify dysfunctional sleep-related thoughts and replace them with sleep-compatible cognitions (Lorenz et al., 2019).	PCG

ACG = active control group, PCG = passive control group.

^a The technique ‘Self-regulation of attention’ was defined by the authors.

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