Background
Chronic non‐cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on ...people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012.
Objectives
To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU).
Search methods
We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials.
Selection criteria
RCTs of psychological treatments compared with active control or TAU of face‐to‐face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end.
Data collection and analysis
Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow‐up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment.
Main results
We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies.
CBT
The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) ‐0.09, 95% confidence interval (CI) ‐0.17 to ‐0.01; 3235 participants; 23 studies; moderate‐quality evidence), disability (SMD ‐0.12, 95% CI ‐0.20 to ‐0.04; 2543 participants; 19 studies; moderate‐quality evidence), and distress (SMD ‐0.09, 95% CI ‐0.18 to ‐0.00; 3297 participants; 24 studies; moderate‐quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD ‐0.22, 95% CI ‐0.33 to ‐0.10; 2572 participants; 29 studies; moderate‐quality evidence), disability (SMD ‐0.32, 95% CI ‐0.45 to ‐0.19; 2524 participants; 28 studies; low‐quality evidence), and distress (SMD ‐0.34, 95% CI ‐0.44 to ‐0.24; 2559 participants; 27 studies; moderate‐quality evidence). Effects were largely maintained at follow‐up for CBT versus TAU, but not for CBT versus active control.
Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons.
BT
We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD ‐0.67, 95% CI ‐2.54 to 1.20, very low‐quality evidence; disability SMD ‐0.65, 95% CI ‐1.85 to 0.54, very low‐quality evidence; or distress SMD ‐0.73, 95% CI ‐1.47 to 0.01, very low‐quality evidence). At follow‐up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD ‐0.08, 95% CI ‐0.33 to 0.17, low‐quality evidence; disability SMD ‐0.02, 95% CI ‐0.24 to 0.19, moderate‐quality evidence; distress SMD 0.22, 95% CI ‐0.10 to 0.54, low‐quality evidence) at treatment end. At follow‐up, we found one to three studies with no evidence of difference between BT and TAU.
We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs.
ACT
We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD ‐0.25, 95% CI ‐0.63 to 0.12, very low‐quality evidence), disability (SMD ‐0.67, 95% CI ‐1.56 to 0.22, very low‐quality evidence) or distress (SMD ‐0.30, 95% CI ‐0.70 to 0.10, very low‐quality evidence) at treatment end. At follow‐up, there was no evidence of effect for pain or distress (both very low‐quality evidence), but two studies showed a large benefit for reducing disability (SMD ‐1.22, 95% CI ‐2.28 to ‐0.17, very low‐quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD ‐0.83, 95% CI ‐1.57 to ‐0.09, very low‐quality evidence), but none for disability (SMD ‐1.39, 95% CI ‐3.20 to 0.41, very low‐quality evidence), or distress (SMD ‐1.16, 95% CI ‐2.51 to 0.20, very low‐quality evidence). Lack of data precluded analysis at follow‐up.
We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low‐quality evidence because the estimates are uncertain and could be easily overturned.
Authors' conclusions
We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.
Background
Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review.
...Objectives
To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking.
Search methods
We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each ing service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators.
Selection criteria
Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20.
Data collection and analysis
Forty‐two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25.
Main results
Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post‐treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow‐up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.
Authors' conclusions
Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post‐treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post‐treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.
Psychological treatments are designed to treat pain, distress and disability, and are in common practice. No comprehensive systematic review has been published since 1999.
To evaluate the ...effectiveness of psychological therapies on pain, disability, and mood.
Randomised controlled trials (RCTs) of psychological therapy were identified by searching MEDLINE, EMBASE and Psychlit and CENTRAL from the beginning of each abstracting service until January 2008. A further search was undertaken from January 2008 to August 2008. Additional studies were identified from the reference lists of retrieved papers and from discussion with investigators.
Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. Studies were excluded if the pain was primarily headache, or was associated with a malignant disease. Studies were also excluded if the number of patients in any treatment arm was less than 10.
Fifty-two studies were examined with a quality rating scale specifically designed for use with these studies. Data were extracted from 40 studies (4781 participants) by two authors. Two main classes of treatment (Cognitive Behavioural Therapy (CBT) and Behaviour Therapy (BT)), were compared with two control conditions (Treatment as Usual (TAU) and Active control (AC)), at two assessment points (immediately following treatment and six months following treatment), giving eight comparisons. For each comparison, treatment effectiveness was assessed on three outcomes: pain, disability, and mood giving a total of 24 analyses.
Overall there is an absence of evidence for BT, except for pain immediately following treatment compared with TAU. CBT has some small positive effects for pain, disability and mood. At present there is insufficient data on quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.
CBT and BT have weak effects in improving pain. CBT and BT have minimal effects on disability associated with chronic pain. CBT and BT are effective in altering mood outcomes, and there is some evidence that these changes are maintained at six months.
Individuals who experience chronic pain display an attentional bias towards pain-related words or pictures, but the bias is small and largely variable in effect.
This meta-analysis investigated ...whether attentional bias, that is, the preferential allocation of attention to information that is related to pain, is a ubiquitous phenomenon. We also investigated whether attentional bias effects are related to the methodological quality of the study, to procedural differences in their measurement, or to individual differences in pain severity, pain-related fear, anxiety, and depression. Results indicated that individuals who experience chronic pain (n=1023) display an attentional bias towards pain-related words or pictures, but this bias was of a small effect size (d=0.134), and did not differ from that in control groups (d=0.082; n=1398). No evidence was found for an attentional bias towards pain-related words and pictures for acute pain (d=0.049), procedural pain (d=0.142), and experimental pain (d=0.069). However, research in which attentional bias towards signals of impending experimental pain in healthy volunteers was investigated, revealed an attentional bias of medium effect size (d=0.676). Moderator analyses in the chronic pain group identified important procedural variables that affected the presence and magnitude of an attentional bias towards pain-related words and pictures, that is, type and exposure time of pain-related information. None of the individual difference variables affected the magnitude of the attentional bias. Implications of current findings and future directions are discussed.
The ability to predict the consequences of our actions is imperative for the everyday success of our interactions. From negotiating an uneven surface, to mounting an immune response, we continually ...infer the limits of our body. The current investigation considered the impact that the inferred consequences of action has on the placement of limits. We hypothesised that the performance of individuals in a novel, sprint task would reflect both their ability to accurately detect changes in bodily arousal (Interoceptive Accuracy) and the inferred consequences associated with heightened arousal signals (Anxiety Sensitivity). We found that individuals who demonstrated accuracy associated with physiological arousal changes, and who showed a heightened fear of the consequences of arousal symptoms, modified their actions by decreasing their power output (mean Watts•kg-1) in a sprint task (ΔR2 = 0.19; F(1,34) = 19.87); p<0.001). These findings provide a basis for understanding the varying actions taken as we encounter bodily perturbation.
There is a strong tradition of therapy development and evaluation in the field of psychological interventions for chronic pain. However, despite this research production, the effects of treatments ...remain uncertain, and treatment development has stalled. This review summarises the current evidence but focusses on promising areas for improvement. Advancing psychological therapies for chronic pain will come from a radical re-imagining of the content, delivery, place, and control of therapy. The next generation of therapeutic interventions will also need alternative methods of measurement and evaluation, and options are discussed.
The purpose of this meta-analytic review was to quantify the effects of psychological therapies for the management of chronic pain in youth. Specifically, in this review we updated previous ...systematic reviews of randomized controlled trials by including new trials, and by adding disability and emotional functioning to pain as treatment outcomes. Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE, PsycLIT, EMBASE, and the Social Sciences Citation Index were conducted from inception through August 2008. Methodological quality of the studies was assessed, and data extracted on the three primary outcomes of interest. Twenty-five trials including 1247 young people met inclusion criteria and were included in the meta-analysis. Meta-analytic findings demonstrated a large positive effect of psychological intervention on pain reduction at immediate post-treatment and follow-up in youth with headache, abdominal pain, and fibromyalgia. Small and non-significant effects were found for improvements in disability and emotional functioning, although there were limited data on these outcomes available in the included studies. Omnibus cognitive–behavioral therapy, relaxation therapy, and biofeedback all produced significant and positive effects on pain reduction. Studies directly comparing the effects of self-administered versus therapist-administered interventions found similar effects on pain reduction. Psychological therapies result in improvement in pain relief across several different pain conditions in children. Future trials are needed that incorporate non-pain outcome domains, that focus significant therapeutic content on reductions in disability, and that include extended follow-up to better understand maintenance of treatment effects.
Acceptance of chronic pain entails that an individual reduce unsuccessful attempts to avoid or control pain and focus instead on participation in valued activities and the pursuit of personally ...relevant goals. Recent research suggests that pain-related acceptance leads to enhanced emotional and physical functioning in chronic pain patients above and beyond the influence of depression, pain intensity, and coping. In these studies, acceptance was measured using the Chronic Pain Acceptance Questionnaire (CPAQ). Preliminary analyses of the CPAQ have supported its psychometric properties. The present study sought to further refine the CPAQ by examining its factor structure and evaluating the relations of these factors to other indices of pain-related distress and disability. Although a previously demonstrated factor structure of the CPAQ was generally supported, only factors assessing (a) the degree to which one engaged in life activities regardless of the pain and (b) willingness to experience pain had adequate reliability and validity and were significantly related to the other measures of patient functioning. A revised version of the CPAQ is suggested.
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