Background Noncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain. Objective In this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain. Methods We conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ≥5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes. Results In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (–3.4 points, 95% CI –5.7 to –1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (–2.7 points, 95% CI –5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions. Conclusions This study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain. Trial Registration ClinicalTrials.gov NCT03096925; http://clinicaltrials.gov/ct2/show/NCT03096925

Objectives:The aims of the study were to investigate the feasibility and preliminary outcome of a Norwegian web-based self-help application for vestibular rehabilitation (VR) among patients with high symptom burden of chronic dizziness fulfilling the criteria for persistent postural-perceptual dizziness (PPPD). Materials and methods:The web application consists of six weekly online sessions, with written information and video presentations. It is self-instructive and freely available on NHI.no (https://nhi.no/for-helsepersonell/vestibular-rehabilitering/). Ten consecutive patients referred to a neurologic outpatient clinic for chronic dizziness were included. They signed informed consent forms and were examined at inclusion and after three months. State of health and symptom burden were recorded using Vertigo symptom score (VSS), Niigata symptom score (NPQ), Patient Health Questionnaire (PHQ-9) and health-related quality of life score (EQ5D-5L). Experiences with the program were measured using a semi-structured interview at the end of the study.Results: Nine out of ten patients completed the program. The findings suggest that the web application was easy to use, instructive and educatable. Challenges were the load of exercises, motivation to continue training during relapses and performing the body rolling on the floor. Participants had high symptom burden (VSS mean 32.9) and long duration of symptoms in years (mean 11.5). The participants improved on average 6.9 points on the VSS score.Conclusions: This web application for chronic dizziness appears to be feasible and may reduce symptoms in patients who have struggled with serious and long-lasting dizziness.

Nearly half of patients with non-cardiac chest pain (NCCP) experience significant complaints after a negative cardiac evaluation, at considerable costs for society. Due to the lack of treatment capacity and low interest for psychological treatment among patients with somatic complaints, only a minority receive effective treatment. The aim of this study was to assess the feasibility and usefulness of internet-assisted cognitive behavioural therapy (I-CBT), including encouragement of physical activity for this condition. Ten patients with NCCP received a six-session I-CBT intervention with minimal support from a therapist. Questionnaires assessing cardiac anxiety, fear of bodily sensations, depression, interpretation of symptoms, frequency of chest pain and impact of chest pain symptoms were collected at baseline, post-treatment and at 3-month follow-up. Semi-structured interviews employing a phenomenological hermeneutic approach assessed the participants’ experience of the intervention. Quantitative results showed clear improvements in several measures both at end of treatment and at 3-month follow-up. The retention rate was 100% and client satisfaction was high. The intervention was feasible to implement in a cardiac setting. This setting made it easier for patients to accept a psychological approach. Qualitative interviews revealed that the participants felt respected and taken care of, and they obtained a better understanding of their chest pain and how to cope with it. This pilot study yielded promising results regarding feasibility, clinical effect and patient satisfaction from a brief I-CBT intervention for NCCP in a cardiac setting. These results indicate that a randomized controlled trial with a larger sample size is warranted. Key learning aims (1) Feasibility of internet-assisted cognitive behavioural therapy (I-CBT) for non-cardiac chest pain (NCCP). (2) How NCCP patients experience I-CBT. (3) Possible effects of I-CBT. (4) How I-CBT can be delivered at the Cardiac Department.

BACKGROUND Non-cardiac chest pain (NCCP) is highly prevalent and associated with reduced quality of life, anxiety, avoidance of physical activity and high societal costs. There is a lack of an effective low-cost, easy to distribute intervention to assist NCCP patients. OBJECTIVE This study aimed to investigate the effectiveness of internet-based cognitive behavioural therapy (I-CBT) with telephone support for non-cardiac chest pain (NCCP). METHODS A randomized controlled trial comparing I-CBT to a treatment-as-usual (TAU) control condition with 12-month follow-up was conducted at a cardiac department. A total of 162 participants aged 18-70 with a diagnosis of NCCP were randomized to I-CBT (n=81) or TAU (n=81). The participants in the experimental condition received six weekly sessions of I-CBT. The sessions covered different topics related to coping with NCCP (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to the I-CBT sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence and to provide access to the next session. Participants in the TAU group received standard care for their NCCP without any restrictions. Primary outcomes were cardiac anxiety measured by the Cardiac Anxiety Questionnaire (CAQ) and fear of bodily sensations measured by the Body Sensations Questionnaire (BSQ). Secondary outcomes were depression measured using the Patient Health Questionnaire (PHQ-9), health related quality of life measured using EuroQol Visual Analogue Scale (EQ-VAS) and level of physical activity assessed by an investigator-developed self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 ≥5) was conducted. Linear mixed models were used to evaluate treatment effects. Cohen’s d were used to calculate effect sizes. RESULTS In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the I-CBT group had significant improvements in CAQ (-3.4 points, 95% CI -5.7 to -1.1; P=.004, d=0.38) and a non-significant improvement in BSQ (-2.7 points, 95% CI -5.6 to 0.3; P=.073) compared with TAU. EQ-VAS at the 12-month follow-up improved with statistical and clinical significance in the I-CBT group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with TAU. Physical activity was significantly (P<.001) increased during the intervention period for the I-CBT group. Depression was significantly improved at post-treatment and 3-month follow-up, but not at 12-month follow-up. Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on CAQ (d=0.55) and EQ-VAS (d=0.71) at the 12-month follow-up. In the I-CBT group 84 % (n=68) completed at least five of the six sessions. CONCLUSIONS This study provides evidence that I-CBT with minimal therapist contact and focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with NCCP. CLINICALTRIAL ClinicalTrials.gov ID: NTC03096925