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.
Emerging research suggests that pain may persist longer-term for many children after major surgery, with significant effects on their health outcomes. This systematic review identified the prevalence ...of chronic postsurgical pain (CPSP) in children after surgery, and determined presurgical biomedical and psychosocial risk factors associated with CPSP prevalence or severity. Prospective studies assessing CPSP 3 to 12 months after surgery in children 6 to 18 years of age published in English in MedLine, EMBASE, PsycINFO, and Cochrane Database of Systematic Reviews since 1996 were eligible for inclusion. Of 16,084 abstracts yielded by the search, 123 full articles were assessed for eligibility, and 12 studies were included in the review. Overall quality of included studies assessed using the Quality in Prognostic Studies tool was low. On the basis of 4 studies with a total of 628 participants across all surgery types, median prevalence of CPSP across studies was 20% (25th percentile = 14.5%, 75th percentile = 38%) at 12 months after surgery. Presurgical pain intensity, child anxiety, child pain coping efficacy, and parental pain catastrophizing were the only presurgical factors identified as predictive of CPSP. Biological and medical factors assessed were not associated with CPSP in any study. Well designed studies examining prevalence and predictors of CPSP are critically needed in children.
In this systematic review, the median prevalence of CPSP in children was 20% across studies. Presurgical pain intensity, and child and parent psychosocial factors predicted CPSP. Additional resources and interventions are needed for youth who report persistent pain after surgery.
Numerous studies have examined how alexithymia (difficulty identifying and describing one's emotions and a preference for externally oriented thinking) relates to chronic pain and associated ...disability. We conducted a systematic review and meta-analysis to summarize individual studies that either assessed alexithymia in individuals with chronic pain vs controls or related alexithymia to pain intensity, physical interference, depression, and anxiety. We searched MEDLINE, Embase, and PsycINFO from inception through June 2017; 77 studies met the criteria (valid assessment of alexithymia in adults or children with any chronic pain condition) and were included in analyses (n = 8019 individuals with chronic pain). Primary analyses indicated that chronic pain samples had significantly higher mean alexithymia scores compared with nonclinical (d = 0.81) and clinical nonpain (d = 0.55) controls. In chronic pain samples, alexithymia was significantly positively associated with pain intensity (d = 0.20), physical interference (d = 0.17), depression (d = 0.46), and anxiety (d = 0.43). Secondary meta-analyses of 14 studies that conducted partial correlations that controlled for negative affect-related measures revealed that alexithymia was no longer significantly related to pain intensity or interference. Meta-analysis findings demonstrated that alexithymia is elevated in individuals with chronic pain and related to greater pain intensity and physical interference, although the latter relationships may be accounted for by negative affect. Critical future work is needed that examines alexithymia assessed using non-self-report measures, develops a person-centered perspective on this construct, and identifies how alexithymia is relevant to the assessment and treatment of individuals with chronic pain.
This study presents roadmaps for each of the 50 United States to convert their all-purpose energy systems (for electricity, transportation, heating/cooling, and industry) to ones powered entirely by ...wind, water, and sunlight (WWS). The plans contemplate 80-85% of existing energy replaced by 2030 and 100% replaced by 2050. Conversion would reduce each state's end-use power demand by a mean of similar to 39.3% with similar to 82.4% of this due to the efficiency of electrification and the rest due to end-use energy efficiency improvements. Year 2050 end-use U.S. all-purpose load would be met with similar to 30.9% onshore wind, similar to 19.1% offshore wind, similar to 30.7% utility-scale photovoltaics (PV), similar to 7.2% rooftop PV, similar to 7.3% concentrated solar power (CSP) with storage, similar to 1.25% geothermal power, similar to 0.37% wave power, similar to 0.14% tidal power, and similar to 3.01% hydroelectric power. Based on a parallel grid integration study, an additional 4.4% and 7.2% of power beyond that needed for annual loads would be supplied by CSP with storage and solar thermal for heat, respectively, for peaking and grid stability. Over all 50 states, converting would provide similar to 3.9 million 40-year construction jobs and similar to 2.0 million 40-year operation jobs for the energy facilities alone, the sum of which would outweigh the similar to 3.9 million jobs lost in the conventional energy sector. Converting would also eliminate similar to 62 000 (19 000-115 000) U.S. air pollution premature mortalities per year today and similar to 46 000 (12 000-104 000) in 2050, avoiding similar to $600 ($85-$2400) bil. per year (2013 dollars) in 2050, equivalent to similar to 3.6 (0.5-14.3) percent of the 2014 U.S. gross domestic product. Converting would further eliminate similar to $3.3 (1.9-7.1) tril. per year in 2050 global warming costs to the world due to U.S. emissions. These plans will result in each person in the U.S. in 2050 saving similar to $260 (190-320) per year in energy costs ($2013 dollars) and U.S. health and global climate costs per person decreasing by similar to $1500 (210-6000) per year and similar to $8300 (4700-17 600) per year, respectively. The new footprint over land required will be similar to 0.42% of U.S. land. The spacing area between wind turbines, which can be used for multiple purposes, will be similar to 1.6% of U.S. land. Thus, 100% conversions are technically and economically feasible with little downside. These roadmaps may therefore reduce social and political barriers to implementing clean-energy policies.
Fibromyalgia syndrome (FMS) is defined as chronic widespread pain associated with sleep disorders, cognitive dysfunction, and somatic symptoms present for at least three months and cannot be better ...explained by another diagnosis.
To examine efficacy and safety of non-pharmacological interventions for FMS in adults reported in Cochrane Reviews, and reporting quality of reviews.
Systematic reviews of randomised controlled trials (RCTs) of non-pharmacological interventions for FMS were identified from the Cochrane Database of Systematic Reviews (CDSR 2022, Issue 3 and CDSR 2023 Issue 6). Methodological quality was assessed using the AMSTAR-2 tool and a set of methodological criteria critical for analgesic effects. The primary efficacy outcomes of interest were clinically relevant pain relief, improvement in health-related quality of life (HRQoL), acceptability, safety, and reduction of mobility difficulties as reported by study participants. No pooled analyses were planned. We assumed a clinically relevant improvement was a minimal clinically important difference (MCID) between interventions and controls of 15%, or a SMD of more than 0.2, or a MD of more than 0.5, on a 0 to 10 scale.
Ten Cochrane reviews were eligible, reporting 181 randomized or quasi- randomized trials (11,917 participants, average trial size 66 participants). The reviews examined exercise training, acupuncture, transcutaneous electrical nerve stimulation, and psychological therapies.
One review was rated moderate according to AMSTAR 2, seven were rated low and two were rated critically low. All reviews met most of the additional methodological quality criteria. All reviews included studies with patient-reported outcomes for pain.
We found low certainty evidence of clinically relevant positive effects of aerobic and mixed exercise training and for cognitive behavioural therapies (CBTs) at reducing mobility difficulties and for mixed exercise training and CBTs for improving HRQoL at the end of the intervention. Number needed to treat for an additional beneficial outcome (NNTB) values for a MCID of 15% ranged between 4 and 9. We found low certainty evidence that was clinically relevant for mixed exercise and CBTs for reducing mobility difficulties at an average follow up of 24 weeks. We found low certainty evidence of clinically relevant positive effects of mixed exercise on HRQoL at an average follow up of 24 weeks. NNTB values for a MCID of 15% ranged from 5 to 11. The certainty of evidence of the acceptability (measured by dropouts) of the different non-pharmacological interventions ranged from very low to moderate and the dropout rate for any reason did not differ across the interventions or the controls, except for biofeedback and movement therapies. All the systematic reviews stated that the reporting of adverse events was inconsistent in the studies analysed (very low certainty evidence).
There is low certainty evidence of clinically relevant reduction of mobility difficulties and of improvement of HRQoL among individuals with FMS by aerobic and mixed exercise training and by CBTs at the end of the intervention. There is low certainty evidence that CBTs and mixed exercise training reduces mobility difficulties post-treatment and that mixed exercise training improves HRQoL at follow-up by clinically meaningful scores.
How to prevent the onset, maintenance, or exacerbation of pain is a major focus of clinical pain science. Pain prevention can be distinctly organised into primary, secondary, and tertiary prevention. ...Primary prevention describes avoiding hurt or pain, secondary prevention describes reducing pain when pain is unavoidable, and tertiary prevention describes preventing or reducing ongoing negative consequences such as high functional disability or distress due to chronic pain. Each poses separate challenges where unique psychological factors will play a role. In this short review article, we highlight psychological factors important to primary, secondary, and tertiary prevention and provide direction for the field. We present 2 case studies on secondary prevention in children and adolescents and tertiary prevention in adults with chronic pain. Finally, we provide research directions for progression in this field, highlighting the importance of clear theoretical direction, the identification of risk factors for those most likely to develop pain, and the importance of treatment.
Purpose/Objective: Alexithymia refers to reduced emotional awareness and is associated with higher levels of burden and disability in adults with chronic pain. Limited research has examined ...alexithymia in adolescents with chronic pain. The current study aimed to (a) determine whether alexithymia was higher in adolescents with (vs. without) chronic pain and (b) examine the relationship between alexithymia and pain experiences in youth. Research Method/Design: We assessed alexithymia in 22 adolescents with chronic pain and in 22 adolescents without chronic pain (otherwise healthy), and its relation to pain experiences (i.e., self-reported pain intensity, pain bothersomeness, and pain interference), while controlling for the concomitant effects of psychological distress (i.e., depressive and anxiety symptoms). Results: After controlling for psychological distress, adolescents with versus without chronic pain had higher total alexithymia scores (p = .042; η2 = .10), and specifically, greater difficulty identifying feelings (p = .001; η2 = .23). Difficulty identifying feelings was related to worse pain interference (r = .55; p = .015) and pain bothersomeness (r = .55; p = .015). Conclusions/Implications: These preliminary findings suggest that adolescents with chronic pain may have greater difficulty identifying their emotions, and that this might be related to increased pain interference and pain bothersomeness.
Impact and Implications
Emerging research suggests that alexithymia can be reduced in targeted interventions for adults with chronic pain, and that changes in alexithymia are associated with improvements in pain experiences. Limited research examining the relationship between alexithymia and chronic pain in adolescents hinders the application of such research to pediatric samples. In this project, we took one step toward this larger goal by establishing preliminary findings regarding the association between alexithymia and pain in adolescents. Adolescents with chronic pain may have reduced ability to identify their feelings, compared to their peers without chronic pain. This may have implications for emotion regulation and mental health. This may also impact the delivery of psychological interventions to youth with chronic pain; for example, these youth may benefit from strategies to label and identify their emotions in therapy.
Secondary students with persistent mathematics difficulties need the most intensive intervention in order to improve their mathematics outcomes. One approach to intensifying and individualizing ...intervention is through data–based individualization (DBI). The present study used a single–subject, multiple–baseline–across–participants, replicated–across–skills design to investigate the effectiveness of DBI process on mathematics computation and mathematics concept and application performance of high school students who had intense needs in mathematics. Results suggest the interventions guided by the DBI process improved mathematics computation and mathematics concept and application performance of the participants. Implications of these findings and indications for future research are discussed.
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