Psychological therapies for the management of chronic … · [Intervention Review] Psychological therapies for the management of chronic pain (excluding headache) in adults Christopher

Psychological therapies for the management of chronic pain

(excluding headache) in adults (Review)

Eccleston C, Williams ACDC, Morley S

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2009, Issue 3

http://www.thecochranelibrary.com

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Figure 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Figure 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Figure 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Figure 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Figure 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Figure 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Figure 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Figure 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Figure 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Figure 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Figure 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Figure 26. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

20DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

84DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 1 Pain. . . . . . . 86

Analysis 1.2. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 2 Disability. . . . . 87

Analysis 1.3. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 3 Mood. . . . . . 88

Analysis 2.1. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 1 Pain. . . . . . . . 89

Analysis 2.2. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 2 Disability. . . . . . . 90

Analysis 2.3. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 3 Mood. . . . . . . . 91

Analysis 3.1. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 1 Pain. . . . . . . . . . 92

Analysis 3.2. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 2 Disability. . . . . . . . . 93

Analysis 3.3. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 3 Mood. . . . . . . . . . 94

Analysis 4.1. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 1 Pain. . . . . . . 95

Analysis 4.2. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 2 Disability. . . . . 96

Analysis 4.3. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 3 Mood. . . . . . 97

iPsychological therapies for the management of chronic pain (excluding headache) in adults (Review)


Analysis 5.1. Comparison 5 Behavioural vs active control post-treatment, Outcome 1 Pain. . . . . . . . . . 97

Analysis 5.2. Comparison 5 Behavioural vs active control post-treatment, Outcome 2 Disability. . . . . . . . 98

Analysis 5.3. Comparison 5 Behavioural vs active control post-treatment, Outcome 3 Mood. . . . . . . . . . 98

Analysis 6.1. Comparison 6 Behavioural vs active control follow-up, Outcome 1 Pain. . . . . . . . . . . . 99

Analysis 6.2. Comparison 6 Behavioural vs active control follow-up, Outcome 2 Disability. . . . . . . . . . 99

Analysis 6.3. Comparison 6 Behavioural vs active control follow-up, Outcome 3 Mood. . . . . . . . . . . 100

Analysis 7.1. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 1 Pain. . . . . . . . . 100

Analysis 7.2. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 2 Disability. . . . . . . 101

Analysis 7.3. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 3 Mood. . . . . . . . 102

Analysis 8.1. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 1 Pain. . . . . . . . . . 102

Analysis 8.2. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 2 Disability. . . . . . . . . 103

Analysis 8.3. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 3 Mood. . . . . . . . . . 103

103APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

104HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

105CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

105DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

105SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

105DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .

iiPsychological therapies for the management of chronic pain (excluding headache) in adults (Review)


[Intervention Review]

Psychological therapies for the management of chronic pain(excluding headache) in adults

Christopher Eccleston1, Amanda C de C Williams2, Stephen Morley3

1Cochrane Pain, Palliative and Supportive Care Review Group, Centre for Pain Research, University of Bath, Bath, UK. 2Research

Department of Clinical, Educational & Health Psychology, University College London, London, UK. 3Leeds Institute of Health

Sciences, University of Leeds, Leeds, UK

Contact address: Christopher Eccleston, Cochrane Pain, Palliative and Supportive Care Review Group, Centre for Pain Research,

University of Bath, Claverton Down, Bath, BA2 7AY, UK. [email protected]. [email protected]. (Editorial group: Cochrane

Pain, Palliative and Supportive Care Group.)

Cochrane Database of Systematic Reviews, Issue 3, 2009 (Status in this issue: Unchanged)


DOI: 10.1002/14651858.CD007407.pub2

This version first published online: 15 April 2009 in Issue 2, 2009.

Last assessed as up-to-date: 3 February 2009. (Help document - Dates and Statuses explained)

This record should be cited as: Eccleston C, Williams ACDC, Morley S. Psychological therapies for the management of

chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007407. DOI:

10.1002/14651858.CD007407.pub2.

A B S T R A C T

Background

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. No comprehensive systematic

review has been published since 1999.

Objectives

To evaluate the effectiveness of psychological therapies on pain, disability, and mood.

Search strategy

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.

Selection criteria

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.

Data collection and analysis

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.

Main results

1Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)


mailto:[email protected]

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http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/DatesStatuses.pdf

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.

Authors’ conclusions

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.

P L A I N L A N G U A G E S U M M A R Y

Psychological therapy for adults with longstanding distressing pain and disability

Many people have pain that lasts for a long time, and pain that is not relieved or cured by physical therapy or medicines. The search

for a diagnosis and for pain relief is often long, discouraging, and even damaging. For some people the pain leads to physical disability,

changes in mood such as depression and anxiety, and social isolation. These are not inevitable and are thought to be reversible, at least

to some extent, using a rehabilitation approach which aims to reduce disability and distress despite continuing pain. The treatments

are based on robust psychological principles and practices and have been in use and developing for about 40 years.

The search found 52 trials of treatments, but only 40 provided data in a form that could be used. The two main types of psychological

treatment were Cognitive Behavioural Therapy (CBT), and Behaviour Therapy (BT). Both focus on trying to help people change

behaviour that makes pain, disability and distress worse. CBT also works directly on the thoughts and feelings that are a problem

for people with persistent pain. The effects of these two treatments on pain, disability, and mood were tested immediately after the

treatment, and six months later.

Psychological therapies can help people with chronic pain reduce negative mood (depression and anxiety), disability, and in some cases

pain, but guidance is still required on the best content, duration, intensity, and format of treatment.

B A C K G R O U N D

Chronic pain is a common problem causing significant distress

and disability. Behavioural and cognitive treatments designed to

ameliorate pain, distress and disability were first introduced over

40 years ago and are now well established (Fordyce 1968; Keefe

2004). There are many uncontrolled trials, case studies, observa-

tions, and clinical reports of treatment methods. Narrative reviews

generally report positive effects of psychological treatments on a

range of outcomes. In addition there have been periodic publica-

tion of meta-analyses and systematic reviews (Flor 1992; Morley

1999) and many recent studies have focused on specific patient

groups such as those with musculoskeletal pain syndromes (Dixon

2007; Guzman 2001; Hoffman 2007; Ostelo 2005).

There is a broad family of treatments included in the general term

“psychological”. In essence, treatments have been developed that

are specifically designed to alter psychological processes thought

to underlie or significantly contribute to pain, distress, and/or

disability. The design of psychological treatments is normally in-

formed by specific theories of the etiology of human behaviour,

or have developed pragmatically through observation and study

of response to intervention. Although in practice there is variety

in the types of interventions used, not all have been evaluated for

their effectiveness. The evidence base for psychological therapies

is over-represented by studies of programmatic and protocolised

treatments from a behavioural or cognitive-behavioural tradition

of clinical psychology. Psychological therapies are commonly pre-

sented as being offered after orthodox treatments have failed when

the treatment goal shifts from one of removing or alleviating pain

to one of managing pain and its myriad adverse consequences

on quality of life. A typical treatment protocol for cognitive be-

havioural therapy (CBT) will involve methods aimed directly at as-

sessing the thoughts associated with pain, and the extent of avoid-

ance of unpleasant thoughts and of painful experiences, and the

consequences of these. A common focus is on strongly held beliefs

about pain and their relationship with behaviour, which typically

worsens the situation in the shorter or longer term. Behavioural

methods focus on the identification of behaviour that is contin-

gent upon pain, or upon events which provide pain relief or com-

fort, and the development of behaviour that is contingent instead

upon goal achievement related to the values of the individual with

pain. Most therapies involve education, and many are incorpo-

rated within larger treatment programmes involving physical and



occupational therapy.

In an earlier published review on this topic (Morley 1999), we

searched for all published randomised controlled trials (RCTs)

of interventions described as psychological in nature, and recov-

ered trials principally of behaviour therapy (BT) or CBT (Morley

1999). RCTs of interventions for headache were excluded in the

previous review as a Cochrane review on this topic is underway (

Nicholson 2004). We also note two more recent completed pub-

lications on the efficacy of biofeedback treatments for tension and

migraine headaches (Nestoriuc 2007; Nestoriuc 2008). In the ear-

lier published review 33 papers were recovered that described 30

trials (Morley 1999). Twenty-five had data that could be entered

into a meta-analysis. Compared with waiting list controls, the find-

ings were that CBT had a compound effect size of 0.5 (a median

figure across the range of outcomes). However, comparison with

active treatments produced smaller effect sizes for some outcomes

(such as coping) but no differences on key outcome variables such

as negative affect. The (Morley 1999) review is now out of date

and in need of updating (Shojania 2007). Other developments in

psychological science have led to new forms of treatments being

promoted, and the quality of trials and trial reporting is thought to

be improving (Morley 2006). The aim of this review is to establish

the published evidence on the efficacy of psychological treatments

for chronic pain in adults. Further, key variables that are thought

to influence the effectiveness of many psychological interventions

will also be assessed and evaluated if possible.

O B J E C T I V E S

To determine the clinical effectiveness of psychological therapy

for non-malignant chronic pain (excluding headache) for adults

compared with medical or physical treatments, placebo or waiting

list controls.

M E T H O D S

Criteria for considering studies for this review

Types of studies

RCTs comparing a credible psychological treatment, or a com-

pound treatment with primary psychological content, with

placebo, other active treatment, treatment as usual, or waiting list

control, in chronic pain. Studies were excluded if they were con-

cerned with headache or associated with a malignant life-threat-

ening disease. A psychological treatment was judged credible if it

was based on an extant psychological model or framework, and its

delivery was from, or was supervised by, a health care professional

qualified in psychology.

Studies were included if they:

• were available as a full publication or report of a RCT;

• had a design that placed a psychological treatment as an

active treatment of primary interest;

• had a psychological treatment with definable psy-

chotherapeutic content;

• were published (or electronically pre-published) in a

peer reviewed science journal;

• were with participants reporting chronic pain (i.e. at

least three months duration); and

• had ten or more participants in each treatment arm at

the end of the treatment assessment.

Types of participants

Adults (aged 18 years or older) reporting pain of at least three

months’ duration in any body site, not associated with a malignant

disease process. Patients with headache or migraine were excluded

but those with neck, facial or dental pain, or looking at all of these

together, were included. Studies of participants with headache or

migraine, or both, were excluded because the psychological treat-

ments for headache and migraine are sufficiently different, have a

separate history, and a separate audience, and for that reason are

the subject of a separate review (Nicholson 2004).

Types of interventions

Studies were included if at least one trial arm consisted of a psy-

chology intervention, and a comparator arm using placebo, other

active treatment, treatment as usual, or waiting list control.

Types of outcome measures

• Data were collected on descriptive characteristics of par-

ticipants and characteristics of the treatments, includ-

ing treatment setting, mode of delivery and therapist.

• Following the Morley 1999 review, data were collected

on outcomes in the domains of pain experience, nega-

tive mood, and disability for this review; all outcomes

were recorded and described.

Search methods for identification of studies

Electronic searches

RCTs of any psychological therapy were identified by MEDLINE,

EMBASE and Psychlit from their inception to January 2008. The

Cochrane Central Register of Controlled Trials (CENTRAL) was

also searched. Additional studies were identified from the refer-

ence lists of retrieved papers and from discussion with investiga-

tors. Searching was performed in two sets. The first was under-

taken prior to the previously published systematic review (Morley



1999). The second was undertaken focusing on the ten years since

that review using the same search strategy but taking account of

changes in search architecture and terminology. No language re-

strictions were applied and no unpublished studies were included

(see Appendix 1). All abstracts were reviewed by at least two review

authors and were included on the basis of consensus agreement

and discussion with the third review author when necessary. An

update search was later undertaken from January 2008 to August

2008.

Data collection and analysis

Selection of studies

The trials used in the previous (non-Cochrane) systematic review

and meta-analysis (Morley 1999) were automatically included,

although a few were subsequently excluded by the stricter criteria

adopted here. The search of the literature since the end of the

previous search produced 519 possible abstracts. From these 44

were selected by one or more of four raters for examination of

the full paper. Over the same period, search of reviews and other

sources revealed several relevant RCTs which had not been found

by the search, so the search was repeated. The final total of papers

from the previous systematic review and from the two (duplicate)

searches was 98 papers which reported on 89 separate RCTs. All

these papers were read in full.

Data extraction and management

A data extraction book was devised jointly by review authors based

on that used in Morley 1999 and Eccleston 2002. It includes def-

initions of information to be extracted that relate to the design

of the study, the participants, primary diagnosis, method of treat-

ment and outcome measurement tools used.

Data were extracted by two review authors for each paper and

recorded on a standard data extraction form. Data suitable for

pooling were entered into RevMan 5.

The primary data type was measurement using continuous scales.

We estimated treatment effects using standardized mean differ-

ences by extracting means, standard deviations, and sample size at

post-treatment and follow-up. When data were not available we

did not infer any parameters. Studies were excluded because it was

not possible to extract the necessary data. Dichotomous outcome

data based on clinical improvement were not extracted. These data

were rarely reported.

Assessment of risk of bias in included studies

The quality rating scale was applied (Yates 2005). All studies were

scored by two of the three review authors and a consensus reached

after initial comparison or ratings and calculation of reliability.

The quality rating scale was designed specifically for application

to psychological treatment studies in pain. It provides an over-

all total score (0 to 35) consisting of two subscales: first a treat-

ment quality scale (0 to 9) covering stated rationale for treatment,

manualisation, therapist training, and patient engagement. The

second subscale is a design and methods scale (0 to 26) covering

inclusion/exclusion criteria, attrition, sample description, mini-

mization of bias (randomisation method, allocation bias, blinding

of assessment, and equality of treatment expectations), selection

of outcomes, length of follow-up, analyses, and choice of control.

This comprehensive quality assessment method was used in place

of the single item of allocation bias, and is represented in the risk

of bias figures (Figure 1; Figure 2).

Figure 1. Methodological quality graph: review authors’ judgements about each methodological quality

item presented as percentages across all included studies.



Figure 2. Methodological quality summary: review authors’ judgements about each methodological quality

item for each included study.



Measures of treatment effect

Two classes of psychological treatment were investigated and la-

belled Cognitive Behavioural Therapy (CBT) and Behavioural

Therapy (BT). CBT involves treatments that include specific di-

rect cognitive therapeutic content. BT includes treatments that are

purely behavioural technologies such as biofeedback. Two classes

of comparator treatments are investigated and labelled Active Con-

trol (AC) and Treatment as Usual (TAU). The active compara-

tor involves a treatment designed to change pain behaviour such

as physical therapy, education, or medical regime. Patients ran-

domised to the AC within each trial are selected to all receive the

same treatment. Patients in TAU conditions are either selected to

a waiting list on which they are restricted from accessing other

care, or they are selected to no other structured treatment but are

not restricted from seeking care. Two assessment time points are

also selected: Post-treatment and Follow-up. Post-treatment is the

assessment point immediately following treatment, and follow-up

is the assessment point at least six months after the end of treat-

ment, but not more than 12 months, and the longer of the two

if there were two follow-up assessments within this timeframe.

Therefore eight separate comparisons were designed comprising of

two classes of psychological treatment under investigation (CBT,

BT), two forms of comparator (AC, TAU), and two assessment

time points (post-treatment and follow-up). They are labelled:

1. Cognitive behavioural vs active control post-treatment.

2. Cognitive behavioural vs active control follow-up.

3. Cognitive behavioural vs treatment as usual post-treat-

ment.

4. Cognitive behavioural vs treatment as usual follow-up.

5. Behavioural vs active control post-treatment.

6. Behavioural vs active control follow-up.

7. Behavioural vs treatment as usual post-treatment.

8. Behavioural vs treatment as usual follow-up.

Multiple measurement tools are typically used in each trial. For

each comparison three outcomes were identified and labelled

’Pain’, ’Disability’, and ’Mood’. Although standard trial reporting

guidance promotes the definition of primary outcomes (Boutron

2008) most trials do not state a single or preferred a priori pri-

mary outcome, so a judgement must be made. From each trial we

selected the measure considered most appropriate for each of the

three outcomes. When there was more than one measure for an

outcome we gave preference to the measure that has documented

frequent usage in the field as opposed to a novel measure. Also,

when there was a choice between single item and multi-item self-

report tools, longer tools were chosen on the basis of inferred in-

creased reliability. Not all trials reported data on all three outcomes

of pain, disability and mood, and not all trials reported follow-up

data.

Assessment of heterogeneity

Heterogeneity was assessed according to the standard method us-

ing the Chi-squared and the I-squared statistic, calculated for each

comparison on each outcome. I-Squared values above 50% indi-

cate high heterogeneity, between 25% and 50% medium hetero-

geneity, and below 25% low heterogeneity.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies; Characteristics of studies awaiting classification.

Results of the search

A total of 97 publications reported on 87 RCTs. Of these 35 studies

(36 papers) did not meet the inclusion criteria and were excluded

(Alaranta 1994; Appelbaum 1988; Asenlof 2005; Bendix 1997;

Broderick 2004; Brox 2003; Corrado 2003; Currie 2000; Dahl

2004; Dalton 2004; Dworkin 2002a; Edinger 2005; Evans 2003;

Fors 2000; Haugstad 2006; Keefe 2004; Keller 2004; Kerns 1986;

Linton 1984; Linton 1985; Linton 2001; Linton 2005; Moffett

2005; Moore 2000; Nicholas 1991; Nicholas 1992; Parker 2003;

Peters 1990; Schweikert 2006; Sharpe 2001; Soderlund 2001;

Spence 1995; Turner 1982; Van den Hout 2003; Van Lankveld

2004). Sixty-two publications reported on the remaining 52 RCTs

that met the inclusion criteria. Data were not provided in a form

that allowed extraction for quantitative analysis in 12 of these

52 studies (reported in 17 articles) (Buckelew 1998; Dworkin

1994; Dworkin 2002b; Fairbank 2005; Freeman 2002; Geraets

2005; Kole-Snijders 1999; Marhold 2001; Parker 1988; Smeets

2006; Strauss 1986; Turner-Stokes 2003): these presented data

as mean differences without a standard deviation, as graphs, or

subgrouped in a way which cut across the trial conditions. There-

fore a total of 40 RCTs (with a total of 4781 participants) re-

ported in 43 separate publications provided data for analysis in at

least one of the comparisons (Altmaier 1992; Astin 2003; Basler

1997; Becker 2000; Bradley 1987; Buhrman 2004; Carson 2005;

Cook 1998; Ersek 2003; Evers 2002; Flor 1993; Greco 2004;

Haldorsen 1998; Hammond 2001; Jensen 1997; Jensen 2001;

Johansson 1998; Kaapa 2006; Keefe 1990; Keefe 1996; Kraaimaat

1995; McCarberg 1999; Mishra 2000; Moore 1985; Newton-

John 1995; Nicassio 1997; O’Leary 1988; Puder 1988; Radojevic

1992; Redondo 2004; Spence 1989; Strong 1998; Thieme 2003;

Turner 1988; Turner 1990; Turner 1993; Turner 2006; Vlaeyen

1995; Vlaeyen 1996; Williams 1996).

Included studies

Almost half of the studies are new since the review that was pub-

lished in 1999 (Morley 1999), with 50% of the trials published

being published before 1997, and 75% by 2002, producing a

steady increase in publication of trials over these years. Six of the

25 studies from Morley 1999 were excluded from the current

analysis, primarily for reasons of small sample size, and because



of the lack of descriptive data for use in computing effect sizes

(Appelbaum 1988; Kerns 1986; Nicholas 1991; Nicholas 1992;

Peters 1990; Turner 1982). Of the 52 included studies, 29 had

just two arms; 15 had three, and eight had four. The quality of

trial design improved markedly with the publication date of the

trial (Spearman’s rho = 0.475, P < 0.01), as did the sample size.

The total number of patients entered in to these studies was 5679

(with a mean of 109 per study). The total number of patients

giving data immediately post-treatment was 4781 (with a mean

of 92 per study). Study Completion Rates (from entry to post-

treatment assessment) ranged from 53 % to 100%. The overall

completion rate was 84%; the overall attrition rate is therefore

16%. Overall, the mean number of patients from each trial was

91.4 (range 21 to 387) but the improvement in sample size over

the years is evident from the difference between trials up to 1997

with a mean number entering of 81 (s.d. 34), and for those studies

from 1998 onwards the number entering was a mean of 133 (s.d.

107). Women usually outnumbered men, with a mean of 73%

(range 2 to 100%). The mean age was 48.7 (s.d. 10.5), and the

median years of pain (from the 42 studies which provided data)

was 9.9 (range four months to 25 years).

Participants were recruited from a range of healthcare and other

sources. Thirty-nine studies (75%) came from hospital based clin-

ics: 23 pain clinics, nine rheumatology clinics, one orthopaedic

clinic, and six mixed. Five trials recruited exclusively from volun-

teers. Six trials recruited exclusively from community based ser-

vices. Finally, two studies recruited using national government or

insurance based databases.

Fourteen studies (26%) were solely of treatments for patients with

low back pain and 14 were for treatments of mixed groups of

musculoskeletal pain patients in which back pain was usually the

most common complaint. Nine studies had patient groups with

rheumatoid arthritis (in one case specifically in the hand) and one

had Systemic Lupus Erythematosus; six had fibromyalgia; four

had temporomandibular joint pain; two had osteoarthritis of the

knee; one had upper limb pain; and one was a trial of patients with

shoulder pain.

Treatment arms were classified on the basis of their content and of

the label given by the authors as cognitive behavioural treatment

or as behavioural treatment. Control conditions were classified as

“active control” when there was a protocolised treatment which

engaged the patient, such as an exercise programme, a medical

procedure, an education programme, a support group, or a self-

instruction booklet, and as waiting list or treatment as usual. We

did not distinguish between these because for some patients treat-

ment as usual is elective treatment which may be none at all and

therefore equivalent to being on a waiting list. We are aware that

there might be a grey area of classification where treatment as usual

involves some active and regular physiotherapy or pharmacother-

apy, but when available information did not allow us to assign to

an active control, we classified a condition as treatment as usual.

Excluded studies

Thirty-five studies (36 papers) did not meet the inclusion criteria

and were excluded. Thirty-five studies may seem a large propor-

tion of the total 88 RCTs to exclude, but seven of these did not

concern chronic pain but sub-chronic or acute pain, and another

five targeted a problem other than non-cancer chronic pain, al-

beit that some or all patients had a pain problem. The fact that

these studies survived the search strategies and filters is evidence of

the diversity of terminology used to describe pain and treatments,

which necessitated a broad search to maximise yield.

Of the remaining 23 RCTs, two compared two versions of a treat-

ment which were equally psychological in content (Keefe 2004;

Van Lankveld 2004). Nine studies had an insufficient number of

participants (n < 10) in one or more arms at the end of treat-

ment (Appelbaum 1988; Dahl 2004; Kerns 1986; Linton 1984

Linton 1985; Nicholas 1991; Nicholas 1992; Peters 1990; Turner

1982). Twelve had content which, even if described in psycho-

logical terms, appeared to us from the description of treatment to

lack the definable psychotherapeutic content specified in our cri-

teria, approximating to education, instruction, or nonspecific sup-

port (Alaranta 1994; Bendix 1997; Broderick 2004; Brox 2003;

Dworkin 2002a; Fors 2000; Haugstad 2006; Keller 2004; Moffett

2005; Schweikert 2006; Soderlund 2001; Spence 1995). This

judgement was difficult to apply in some cases and led to extended

discussion between the review authors to reach a decision.

Risk of bias in included studies

For the 52 studies which met the inclusion criteria, the mean

overall quality of the studies was 19.3 (s.d. 4.8, range nine to 28).

The mean design quality score was 14.4 (s.d. 3.7, range seven

to 23) and the mean treatment quality score was 4.9 (s.d. 2.2,

range one to eight). A Spearman’s correlation was conducted to

investigate the association between year of study and treatment

quality score, design quality score, and total quality score (sum of

treatment quality and design quality). This was conducted on all

trials providing an n for end of treatment reducing the number

of available studies from 52 to 42. Treatment quality was not

associated with year of study: rho = -0.073, P > 0.1. However,

design quality was associated with the year of study, as was the

total: rho = 0.453, P < 0.01; 0.344, P < 0.01 respectively. Design

quality was weakly associated with treatment quality: rho = 0.306,

P = 0.05. n at the end of treatment was strongly associated with

design quality score and with total quality score (rho = 0.592, P <

0.01; rho = 0.460, P = 0.01).

Of the 24 analyses reported (CBT or BT vs Active control or Treat-

ment as usual, post-treatment and follow-up, for ’pain’, ’disability’,

and ’mood’), 10 showed low heterogeneity (I-Squared < 25%),

five showed modest heterogeneity (I-Squared > = 25% to <50%)

and seven showed large heterogeneity (I-Squared > = 50%) and

for two comparisons there was only one study. Large heterogeneity

was primarily associated with analyses of BT.



Effects of interventions

Cognitive behavioural vs active control post-

treatment

Fourteen studies of 861 participants were entered into an analysis

of the effects of CBT on pain. The overall effect of CBT on pain

was not significant (Z = 1.52, P > 0.05) (Analysis 1.1; Figure 3).

Twelve studies of 728 participants were entered into an analysis of

the effects of CBT on disability. The overall effect was significant

(Z = 2.20, P < 0.05) with a small effect size of -0.16 (CI -0.31 to

-0.02) (Analysis 1.2; Figure 4). Fifteen studies of 890 participants

were entered into a study of the effects of CBT on mood. The

overall effects of CBT on mood was not significant (Z = 1.27, P

> 0.05) (Analysis 1.3; Figure 5).

Figure 3. Forest plot of comparison: 1 Cognitive Behavioural vs Active Control Post-treatment, outcome:

1.1 Pain.


1.2 Disability.




1.3 Mood.

Cognitive behavioural vs active control follow-up

Twelve studies with 935 participants were entered into an analysis

of the effects of CBT on pain at follow-up. The overall effect of

CBT on pain at follow-up was significant (Z = 2.27, P < 0.05)

with a small effect size of -0.15 (CI -0.28 to -0.02) (Analysis 2.1;

Figure 6). Eleven studies, with 876 participants, were entered into

an analysis of the effects of CBT on disability at follow-up. The

overall effect of CBT at follow-up was significant, (Z = 2.71, P <

0.05) with a small effect size of -0.21 (CI -0.36 to -0.06) (Analysis

2.2; Figure 7). Twelve studies, with 934 participants, were entered

into an analysis of the effects of CBT on mood at follow-up. The

overall effect of CBT on mood at follow-up was significant (Z =

2.44, P < 0.05) with a small effect size of -0.16 (CI -0.29 to -0.03)

(Analysis 2.3 Figure 8).

Figure 6. Forest plot of comparison: 2 Cognitive Behavioural vs Active Control Follow-up, outcome: 2.1

Pain.




Disability.


Mood.

Cognitive behavioural vs treatment as usual post-

treatment

Twenty three studies of 1199 participants were entered into an

analysis of the effects of CBT on pain. The overall effect of CBT

on pain was significant (Z = 2.71, P < 0.05) with an effect size of -

0.19 (CI -0.32 to -0.05) (Analysis 3.1; Figure 9). Eighteen studies

of 972 participants were entered into an analysis of the effects

of CBT on disability. The overall effect was not significant (Z =

0.76, P > 0.05) (Analysis 3.2; Figure 10). Sixteen studies of 839

participants were entered into an analysis of the effects of CBT on

mood. The overall effect of CBT on mood was not significant (Z

= 1.43, P > 0.05) (Analysis 3.3; Figure 11).



Figure 9. Forest plot of comparison: 3 Cognitive Behavioural vs Treatment as Usual, outcome: 3.1 Pain.



Figure 10. Forest plot of comparison: 3 Cognitive Behavioural vs Treatment as Usual, outcome: 3.2

Disability.

Figure 11. Forest plot of comparison: 3 Cognitive Behavioural vs Treatment as Usual, outcome: 3.3 Mood.



Cognitive behavioural vs treatment as usual follow-up

Nine studies with 693 participants were entered into analysis of

the effects of CBT on pain at follow-up. The overall effect of CBT

on pain at follow-up was not significant (Z = 1.48, P> 0.05) (

Analysis 4.1; Figure 12). Eight studies, with 496 patients, were

entered into analysis of the effects of CBT on disability at follow-

up. The overall effect of CBT at follow up was not significant (Z =

0.66, P > 0.05) (Analysis 4.2; Figure 13). Nine studies, with 684

patients, were entered into analysis of the effects of CBT on mood

at follow-up. The overall effect of CBT on mood at follow-up was

significant (Z = 2.04, P < 0.05) with a small effect size of -0.16 (-

0.31 to -0.01) (Analysis 4.3; Figure 14).

Figure 12. Forest plot of comparison: 4 Cognitive Behavioural vs Treatment as Usual Follow-up, outcome:

4.1 Pain.


4.2 Disability.




4.3 Mood.



Behavioural vs active control post-treatment

One study of 39 participants was analysed for the effects of BT

on pain. The overall effect of BT on pain was not significant (Z

= 0.77, P > 0.05) (Analysis 5.1; Figure 15. Two studies of 110

participants were entered into an analysis of the effects of BT on

disability. The overall effect was not significant (Z = 1.46, P >

0.05) (Analysis 5.2; Figure 16). Two studies of 110 participants

were entered into an analysis of the effects of BT on mood. The

overall effects of BT on mood was not significant (Z = 1.26, P >

0.05) (Analysis 5.3; Figure 17).

Figure 15. Forest plot of comparison: 5 Behavioural vs Active Control Post-treatment, outcome: 5.1 Pain.

Figure 16. Forest plot of comparison: 5 Behavioural vs Active Control Post-treatment, outcome: 5.2

Disability.

Figure 17. Forest plot of comparison: 5 Behavioural vs Active Control Post-treatment, outcome: 5.3 Mood.



Behavioural vs active control follow-up

One study with 39 participants was entered into an analysis of the

effects of BT on pain at follow-up. The overall effect of BT on pain

at follow-up was not significant (Z = 0.92, P > 0.05) (Analysis 6.1;

Figure 18). Two studies with 110 participants were entered into an

analysis of the effects of BT on disability at follow-up. The overall

effect of BT at follow-up was not significant (Z = 0.66, P > 0.05) (

Analysis 6.2; Figure 19). Two studies, with 110 participants, were

entered into analysis of the effects of BT on mood at follow-up.

The overall effect of BT on mood at follow-up was not significant

(Z = 0.85, P > 0.05) (Analysis 6.3; Figure 20).

Figure 18. Forest plot of comparison: 6 Behavioural vs Active Control Follow-up, outcome: 6.1 Pain.

Figure 19. Forest plot of comparison: 6 Behavioural vs Active Control Follow-up, outcome: 6.2 Disability.

Figure 20. Forest plot of comparison: 6 Behavioural vs Active Control Follow-up, outcome: 6.3 Mood.



Behavioural vs treatment as usual post-treatment

Nine studies of 430 participants were entered into an analysis of

the effects of BT on pain. The overall effect of BT on pain was

significant (Z = 3.03, P = < 0.05) with a moderate effect size of

0.55 (CI -0.90 to -0.19) (Analysis 7.1; Figure 21). Seven studies of

374 participants were entered into an analysis of the effects of BT

on disability. The overall effect was not significant (Z = 1.67, P =

< 0.05) (Analysis 7.2; Figure 22). Six studies of 357 participants

were entered into a study of the effects of BT on mood. The overall

effects of BT on mood was not significant (Z = 1.52, P > 0.05) (

Analysis 7.3; Figure 23).

Figure 21. Forest plot of comparison: 7 Behavioural vs Treatment as Usual Post-treatment, outcome: 7.1

Pain.


Disability.




Mood.



Behavioural vs treatment as usual follow-up

Three studies, with 232 participants, were entered into a study

of the effects of BT on pain at follow-up. The overall effect of

BT on pain at follow-up was not significant (Z = 1.09, P > 0.05)

(Analysis 8.1; Figure 24). Three studies, with 230 participants,

were entered into an analysis of the effects of BT on disability at

follow-up: the overall effect of BT at follow-up was not significant

(Z = 1.25, P > 0.05) (Analysis 8.2; Figure 25). Three studies, with

230 participants, were entered into a study of the effects of BT on

mood at follow-up. The overall effect of BT on mood at follow-

up was not significant (Z = 1.68, P > 0.5) (Analysis 8.3; Figure

26).

Figure 24. Forest plot of comparison: 8 Behavioural vs Treatment as Usual Follow-up, outcome: 8.1 Pain.

Figure 25. Forest plot of comparison: 8 Behavioural vs Treatment as Usual Follow-up, outcome: 8.2

Disability.

Figure 26. Forest plot of comparison: 8 Behavioural vs Treatment as Usual Follow-up, outcome: 8.3 Mood.

Pain outcomes

CBT and BT appear to have a small to moderate effect on pain

measured immediately post-treatment when compared with doing

nothing (TAU or Waiting List); that is, randomly assigning them

to a wait list or usual treatment arm. There is no effect at follow-up.

When compared with another active treatment CBT appears to



have a small effect on pain at follow-up, but not immediately post-

treatment. There are too few studies for a meaningful conclusion

on the effects of BT on pain, immediately post-treatment or at

follow-up.

Disability outcomes

CBT has a small effect on disability immediately post-treatment

and at follow-up, compared with an active control. There were

no effects of CBT compared with doing nothing (TAU or Wait-

ing List) immediately post-treatment or at follow-up. BT had no

effect on disability in comparison with doing nothing (TAU or

Waiting List) immediately post-treatment or at follow-up. There

are too few studies for a meaningful conclusion on the effects of

BT on disability compared with an active control, immediately

post-treatment or at follow-up.

Mood outcomes

CBT has no effect on mood immediately post-treatment com-

pared with either active control or doing nothing (TAU or Waiting

List). There is a small effect at follow-up for both comparisons in

improving mood outcomes compared to waiting list or treatment

as usual, immediately post-treatment, and at follow-up. BT had

no effect on mood in comparison with doing nothing (TAU or

Waiting List) immediately post-treatment or at follow-up. There

are too few studies for a meaningful conclusion on the effects of

BT on mood compared with an active control, immediately post-

treatment or at follow-up.

Heterogeneity inspection

In the seven analyses showing high heterogeneity of study samples

(I-squared > 50%) further exploratory analyses were undertaken.

By visual inspection we removed the outliers to test for their influ-

ence on the overall effect. In analyses 8.1, 8.2 and 8.3 the samples

were made up of only three studies reporting different findings.

In the analyses 7.1, 7.2, and 7.3 the high heterogeneity appeared

to be caused largely by two studies (Newton-John 1995; Thieme

2003) which in all cases were extreme positive outliers. Their re-

moval reduced heterogeneity to acceptable levels without affecting

the overall result. Finally, in analysis 3.2 there was one positive

outlier (Williams 1996) the removal of which again reduced het-

erogeneity to acceptable levels without affecting the overall result.

Effects of quality ratings

Three further analyses were undertaken to assess the potential

effects of quality. Studies below the median total quality score

were excluded from the analyses. This had no effect on the overall

findings making only minor changes to effect sizes, and so are

not reported further. The lack of any major effect is due largely

to the over-representation of studies with higher quality in the

analyses, and the fact that the n at the end of treatment was strongly

associated with design quality score and with total quality score

(rho = 0.592, P <0.001; rho = 0.460, P = 0.002), and these analyses

are already weighted by sample size.

D I S C U S S I O N

Evidence base

There is a large evidence base for estimating the effectiveness of

psychological treatments in chronic pain: 52 included RCTs in-

volving 5679 participants. All trials are of specific behavioural

technologies such as relaxation and biofeedback or of program-

matic versions of CBT. There were no trials of other psychological

treatments such as psychodynamic, psychotherapy, interpersonal,

or dialectical BT. There was only one small ineligible trial of an ac-

ceptance based intervention (Dahl 2004). A moderate number of

trials were inadequate by our criteria or did not provide analysable

data, and a few were eligible but provided data in a form which

could not be used.

In total, 40 trials (16 from the previous systematic review and 22

new) were entered into a full analysis. CBT and BT dominate

the evidence base. This allowed for greater power in the analyses,

with the largest analysis being of 1199 participants (CBT vs TAU

for Pain at post-treatment) and the smallest of 39 participants

(BT vs AC for Pain immediately post-treatment and at follow-

up). An analysis of the quality rating scores showed that the qual-

ity of the design and reporting of trials has clearly improved over

the years, perhaps as a consequence of the emphasis of Cochrane

and other evidence-focused organisations concerned with method-

ological standards such as CONSORT (Boutron 2008). However,

the quality of treatments, or of their reporting, or both, does not

appear to have improved over time.

Summary of results

The evidence of effectiveness of CBT and BT is weak. For BT

in particular, the evidence is sparse. There were too few trials to

draw any conclusions about the effects of BT compared with ac-

tive control. Compared with doing nothing (TAU or waiting list

controls), however, BT has a small but robust effect on pain im-

mediately post-treatment but not at follow-up. There are no other

effects on disability or mood.

The majority of studies were of CBT. Of the six relevant compar-

isons of CBT versus active control, three outcomes (pain, disabil-

ity, mood) at two time points (immediately post-treatment and six

to 12 months follow-up), four were positive. There were positive

effects of CBT on disability immediately post-treatment and at

follow-up. There were also positive effects on pain and mood at

follow-up but not immediately post-treatment. Compared with

doing nothing (TAU or Waiting List control) the only two effects



were on pain immediately post-treatment and on mood at follow-

up.

Both CBT and BT appear to have effects on pain outcomes im-

mediately post-treatment when compared with no treatment, and

at follow-up for CBT compared with active control. However, for

the majority of the trials pain was not a primary outcome, and

was not necessarily expected to change as a direct result of therapy.

Most trials are concerned with adjustment in terms of function or

mental health outcomes despite continuing pain.

There is no evidence for the effectiveness of BT in altering disabil-

ity. There is evidence for the effectiveness of CBT in altering dis-

ability when compared with an active control immediately post-

treatment and at follow-up.

There is no evidence for the effectiveness of BT in altering mood.

There is evidence for the effectiveness of CBT in altering mood

when compared with an active control and treatment as usual but

only for longer term outcomes, at follow-up.

Issues for consideration

Psychological therapies for the management of chronic pain are

potentially useful treatments. However, there are some caveats.

There is an insufficient evidence base for those therapies we have

labelled BT in improving non-pain outcomes such as mood or

disability. Despite many trials of programmes of CBT, there re-

mains an inconsistent picture. Half of the comparisons show no

effect of CBT, and half show weak effect sizes of unknown clinical

significance on pain, mood and disability outcomes. A number of

issues arise from this analysis for further consideration:

1. We strongly suspect that as a field we have underesti-

mated the complexity of behaviour change and the so-

cial and psychological influences that maintain disabil-

ity in chronic pain patients (Blyth 2007). The typical

chronic pain patient has well established behavioural

patterns reinforced over a long period of failed at-

tempted adjustment to pain and distress. The hypoth-

esis that the psychotherapeutic content of existing tri-

als aimed at achieving reduction in long standing dis-

ability or depression is either absent, insufficient, or has

become dilute merits further investigation, but is out-

side the remit of this particular review. We plan to ad-

dress it in a further analysis, but even where authors

give full details of treatment content, quantity does not

imply proportional quality, and while in psychologi-

cal treatments there appeared for some time to be a

dose effect (a positive relationship between the num-

ber of treatment sessions and the extent of gain) both

the finding and the rationale currently lack evidence

(e.g., Barkham 2006). We speculate, however, that good

clinical outcomes should perhaps not be expected from

dilute and brief treatments delivered by inexperienced

staff to severely distressed patients.

2. After multiple readings of these papers, we would pro-

pose that the next generation of studies pay particular

attention to four main issues. First, therapy needs to be

based on an explicit theoretical model that guides choice

of content, dose, timing and quality. Many of the trials

reviewed are pragmatic mixes of various content, but

without an adequate rationale, and with apparent dis-

junction between stated aims of treatment, actual treat-

ment content, and outcomes measured. Second, trials

of targeted therapies focused on specific treatments for

specific outcomes (e.g. Vlaeyen 2002) should replace

large programmes of multicomponent therapies with

multiple targets. Third, criticism of the heterogeneity

of patients with “chronic pain” led to treatment of spe-

cific diagnostic groups of patients. However, the diag-

nostic group is unlikely to be as important as psycho-

logical variables in defining patients’ needs. A more psy-

chologically-informed subgrouping of patients, rather

than by diagnostic group, should allow better targeted

and more effective treatment, although it is still not

clear on what basis patients should be grouped (Morley

2006). Matching patients to treatment components ac-

cording to baseline problem severity misses the demon-

strated impact of, for instance, the behavioural com-

ponent on emotional problems, or the cognitive com-

ponent on physical activity. Component dismantling

studies likewise offer an illusion of identifying ‘active in-

gredients’ of the total package when we do not yet have

the power of numbers, nor the statistics, to calculate the

effects of each component on each outcome (Grimshaw

1995). Fourth, the field should seriously consider devel-

oping measures which are capable of indexing clinical

improvement to replace or augment statistical change (

Morley 2006) and which have ecological validity. Broad

spectrum measures of the disability domain, such as

quality of life (e.g. Short Form 36 Health Survey) may

have validity problems when applied to trials of the ef-

fectiveness of therapies, caused largely by the inclusion

of content either irrelevant to the patient and/or not

the target of treatment (Bowling 1997; Dworkin 2005).

As a consequence, sensitivity of measures may be com-

promised. In addition, we did not distinguish in our

analysis of ’disability’ measures with a focus on physical

function and those with a focus on other aspects such

as social role functioning. In future analyses it may be

possible to analyze sub-categories of the broad concept

of ’disability’.

3. Twelve studies had insufficient psychotherapeutic con-

tent to enter analyses, and nine studies were seriously

underpowered. Some of these 21 trials were recent and

represent wasted effort in that they could not add any-

thing to existing knowledge. RCTs are expensive and



difficult to undertake, particularly where treatment is

intensive, requires trained and experienced staff from

multiple professions, and follow-up is extended. Col-

laborative effort of multiple sites working with the same

protocol and same treatment manual offer a better

chance of producing reliable data to inform the field.

Indeed, we note that in contrast to many other fields

there is a complete absence of large scale multi-site stud-

ies. Although such studies are complex to organise and

manage to completion the advantages which they confer

with regard to size/power and generalizability are con-

siderable. There are precedents for conducting multi-

site trials with complex behavioural interventions (e.g.,

Dimidjian 2006).

4. Trials report results in terms of statistical rather than

clinical significance, which may have led to earlier op-

timistic summaries of effectiveness. Rarely do trials re-

port binary outcomes based on a clinical significance

criteria (Morley 2006; Morley 2008). As a consequence

we have no basis on which to estimate the number of

people who are “successfully” treated by CBT or BT.

Therefore there is a need for the field to develop meth-

ods to identify treatment responders (Dworkin 2005;

Dworkin 2008). In addition, no trial reported adverse

events, and drop-outs from treatment were rarely inves-

tigated further. The absence of consideration of adverse

effects of psychological therapy is unacceptable: we note

that a recent study of effectiveness observed evidence

of deterioration in a small proportion of patients us-

ing statistically defined criteria for clinically significant

change (Morley 2008).

5. The design of adequate control groups remains prob-

lematic in this field, particularly given potentially large

group effects (Moos 2003). The debate about specificity

or nonspecificity of effects is a familiar and unresolved

issue in psychology more broadly (Roth 2005). In this

review we had separate comparisons between treatment

with an active comparator, and treatment with TAU.

An ideal control is structurally equivalent to the active

treatment. Without such placebic controls we remain

unable to determine whether the differences between

the treatment and control arms of the trial are specific

to treatment. This may be particularly true of stud-

ies that rely on mean data from continuous measures (

Hrobarjtsson 2001; Hrobarjtsson 2004).

6. Relatively few trials provided outcome data on health

care use, although many gave unnecessary health care

use by chronic pain patients among their reasons for

attempting treatment. However, rather than being able

to analyse high quality trials which also collect data on

health care use and costs, many more recent trials appear

to have made economies by reducing treatment length,

the level of training or experience of personnel, or other

variables which might contribute to better outcome. Of

course, where treatment appears not to be effective, data

on costs become irrelevant.

7. The field is already changing. The updated search con-

ducted in August 2008 identified ten additional studies

for possible inclusion and these will be added to the next

update (Babu 2007; Bliokas 2007; Ersek 2008; Leeuw

2008; Linton 2008; Lorig 2008; Morone 2008; Smeets

2008; Woods 2008; Zautra 2008) as it was not possi-

ble to add these to the current publication due to time

constraints. We suspect that not all of these trials will

become included studies, or will give data in an analyz-

able form. However, it is interesting to note the emer-

gence of trials on more specific, theoretically informed

therapies such as exposure for low back pain.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

This large portmanteau analysis shows that there is overall promise

in CBT as an effective treatment for chronic pain in adults. How-

ever, it covers a diverse range of treatment content, quality, length,

and assessment procedures. We are not able to conclude which spe-

cific features of therapy may be critical for outcome. It is important

to note that CBT for other disorders such as anxiety or depression

draws on a functional analysis of cognition and behaviour which

forms the basis for repeated behavioural experiment (i.e., guided

behavioural change). It is not clear how far this essential principle

has been pursued in the field of chronic pain. Similarly it is difficult

to understand how very brief group interventions might have any

specific effects on cognitive, emotional or behavioural outcomes

for a group. Broad implications from these analyses do suggest that

immediate improvements in longstanding pain related mood dis-

orders may be unrealistic, and follow-up assessment is necessary.

Implications for research

The field would benefit from a change of research direction away

from multicomponent and dismantling studies, which cannot

identify processes of change, towards simpler treatment modali-

ties, with a secure foundation in theory, and with some monitoring

between the beginning and end of treatment for treatment engage-

ment (as opposed merely to patient presence). There appears to be

little point in conducting further trials of generic CBT in which

a range of sometimes poorly specified interventions are included.

Better specification of each treatment component is required such

that the effects of that component on both the intended outcomes

and hypothesised mediators of those outcomes is clearly defined

and measured.



Additionally, the outcome measures selected should be as closely

related as possible to the aims and methods of the intervention;

they should minimise multiple measurement of the same variable

and try to sample from the major outcome domains (Dworkin

2005); and they should include measures of health care use such

as doctor and hospital visits and analgesic use. Additionally, and

perhaps first, debate is necessary on what constitutes an accept-

able outcome of treatment by patients and other stakeholders (

Dworkin 2008; Turk 2008).

Finally, the quality of the studies, or of the reporting of studies (or

both), could be improved with authors paying significant atten-

tion to issues concerning power, randomization procedures, con-

trol of measurement bias, and the inclusion of intention-to-treat

analyses (present in only a minority of studies). With regard to

treatment implementation, trialists will need to pay more atten-

tion to ensuring therapist adherence to protocol, and to the pro-

vision of evidence of the competence of the person delivering the

treatment (Kerns 2008).

A C K N O W L E D G E M E N T S

We thank Malcolm Adams and Shona Yates for earlier contribu-

tions to the protocol, in particular for discussion on coding. We

thank also the PaPaS review group, and the referees for their de-

tailed and helpful feedback.

R E F E R E N C E S

References to studies included in this review

Altmaier 1992 {published data only}

Altmaier EM, Lehmann TR, Russell DW, Weinstein JN, Kao CF.

The effectiveness of psychological interventions for the rehabilitation

of low back pain: a randomized controlled trial evaluation. Pain

1992;49:329–35.

Astin 2003 {published data only}

Astin JA, Berman BM, Bausell B, Lee WL, Hochberg M, Forys KL.

The efficacy of mindfulness meditation plus Qigong movement ther-

apy in the treatment of fibromyalgia: A randomized controlled trial.

Journal of Rheumatology 2003;30:2257–62.

Basler 1997 {published data only}

Basler HD, Jakle C, Kroner-Herwig B. Incorporation of cognitive-

behavioral treatment into the medical care of chronic low back pa-

tients: A controlled randomized study in German pain treatment

centers. Patient Education & Counseling 1997;31:113–24.

Becker 2000 {published data only}

Becker N, Sjogren P, Bech P, Olsen AK, Eriksen J. Treatment out-

come of chronic non-malignant pain patients managed in a Danish

multidisciplinary pain centre compared to general practice: a ran-

domised controlled trial. Pain 2000;84:203–11.

Bradley 1987 {published data only}

Bradley LA, Young LD, Anderson KO, Turner RA, Agudelo CA,

McDaniel LK, et al.Effects of psychological therapy on pain behavior

of rheumatoid arthritis patients. Treatment outcome and six-month

follow up. Arthritis & Rheumatism 1987;30:1105–14.

Buckelew 1998 {published data only}

Buckelew SP, Conway R, Parker J, Deuser WE, Read J, Witty TE,

et al.Biofeedback/relaxation training and exercise interventions for

fibromyalgia: A prospective trial. Arthritis Care & Research 1998;11:

196–209.

Buhrman 2004 {published data only}

Buhrman M, Faltenhag S, Strom L, Andersson G. Controlled trial

of Internet-based treatment with telephone support for chronic back

pain. Pain 2004;111:368–77.

Carson 2005 {published data only}

Carson JW, Keefe FJ, Lynch TR, Carson KM, Goli V, Fras AM,

et al.Loving-kindness meditation for chronic low back pain: results

from a pilot trial. Journal of Holistic Nursing 2005;23:287–304.

Cook 1998 {published data only}

Cook AJ. Cognitive-behavioral pain management for elderly nursing

home residents. Journals of Gerontology Series B Psychological Sciences

& Social Sciences 1998;53B:51–9.



Dworkin 1994 {published data only}

Dworkin SF, Turner JA, Wilson L, Massoth D, Whitney C, Huggins

KH, et al.Brief group cognitive-behavioral intervention for temporo-

mandibular disorders. Pain 1994;59:175–87.

Dworkin 2002b {published data only}

Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J, Massoth

D, et al.A randomized clinical trial using research diagnostic criteria

for temporomandibular disorders-axis II to target clinic cases for a

tailored self-care TMD treatment program. Journal of Orofacial Pain

2002;16:48–63.

Ersek 2003 {published data only}

Ersek M, Turner JA, McCurry SM, Gibbons L, Kraybill BM. Efficacy

of a self-management group intervention for elderly persons with

chronic pain. Clinical Journal of Pain 2003;19:156–67.

Evers 2002 {published data only}

Evers AW, Kraaimaat FW, van Riel PL, de Jong AJ. Tailored cognitive-

behavioral therapy in early rheumatoid arthritis for patients at risk:

A randomized controlled trial. Pain 2002;100:141–53.

Fairbank 2005 {published data only}∗ Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K,

Collins R. Randomised controlled trial to compare surgical stabilisa-

tion of the lumbar spine with an intensive rehabilitation programme

for patients with chronic low back pain: the MRC spine stabilisation

trial. BMJ 2005;330:1–7.

Rivero-Arias O, Campbell H, Gray A, Fairbank J, Frost H, Wilson-

MacDonald J. Surgical stabilisation of the spine compared with a

programme of intensive rehabilitation for the management of pa-

tients with chronic low back pain: Cost utility analysis based on a

randomised controlled trial. BMJ 2005;330:1239–43.

Flor 1993 {published data only}

Flor H, Birbaumer N. Comparison of the efficacy of electromyo-

graphic biofeedback, cognitive-behavioral therapy, and conservative

medical interventions in the treatment of chronic musculoskeletal

pain. Journal of Consulting & Clinical Psychology 1993;61:653–8.

Freeman 2002 {published data only}

Freeman K, Hammond A, Lincoln N. Use of cognitive-behavioural

arthritis education programmes in newly diagnosed rheumatoid

arthritis. Clinical Rehabilitation 2002;16:828–36.

Geraets 2005 {published data only}

Geraets J, Goossens M, De Bruijn CPC, De Groot IJM, Koke AJS,

Pelt R, et al.Cost-effectiveness of a graded exercise therapy program

for patients with chronic shoulder complaints. International Journal

of Technology Assessment in Health Care 2006;22:76–83.

Geraets J, Goossens M, de Groot IJM, de Bruijn, CPC, de Bie RA,

Dinant GJ, et al.Effectiveness of a graded exercise therapy program

for patients with chronic shoulder complaints. Australian Journal of

Physiotherapy 2005;51:87–94.∗ Geraets JJ, Goossens ME de Bruijn CP, Koke AJ, de Bie RA,

Pelt RAGB, et al.A behavioural treatment for chronic shoulder com-

plaints: concepts, development, and study design. Australian Journal

of Physiotherapy 2005;50:33–8.

Greco 2004 {published data only}

Greco CM, Rudy TE, Manzi S. Effects of a stress-reduction program

on psychological function, pain, and physical function of systemic

lupus erythematosus patients: a randomized controlled trial. Arthri-

tis & Rheumatism 2004;51:625–34.

Haldorsen 1998 {published data only}

Haldorsen EM, Kronholm K, Skouen JS, Ursin H. Multimodal cog-

nitive behavioral treatment of patients sicklisted for musculoskele-

tal pain: a randomized controlled study. Scandinavian Journal of

Rheumatology 1998;27:16–25.

Hammond 2001 {published data only}∗ Hammond A, Freeman K. One-year outcomes of a randomized

controlled trial of an educational-behavioural joint protection pro-

gramme for people with rheumatoid arthritis. Rheumatology 2001;

40:1044–51.

Hammond A, Freeman K. The long-term outcomes from a random-

ized controlled trial of an educational-behavioural joint protection

programme for people with rheumatoid arthritis. Clinical Rehabili-

tation 2004;18:520–8.

Jensen 1997 {published data only}

Jensen IB, Bergstrom G, Ljungquist T, Bodin L. A 3-year follow-up

of a multidisciplinary rehabilitation programme for back and neck

pain. Pain 2005;115:273–83.

Jensen 2001 {published data only}∗ Jensen IB, Bergstroem G, Ljungquist T, Bodin L, Nygren AL. A

randomized controlled component analysis of a behavioral medicine

rehabilitation program for chronic spinal pain: Are the effects de-

pendent on gender?. Pain 2001;91:65–78.

Jensen IB, Bergstrom G, Ljungquist T, Bodin L. A 3-year follow-up

of a multidisciplinary rehabilitation programme for back and neck

pain. Pain 2005;115:273–83.

Johansson 1998 {published data only}

Johansson C, Dahl J, Jannert M, Melin L, Andersson G. Effects of a

cognitive-behavioral pain-management program. Behaviour Research

& Therapy 1998;36:915–30.

Kaapa 2006 {published data only}

Kaapa EH, Frantsi K, Sarna S, Malmivaara A. Multidisciplinary

group rehabilitation versus individual physiotherapy for chronic non-

specific low back pain: a randomized trial. Spine 2006;31:371–6.

Keefe 1990 {published data only}

Keefe FJ, Caldwell DS, Williams DA, Gil KM, Mitchell D, Robert-

son C, et al.Pain coping skills training in the management of os-

teoarthritic knee pain: II. Follow-up results. Behavior Therapy 1990;

21:435–47.∗ Keefe FJ, Caldwell DS, Williams DA, Gil KM, Mitchell D, Robert-

son C, Martinez S, et al.Pain coping skills training in the manage-

ment of osteoarthritic knee pain: A comparative study. Behavior

Therapy 1990;21:49–62.


Keefe FJ, Caldwell DS, Baucom D, Salley A, Robinson E, Timmons

K, et al.Spouse-assisted coping skills training in the management of

knee pain in osteoarthritis: long-term follow up results. Pain 1999;

12:49–62.∗ Keefe FJ, Caldwell DS, Baucom D, Salley A, Robinson E, Timmons

K, et al.Spouse-assisted coping skills training in the management of

osteoarthritic knee pain. Arthritis Care & Research 1996;9:279–91.

Kole-Snijders 1999 {published data only}∗ Kole-Snijders AM, Vlaeyen JW, Goossens ME, Rutten-van

Moelken MP, Heuts PH. van Breukelen G, et al.Chronic low-back

pain: What does cognitive coping skills training add to operant be-



havioral treatment? Results of a randomized clinical trial. Journal of

Consulting & Clinical Psychology 1999;67:931–44.

Spinhoven P, ter Kuile M, Kole-Snijders AMJ, Mansfield MH, den

Ouden D-J, Vlaeyen JWS. Catastrophizing and internal pain control

as mediators of outcome in the multidisciplinary treatment of chronic

low back pain. European Journal of Pain 2004;8:211–9.

Kraaimaat 1995 {published data only}

Kraaimaat FW, Brons MR, Geenen R, Bijlsma JWJ. The effect of

cognitive behavior therapy in patients with rheumatoid arthritis. Be-

haviour Research & Therapy 1995;33:487–95.

Marhold 2001 {published data only}

Marhold C, Linton SJ. Melin L. A cognitive-behavioral return-to-

work program: Effects on pain patients with a history of long-term

versus short-term sick leave. Pain 2001;91:155–63.

McCarberg 1999 {published data only}

McCarberg B, Wolf J. Chronic pain management in a health main-

tenance organization. Clinical Journal of Pain 1999;15:50–7.

Mishra 2000 {published data only}

Mishra KD, Gatchel RJ, Gardea MA. The relative efficacy of three

cognitive-behavioral treatment approaches to temporomandibular

disorders. Journal of Behavioral Medicine 2000;23:293–309.

Moore 1985 {published data only}

Moore JE, Chaney EF. Outpatient group treatment of chronic pain:

Effects of spouse involvement. Journal of Consulting & Clinical Psy-

chology 1985;53:326–34.

Newton-John 1995 {published data only}

Newton-John TO, Spence SH, Schotte D. Cognitive-behavioral

therapy versus EMG biofeedback in the treatment of chronic low

back pain. Behaviour Research & Therapy 1995;33:691–7.

Nicassio 1997 {published data only}

Nicassio PM, Radojevic V, Weisman MH, Schuman C, Kim J,

Schoenfeld-Smith K, et al.A comparison of behavioral and educa-

tional interventions for fibromyalgia. Journal of Rheumatology 1997;

24:2000–7.

O’Leary 1988 {published data only}

O’Leary A, Shoor S, Lorig K, Holman HR. A cognitive-behavioral

treatment for rheumatoid arthritis. Health Psychology 1988;7:527–

44.

Parker 1988 {published data only}

Parker JC, Frank RG, Beck NC, Smarr KL, Buesher KL, Phillips LR,

et al.Pain management in rheumatoid arthritis patients. A cognitive

behavioural approach. Arthritis and Rheumatism 1988;31:593–601.

Puder 1988 {published data only}

Puder RS. Age analysis of cognitive-behavioral group therapy for

chronic pain outpatients. Psychology & Aging 1988;3:204–7.

Radojevic 1992 {published data only}

Radojevic V, Nicassio PM, Weisman MH. Behavioral intervention

with and without family support for rheumatoid arthritis. Behavior

Therapy 1992;23:13–30.

Redondo 2004 {published data only}

Redondo JR, Justo CM, Moraleda FV, Velayos YG, Puche JJ, Zubero

JR, et al.Long-term efficacy of therapy in patients with fibromyal-

gia: a physical exercise-based program and a cognitive-behavioral ap-

proach. Arthritis & Rheumatism 2004;51:184–92.

Smeets 2006 {published data only}∗ Smeets R, Vlaeyen JWS, Hidding A, Kester ADM, Van Der Hei-

jden G, Van Geel ACM, et al.Active rehabilitation for chronic low

back pain: Cognitive-behavioral, physical, or both? First direct post-

treatment results from a randomized controlled trial. BMC Muscu-

loskeletal Disorders 2006;7:1–16.

Smeets R, Vlaeyen JWS, Kester ADM, Knottnerus JA. Reduction of

Pain Catastrophizing Mediates the Outcome of Both Physical and

Cognitive-Behavioral Treatment in Chronic Low Back Pain. Journal

of Pain 2006;7:261–71.

Spence 1989 {published data only}∗ Spence SH. Cognitive-behavior therapy in the management of

chronic, occupational pain of the upper limbs. Behaviour Research &

Therapy 1989;27:435–46.

Spence SH. Cognitive-behaviour therapy in the treatment of chronic,

occupational pain of the upper limbs: A 2 yr follow-up. Behaviour

Research & Therapy 1991;29:503–9.

Strauss 1986 {published data only}

Strauss GD, Spiegel JS, Daniels M, Speigel T, Landsverk J, Roy-Byne

P, et al.Group therapies for rheumatoid arthritis. A controlled study

of two approaches. Arthritis and Rheumatism 1986;29:120.3–12.9.

Strong 1998 {published data only}

Strong J. Incorporating cognitive-behavioral therapy with occupa-

tional therapy: A comparative study with patients with low back

pain. Journal of Occupational Rehabilitation 1998;8:61–71.

Thieme 2003 {published data only}

Thieme K, Gromnica-Ihle E, Flor H. Operant behavioral treatment

of fibromyalgia: a controlled study. Arthritis & Rheumatism 2003;

49:314–20.

Turner 1988 {published data only}

Turner JA, Clancy S. Comparison of operant behavioral and cogni-

tive-behavioral group treatment for chronic low back pain. Journal

of Consulting & Clinical Psychology 1988;56:261–6.


Turner JA, Clancy S, McQuade KJ, Cardenas DD. Effectiveness of

behavioral therapy for chronic low back pain: A component analysis.

Journal of Consulting & Clinical Psychology 1990;58:573–9.


Turner JA, Jensen MP. Efficacy of cognitive therapy for chronic low

back pain. Pain 1993;52:169–77.


Turner JA, Mancl L, Aaron LA. Short- and long-term efficacy of

brief cognitive-behavioral therapy for patients with chronic temporo-

mandibular disorder pain: A randomized, controlled trial.. Pain

2006;121:181–94.

Turner-Stokes 2003 {published data only}

Turner-Stokes L, Erkeller-Yuksel F, Miles A, Pincus T, Shipley M,

Pearce S. Outpatient cognitive behavioral pain management pro-

grams: A randomized comparison of a group-based multidisciplinary

versus an individual therapy model. Archives of Physical Medicine &

Rehabilitation 2003;84:781–8.

Vlaeyen 1995 {published data only}

Vlaeyen JW, Haazen IW, Schuerman JA, Kole-Snijders AM, van Eek

H. Behavioural rehabilitation of chronic low back pain: Compari-

son of an operant treatment, an operant-cognitive treatment and an



operant-respondent treatment. British Journal of Clinical Psychology

1995;34:95–118.

Vlaeyen 1996 {published data only}

Vlaeyen JW, Teeken-Gruben NJ, Goossens ME, Rutten-van Molken

MP, Pelt RA, van Eek H, et al.Cognitive-educational treatment of

fibromyalgia: a randomized clinical trial. I. Clinical effects. Journal

of Rheumatology 1996;23:1237–45.

Williams 1996 {published data only}

Williams A, Richardson P, Nicholas M, Pither C, Harding VR, Rid-

out KL, et al.Inpatient vs. outpatient pain management: Results of

a randomised controlled trial. Pain 1996;66:13–22.

References to studies excluded from this review

Alaranta 1994 {published data only}

Alaranta H, Rytokoski U, Rissanen A, Talo S, Ronnemaa T, Puukka P,

et al.Intensive physical and psychosocial training program for patients

with chronic low back pain. A controlled clinical trial. Spine 1994;

19:1339–49.

Appelbaum 1988 {published data only}

Appelbaum KA, Blanchard EB, Hickling EJ, Alfonso M. Cognitive

behavioral treatment of a veteran population with moderate to severe

rheumatoid arthritis. Behavior Therapy 1988;19:489–502.

Asenlof 2005 {published data only}

Asenlof P, Denison E, Lindberg P. Individually tailored treatment

targeting activity, motor behavior, and cognition reduces pain-re-

lated disability: a randomized controlled trial in patients with mus-

culoskeletal pain. Journal of Pain 2005;6:588–603.

Bendix 1997 {published data only}

Bendix A, Bendix T, Lund C, Kirkbak S, Ostenfeld S. Comparison

of three intensive programs for chronic low back pain patients. A

prospective, randomized, observer-blinded study with one-year fol-

low-up. Scandinavian Journal of Rehabilitation Medicine 1997;29:

81–9.

Broderick 2004 {published data only}

Broderick JE, Stone AA, Smyth JM, Kaell AT. The feasibility and

effectiveness of an expressive writing intervention for rheumatoid

arthritis via home-based videotaped instructions. Annals of Behav-

ioral Medicine 2004;27:50–9.

Brox 2003 {published data only}

Brox J, Sorensen I, Friis R, Nygaard A, Indahl O, Keller A, et

al.Randomized clinical trial of lumbar instrumented fusion and cog-

nitive intervention and exercises in patient with chronic low back

pain and disc degeneration. Spine 2003;28:1913–21.

Corrado 2003 {published data only}

Corrado PE, Gottlieb H, Abdelhamid MH. The effect of biofeedback

and relaxation training on anxiety and somatic complaints in chronic

pain patients. American Journal of Pain Management 2003;13:133–

9.

Currie 2000 {published data only}

Currie SR, Wilson KG, Pontefract AJ, deLaplante L. Cognitive-be-

havioral treatment of insomnia secondary to chronic pain. Journal

of Consulting & Clinical Psychology 2000;68:407–16.

Dahl 2004 {published data only}

Dahl J, Wilson K G, Nilsson A. Acceptance and commitment therapy

and the treatment of persons at risk for long-term disability resulting

from stress and pain symptoms: A preliminary randomized trial.

Behavior Therapy 2004;35:785–801.

Dalton 2004 {published data only}

Dalton JA, Keefe FJ, Carlson J, Youngblood R. Tailoring cognitive-

behavioral treatment for cancer pain. Pain Management Nursing

2004;5:3–18.

Dworkin 2002a {published data only}

Dworkin SF, Turner JA, Mancl L, Wilson L, Massoth D, Huggins

KH, et al.A randomized clinical trial of a tailored comprehensive

care treatment program for temporomandibular disorders. Journal

of Orofacial Pain 2002;16:259–76.

Edinger 2005 {published data only}

Edinger JD, Wohlgemuth WK, Krystal AD, Rice JR. Behavioral

insomnia therapy for fibromyalgia patients: A randomized clinical

trial. Archives of Internal Medicine 2005;165:2527–35.

Evans 2003 {published data only}

Evans S, Fishman B, Spielman L, Haley A. Randomized trial of cog-

nitive behavior therapy versus supportive psychotherapy for HIV-

related peripheral neuropathic pain. Psychosomatics 2003;44:44–50.

Fors 2000 {published data only}

Fors EA, Gotestam KG. Patient education, guided imagery and pain

related talk in fibromyalgia coping. European Journal of Psychiatry

2000;14:233–40.

Haugstad 2006 {published data only}

Haugstad GK, Haugstad TS, Kirste UM, Leganger S, Klemmetsen

I, Malt UF. Mensendieck somatocognitive therapy as treatment ap-

proach to chronic pelvic pain: results of a randomized controlled in-

tervention study. American Journal of Obstetrics & Gynecology 2006;

194:1303–10.


Keefe FJ, Blumenthal J, Baucom D, Affleck G, Waugh R, Caldwell

DS, et al.Effects of spouse-assisted coping skills training and exercise

training in patients with osteoarthritic knee pain: a randomized con-

trolled study. Pain 2004;110:539–49.

Keller 2004 {published data only}

Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikeras O. Trunk

muscle strength, cross-sectional area, and density in patients with

chronic low back pain randomized to lumbar fusion or cognitive

intervention and exercises. Spine 2004;29:3–8.

Kerns 1986 {published data only}

Kerns RD, Turk DC, Holzman AD, Rudy TE. Comparison of cog-

nitive-behavioral and behavioral approaches to the outpatient treat-

ment of chronic pain. Clinical Journal of Pain 1986;1:195–203.

Linton 1984 {published data only}

Linton SJ, Gotestam KG. A controlled study of the effects of applied

relaxation plus operant procedures in the regulation of chronic pain.

British Journal of Clinical Psychology 1984;23:291–9.


Linton SJ, Melin L, Stjernlof K. The effects of applied relaxation and

operant activity on chronic pain. Behavioural Psychotherapy 1985;

13:87–100.


Linton SJ, Ryberg M. A cognitive-behavioral group intervention as

prevention for persistent neck and back pain in a non-patient popu-

lation: a randomized controlled trial. Pain 2001;90:83–90.




Linton SJ, Boersma K, Jansson M, Svard L, Botvalde M. The effects of

cognitive behavioural and physical therapy preventive interventions

on pain related sick leave. Clinical Journal of Pain 2005;21:109–19.

Moffett 2005 {published data only}

Moffett JAK, Jackson DA, Richmond S, Hahn S, Coulton S, Farrin

A. Randomised trial of a brief physiotherapy intervention compared

with usual physiotherapy for neck pain patients: Outcomes and pa-

tients’ preference. British Medical Journal 2005;330:75–8.

Moore 2000 {published data only}

Moore JE, Von Korff M, Cherkin D, Saunders K, Lorig K. A ran-

domized trial of a cognitive-behavioral program for enhancing back

pain self care in a primary care setting. Pain 2000;88:145–53.

Nicholas 1991 {published data only}

Nicholas MK, Wilson PH, Goyen J. Operant-behavioural and cog-

nitive-behavioural treatment for chronic low back pain.. Behaviour

Research & Therapy 1991;29:225–38.

Nicholas 1992 {published data only}

Nicholas MK, Wilson PH, Goyen J. Comparison of cognitive-be-

havioral group treatment and an alternative non-psychological treat-

ment for chronic low back pain. Pain 1992;48:339–47.

Parker 2003 {published data only}

Parker JC, Smarr KL, Slaughter JR, Johnston SK, Priesmeyer ML,

Hanson KD, et al.Management of depression in rheumatoid arthri-

tis: a combined pharmacologic and cognitive-behavioral approach.

Arthritis & Rheumatism 2003;49:766–77.

Peters 1990 {published data only}

Peters J, Large RG, Elkind G. Follow-up results from a randomised

controlled trial evaluating in- and outpatient pain management pro-

grammes. Pain 1992;50:41–50.∗ Peters JL, Large RG. A randomised control trial evaluating in- and

outpatient pain management programmes. Pain 1990;41:283–93.

Schweikert 2006 {published data only}

Schweikert B, Jacobi E, Seitz R, Cziske R, Ehlert A, Knab J, et

al.Effectiveness and cost-effectiveness of adding a cognitive-behav-

ioral treatment to the rehabilitation of chronic low back pain. Journal


Sharpe 2001 {published data only}

Sharpe L, Sensky T, Timberlake N, Ryan B, Brewin C, Allard S. A

blind, randomized, controlled trial of cognitive-behavioural inter-

vention for patients with recent onset rheumatoid arthritis: Prevent-

ing psychological and physical morbidity. Pain 2001;89:275–83.

Soderlund 2001 {published data only}

Soderlund A, Lindberg P. Cognitive behavioural components in phys-

iotherapy management of chronic whiplash associated disorders

(WAD) -- a randomized group study. Physiotherapy Theory & Practice

2001;17:229–38.

Spence 1995 {published data only}

Spence SH, Sharpe L, Newton-John T, Champion D. Effect of EMG

biofeedback compared to applied relaxation training with chronic,

upper extremity cumulative trauma disorders. Pain 1995;63:199–

206.


Turner JA. Comparison of group progressive-relaxation training and

cognitive-behavioral group therapy for chronic low back pain. Jour-

nal of Consulting & Clinical Psychology 1982;50:757–65.

Van den Hout 2003 {published data only}

van den Hout JH, Vlaeyen JW, Heuts PH, Zijlema JH, Wijnen JA.

Secondary prevention of work-related disability in nonspecific low

back pain: does problem-solving therapy help? A randomized clinical

trial. Clinical Journal of Pain 2003;19:87–96.

Van Lankveld 2004 {published data only}

van Lankveld W, van Helmond T, Naring G, de Rooij DJ, van den

Hoogen F. Partner participation in cognitive-behavioral self-manage-

ment group treatment for patients with rheumatoid arthritis. Journal


References to studies awaiting assessment

Babu 2007 {published data only}

Babu AS, Mathew E, Danda D, Prakesh H. Management of patients

with fibromyalgia using biofeedback: A randomized control trial.

Indian Journal of Medical Sciences 2007;61:445–61.

Bliokas 2007 {published data only}

Bliokas VV, Cartmill TK, Nagy BJ. Does systematic graded exposure

in vivo enhance outcomes in multidisciplinary chronic pain manage-

ment groups?. Clinical Journal of Pain 2007;23:361–74.

Ersek 2008 {published data only}

Ersek M, Turner JA, Cain KC, Kemp CA. Results of a randomized

controlled trial to examine the efficacy of a chronic pain self-manage-

ment group for older adults [ISRCTN11899548]. Pain 2008;138:

29–40.

Leeuw 2008 {published data only}

Leeus M, Goossens MEJB, van Breukelen GJP, de Jong JR, Heuts

PHTG, Smeets RJEM, et al.Exposure in vivo versus operant graded

activity in chronic low back pain patients: Results of a randomized

controlled trial. Pain 2008;138(1):192–207.


Linton SJ, Boersma K, Jansson M, Overmeer T, Lindblom K, Vlaeyen

JWS. A randomized controlled trial of exposure in vivo for patients

with spinal pain reporting fear of work-related activities. European

Journal of Pain 2008;12:722–30.

Lorig 2008 {published data only}

Lorig KR, Ritter PL, Laurent DD, Plant K. The internet-based arthri-

tis self-management program: a one-year randomized trial for pa-

tients with arthritis or fibromyalgia. Arthritis Care and Research 2008;

59:1009–17.

Morone 2008 {published data only}

Morone NE, Greco CM, Weiner DK. Mindfulness meditation for

the treatment of chronic low back pain in older adults: a randomized

controlled pilot study. Pain 2008;134:310–9.

Smeets 2008 {published data only}

Smeets RJEM, Vlaeyen JWS, Hidding A, Kester ADM, van der Hei-

jden GJMG, Knottnerus JA. Chronic low back pain: Physical train-

ing, graded activity with problem solving training, or both? The one-

year post-treatment results of a randomized controlled trial. Pain

2008;134:263–76.



Woods 2008 {published data only}

Woods MP, Asmundson GJG. Evaluating the efficacy of graded in

vivo exposure for the treatment of fear in patients with chronic low

back pain: a randomized controlled clinical trial. Pain 2008;136:

271–80.

Zautra 2008 {published data only}

Zautra AJ, Davis MC, Reich JW, Nicassio P, Tennen H, Finan P, Kratz

A, Parrish B. Comparison of cognitive behavioral and mindfulness

meditation interventions on adaptation to rheumatoid arthritis for

patients with and without history of recurrent depression. Journal of

Consulting and Clinical Psychology 2008;76:408–21.

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Blyth 2007

Blyth FM, Macfarlane GJ, Nicholas MK. Topical review: The con-

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Boutron I, Moher D, Altman D, Schulz KF, Ravaud P. Extending the

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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Altmaier 1992

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, six months.

Participants End of treatment n = 42

Start of treatment n = 45

Sex: 12F, 33M

Mean age = 39.9 (sd 8.9)

Source = pain and rehabilitation clinic

Diagnosis = Chronic Low Back Pain

Mean years of pain = not given

Interventions “Psychology based programme: multicomponent CBT”

“Standard inpatient rehabilitation”

Outcomes Primary Pain Outcome: MPQ PRI

Primary Disability Outcome: WHYMPI pain interference

Primary Mood Outcome: WHYMPI distress

1. Primary Aerobic impairment

2. Self-efficacy

3. West Haven Yale Multidimensional Pain Inventory (WHYMPI) self control

4. West Haven Yale Multidimensional Pain Inventory (WHYMPI) pain interference

5. West Haven Yale Multidimensional Pain Inventory (WHYMPI) Mood

6. Disability

7. Melzack Pain Questionnaire Pain Response Index (MPQ PRI)

Notes CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3,3, 4.1, 4.2, 4.3

Risk of bias

Item Authors’ judgement Description

Is the Study Quality adequate? No Total Quality = 15/35

Is the Design Quality adequate? No Design Quality = 11/26

Is the Treatment Quality adequate? No Treatment Quality = 4/9



Astin 2003

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, six weeks, four months



Sex: 127F, 1M (data from start of treatment)

Mean age = 47.7 (sd 10)

Source = volunteer

Diagnosis = Fibromyalgia

Mean years of pain = 3.5

Interventions “mindfulness meditation Qiqong”

“education”

Outcomes Primary Pain Outcome: SF36 Pain (Reversed)

Primary Disability Outcome: Fibromyalgia Impact Questionnaire

Primary Mood Outcome: BDI Depression

1. Fibromyalgia Impact Questionnaire

2. Short Form 36 (Pain)

3. Beck Depression Index (BDI)

4. Six minute Walk Test

5. Physician Rated Tender Point Score

Notes CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3

Risk of bias


Is the Study Quality adequate? Yes Total Quality = 18/35

Is the Design Quality adequate? Yes Design Quality = 14/26


Basler 1997


Participants End of treatment n =76


Sex: 57F, 19M

Mean age = 49.3 (sd 9.7)

Source = Pain or Rehabilitation Clinic





Basler 1997 (Continued)

Interventions “CBT added to Medical Treatment”

“Medical Treatment”

Outcomes Primary Pain Outcome: NRS 0-10 Pain

Primary Disability Outcome: Disability in physical function from Dusseldorf Disability

Scale

Primary Mood Outcome: none

1. Pain Intensity Numerical Rating Scale (0-10)

2. Control over pain Numerical Rating Scale (0-10)

3. Days per week pain free

4. Days per week pain medication use

5. Use of cognitive strategies (self report)

6. Use of avoidance behaviour (self report)

7. Pleasant activities (self report)

8. Social support (self report)

9. Philosophical beliefs (self report)

10. Catastrophizing (bespoke scale)

11. Active coping (bespoke scale)

12. Disability in social relationships from Dusseldorf Disability Scale

13. Disability in social roles from Dusseldorf Disability Scale

14. Disability in physical function from Dusseldorf Disability Scale

15. Disability in mental performance from Dusseldorf Disability Scale

16. Disability in physical performance from Dusseldorf Disability Scale

Notes CBT vs TAU, post-treatment: analyses 3.1, 3.2

Risk of bias




Is the Treatment Quality adequate? Yes Treatment Quality = 6/9

Becker 2000

Methods RCT. Three arms. Assessed at pre-treatment, post-treatment, six months.


Start of treatment n =166

Sex: 106F, 60M (at start of treatment)

Mean age = 56.5 (s.d. 15)



Becker 2000 (Continued)

Source = Pain or Rehabilitation Clinic

Diagnosis = Mixed chronic pain


Interventions “Multidisciplinary pain treatment”

“Primary Care medical treatment”

“Waiting List”

Outcomes Primary Pain Outcome: NRS 0-10 Pain

Primary Disability Outcome: SF36 physical function (reversed)

Primary Mood Outcome: HADS Depression

1. Pain Numerical Rating Scale (NRS) (0-10)

2. Pain Visual Rating Scale (VRS)

3. Psychological general well being

4. Hospital Anxiety and Depression Scale (Anxiety)

5. Hospital Anxiety and Depression Scale (Depression)

6. Short Form 36 Role Physical

7. Short Form 36 Physical Function

8. Short Form 36 Pain

9. Short Form 36 General Health

10. Short Form 36 Vitality

11. Short Form 36 Social Function

12. Short Form 36 Role Emotional

13. Short Form 36 Mental Health

14. Sleep

15. Mean opioid Dose

Notes CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3

Risk of bias







Bradley 1987

Methods RCT. Three arms. Assessed at pre-treatment, post-treatment, six month follow up.



Sex: 43F, 10M (given at 6 month f/u)

Mean age = 50.1 (sd 12.4)

Source = Rheumatology Clinic

Diagnosis = Rheumatoid Arthritis

Mean years of pain = 11.5 years

Interventions “cognitve-behavioral group therapy”

“structured group social support therapy”

“no adjunct treatment” (TAU)

Outcomes Primary Pain Outcome: VAS pain intensity

Primary Disability Outcome: none

Primary Mood Outcome: DACL depression

Pain Intensity Visual Analogue Scale

Pain Unpleasantness Visual Analogue Scale

Observed pain behaviour

Rheumatoid activity

Subjective global assessment

Professional global assessment

Articular index

Grip strength

Rheumatoid Factor

Erythrocyte sedimentation rate (ESR)

State-Trait Anxiety Index: Trait (STAI )

Depression Adjective Checklist (DACL)

Skin temperature change

Health Locus of Control

Arthritis helplessness

Notes

Notes CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.3, 2.1, 2.3

Risk of bias







Buckelew 1998

Methods RCT. Four arms. Assessed at pre-treatment, post-treatment, three months, one year, two years.



Sex: 108F, 11M

Mean age = 44 (sd 10)

Source = mainly community

Diagnosis = fibromyalgia


Interventions “Biofeedback + relaxation + exercise”

“Biofeedback + relaxation”

“Exercise”

“Education attentional control”

Outcomes Primary Pain Outcome: no data available

Primary Disability Outcome: no data available

Primary Mood Outcome: no data available

Arthritis Impact Measurement Scale: Physical Activity subscale (AIMS)

Symptom Checklist (SCL-90R) distress

Center for Epidemiologic Studies Depression Scale (CES-D)

Arthritis Self-Efficacy Scale

sleep rating 0-12

Tender Point Index

Myalgic score

Physician’s VAS rating of disease severity

Keefe & Block Pain Behaviour: observation

Notes

Risk of bias





Buhrman 2004

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment.



Buhrman 2004 (Continued)




Mean age = 44.6 (sd 10.4)

Source = Volunteers



Interventions “Internet based self help”

“Waiting list”

Outcomes Primary Pain Outcome: MPI pain intensity

Primary Disability Outcome: MPI pain interference

Primary Mood Outcome: HADS Depression

Pain Diary (Highest intensity)

Pain Impairment Rating Scale

Coping Strategies Questionnaire

Hospital Anxiety and Depression Scale (HADS Anxiety)

Hospital Anxiety and Depression Scale (HADS Depression)

Multidimensional Pain Inventory: Pain Intensity

Multidimensional Pain Inventory: Pain Interference

Multidimensional Pain Inventory: Life Control

Multidimensional Pain Inventory: Affective Distress

Multidimensional Pain Inventory: support

Multidimensional Pain Inventory: Punishing responses

Multidimensional Pain Inventory: Solicitous responses

Multidimensional Pain Inventory: distracting responses

Notes CBT vs TAU, post-treatment: analyses 3.1, 3.2, 3.3

Risk of bias







Carson 2005

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, three months.



Sex: 26F, 17M

Mean age = 51.1 (no sd given)

Source = Pain or rehabilitation clinic



Interventions “Loving kindness meditation”

“Usual care”

Outcomes Primary Pain Outcome: BPI 0-10 usual pain


Primary Mood Outcome: BSI (Distress) (No data available)

McGill Pain Questionnaire

Brief Pain Inventory: usual pain

Brief Pain Inventory: worse pain

The State Trait Anger Expression Inventory (STAXI)

Brief Symptom Inventory: psychological distress

Notes CBT vs TAU post-treatment:: analysis 3.1

Risk of bias





Cook 1998

Methods RCT. Two arms. Assessed pre-treatment, post-treatment.



Sex: 13F, 8M (at end of treatment)

Mean age = 77.6 (no sd given)

Source = elderly community

Diagnosis = mixed chronic pain




Cook 1998 (Continued)

Interventions “CBT”

“Education attention control”

Outcomes Primary Pain Outcome: NRS Pain

Primary Disability Outcome: Roland & Morris Disability Questionnaire subset 0-16

Primary Mood Outcome: Geriatric Depression Scale

McGill Pain Questionnaire Pain Rating Index

Pain Numerical Rating Scale

Roland Morris Disability Questionnaire

Geriatric Depression Scale

Pain Medication


Risk of bias





Dworkin 1994

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, three months, one year.


Start of treatment n=185

Sex: 118F, 21M (at three months)

Mean age = 37.1 (s.d. 10.2)

Source = community and volunteer

Diagnosis = TMD


Interventions “CBT followed by usual treatment”

“Usual Treatment”




Pain Visual Analogue Scale

Pain Interference 0-10

Mandibular range of motion



Dworkin 1994 (Continued)

Symptom Checklist-90R

Chronic pain grade

Notes

Risk of bias





Dworkin 2002b

Methods RCT. 2 arms. Assessed pre-treatment, post-treatment, six months, one year.



Sex: 105F, 19M

Mean age = 37.5 (s.d. 4.0)

Source = pain clinic

Diagnosis = temporomandibular joint pain (TMD)


Interventions “Structured self-care”

“Specialist treatment as usual”




Characteristic pain intensity 0-10

Pain interference 0-10

Pain-related disability days

Symptom Checklist-90R depression and other symptoms

Chronic pain grade

Jaw movement measures

Notes

Risk of bias



Dworkin 2002b (Continued)





Ersek 2003





Mean age = 82 (no sd given)

Source = elderly community



Interventions “Self Management”

“Educational booklet”

Outcomes Primary Pain Outcome: Graded Pain Scale pain

Primary Disability Outcome: SF-36 (Reversed)

Primary Mood Outcome: Geriatric Depression Scale

Graded Pain Scale (Pain Intensity)

Graded Pain Scale (activity interference)

Short Form 36 (Physical Function)

Short Form 36 Role Physical

Geriatric Depression Scale

Survey of Pain Attitudes: Control belief

Survey of Pain Attitudes: Harm belief

Survey of Pain Attitudes: Medical Care beliefs


Risk of bias






Ersek 2003 (Continued)


Evers 2002

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, six months follow up.



Sex: 42F, 17M

Mean age = 54.1 (s.d. 11.4)

Source = Rheumatology clinic



Interventions “Tailor made CBT”

“Treatment as Usual”

Outcomes Primary Pain Outcome: IRGL Pain

Primary Disability Outcome: IRGL Functional Disability (Composite Z score)

Primary Mood Outcome: BDI depression

Disease Activity

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): Functional Disability

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): Pain

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): Anxiety

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): Perceived support

Social network

Illness Cognitions: Helplessness

Illness Cognitions: Acceptance

Active Coping with Pain

Passive Coping with pain

Active Coping with Stress

Passive Coping with Stress

Fatigue

Beck Depression Inventory

Negative Mood (ZwartSpooren)

Medication compliance


Risk of bias





Evers 2002 (Continued)



Fairbank 2005

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, six months, one year, two years.


Start of treatment n= 349

Sex: 172F, 173M

Mean age = not given

Source = orthopaedic referral

Diagnosis = CLBP

Mean years of pain = 8

Interventions “CBT intensive rehabilitation”

“Surgical stabilisation”




Shuttle Walk

Short Form 36 Physical subscale

Short Form 36 Mental subscale

Oswestry Disability Scale

Modified Somatic Questionnaire

Zung Depression Scale

Mean Cost

Notes

Risk of bias







Flor 1993

Methods RCT. Three arms. Assessed pre-treatment, post-treatment, six months, two years.




Mean age = 42.4 (s.d. 9.7)

Source = Pain or rehab clinic, and volunteer

Diagnosis = Mixed (mostly Chronic Low Back Pain)



“Biofeedback”

“WLC”

Outcomes Primary Pain Outcome: MPI pain intensity


Primary Mood Outcome: MPI affective distress

Multidimensional Pain Inventory: pain intensity

Multidimensional Pain Inventory: interference

Multidimensional Pain Inventory: Affective distress

Multidimensional Pain Inventory: Life control

Pain-related Self Statements Scale (PRSS): catastrophizing

Pain-related Self Statements Scale (PRSS): active coping

Pain behaviour

Use of health care

Electromyography baseline

Electromyography reactivity


BT vs TAU, post-treatment and follow-up: analyses 7.1, 7.2, 7.3, 8.1, 8.2, 8.3

Risk of bias







Freeman 2002

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, three months, six months.



Sex: 46F, 8M

Mean age = 51.4 (s.d. 11.3)

Source = rheumatology clinics


Mean years of pain = 4.5 months since diagnosis

Interventions “Cognitive Behavioural Arthritis Education Programme”

“Arthritis Education Programme”




Arthritis Impact Measurement Scale (AIMS) 2

Visual Analogue Scale pain

Arthritis Impact Measurement Scale: Physical Activity subscale Affect

Rheumatology Attitudes Index: helplessness, internality

Arthritis Self-Efficacy Scale

Erythrocyte sedimentation rate (ESR)

morning stiffness

28 joint score

Notes

Risk of bias





Geraets 2005

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, one year.




Mean age = 52.5 (s.d. 12.4)



Geraets 2005 (Continued)

Source = mixed community and volunteer

Diagnosis = Shoulder pain


Interventions “Graded exercise”

“Primary Care TAU”



Primary Mood Outcome: none

Shoulder disability questionnaire

Shoulder pain

Pain intensity NRS

Quality of life

Fear avoidance

Kinesiophobia (2 items)

Pain Coping and Cognition List: catastrophizing

Pain Coping and Cognition List: Coping

General Practitioner visits

Physician visits

Physiotherapy visits

Number of drug prescriptions

Number of days work absence

Total cost of Health Care (Euros)

Notes

Risk of bias





Greco 2004

Methods RCT. Three arms. Assessed pre-treatment, post-treatment, six/nine months.



Greco 2004 (Continued)




Mean age = 47.3 (s.d. 10.4)

Source = volunteers

Diagnosis = SLE


Interventions “CBT with Biofeedback”

“Symptom monitoring and support”

“Treatment as Usual”

Outcomes Primary Pain Outcome: AIMS2 pain 0-10


Primary Mood Outcome: CES-D Depression

Arthritis Impact Measurement Scale (AIMS) 2: Pain



Arthritis Self-efficacy

Perceived Stress

Short Form 36 Physical function

Fatigue severity

Global self assessment

Disease activity systemic lupus activity measure-revised (SLAM-R)

Systemic Lupus Erythematosus Disease Activity Index (SLEDAI).


CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3

Risk of bias





Haldorsen 1998

Methods RCT. Two arms. Assessed pre-treatment, one year.



Haldorsen 1998 (Continued)



Sex: 298F, 171M

Mean age = 43 (s.d. 10.6)

Source = National Insurance system contact



Interventions “Cognitive Behaviour Therapy”

“Treatment As Usual”

Outcomes Primary Pain Outcome: VAS pain


Primary Mood Outcome: HSCL distress

Visual Analogue Scale Pain (in afternoon)

Physical training

Hopkins Checklist (HSCL) Distress (Norwegian version)

Attribution style

Work Satisfaction

Ergonomic performance

Subjective health rating

Notes CBT vs TAU post-treatment: analyses 4.1, 4.3

Risk of bias





Hammond 2001

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, one year.



Sex: 97F, 30M

Mean age = 50.5 (s.d. 10.6)

Source = Rheumatology clinic

Diagnosis = Rheumatoid Arthritis (hand)



Hammond 2001 (Continued)


Interventions “Joint protection arthritis education”

“Standard arthritis education”

Outcomes Primary Pain Outcome: none available

Primary Disability Outcome: AIMS2 activities of daily living

Primary Mood Outcome: none available

Adherence to joint protection

Hand pain Visual Analogue Scale

Overall pain Visual Analogue Scale

Tender count (28 joints)

Swollen joint count (28 joints)

Early morning stiffness

Grip strength

hand joint alignment

Arthritis Impact Measurement Scale (AIMS) 2: ADL

Arthritis Impact Measurement Scale (AIMS) 2: upper limb function

Arthritis Impact Measurement Scale (AIMS) 2: lower limb function

Arthritis Impact Measurement Scale (AIMS) 2: current health status

Arthritis Self Efficacy (Pain)

Arthritis Self Efficacy (Other)

Rheumatoid attitude index (helplessness)

Rheumatoid attitude index (internality)

Satisfaction with health

Notes CBT vs Active, post-treatment and follow-up: analyses 1.2, 2.2

Risk of bias





Jensen 1997

Methods RCT. Two arms. Assessed pre-treatment, post-treatment, six months, 18 months.



Jensen 1997 (Continued)



Sex: 63F, 0 M (at start of treatment)

Mean age = 43.4 (s.d. 8.4)

Source = Pain or rehabilitation clinic

Diagnosis = non specific back or neck pain


Interventions “Woman-specific CBT”

“Regular CBT”


Primary Disability Outcome: Disability Rating Index


Pain intensity Visual Analogue Scale

Beck Depression Inventory (BDI)

Anxiety Visual Analogue Scale

Disability Rating Index

Health Perception Numerical Rating Scale

Coping Strategies Questionnaire (CSQ)

Rheumatoid attitudes index (helplessness)


Risk of bias




Is the Treatment Quality adequate? No Treatment Quality =3/9

Jensen 2001

Methods RCT. Four arms. Assessed at pre-treatment, post-treatment, six months, 18 months, three years.



Sex: 117F, 93M

Mean age = 43.3 (s.d. 10.4)

Source = pain or rehabilitation clinic

Diagnosis = Mixed (mostly Chronic Low Back Pain)



Jensen 2001 (Continued)



“Behavioural medicine rehabilitation”

“Behaviourally orientated physical therapy” (BT)

“Treatment As Usual”

Outcomes Primary Pain Outcome: SF36 pain (reversed)


Primary Mood Outcome: SF36 mental health (reversed)

Short Form 36 Pain

Short Form 36 Physical Function

Short Form 36 Mental Health

Notes CBT vs TAU, post-treatment and follow-up (six months): analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3

BT vs TAU, post-treatment and follow-up (six months): analyses 7.1, 7.2, 7.3, 8.1, 8.2, 8.3

Baseline N used as N unavailable for post-treatment and follow-up results

Risk of bias




Is the Treatment Quality adequate? Yes Treatment Quality =7/9

Johansson 1998

Methods RCT. Two arms. Assessed pre-treatment, post-treatment, one month.




Mean age = 43.5 (s.d. 7.6)

Source = Pain or Rehabilitation clinic

Diagnosis = chronic musculoskeletal pain



“WLC”



Johansson 1998 (Continued)


Primary Disability Outcome: MPI Activity


Visual Analogue Scale: pain intensity

Visual Analogue Scale: pain interference

Sick leave %

Hours of occupational training per day

Multidimensional Pain Index

Coping Strategies Questionnaire CSQ

Notes CBT vs TAU, post-treatment:analyses 3.1, 3.2

Risk of bias





Kaapa 2006

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, 6 months, one year, two years.



Sex: 120F, 12M (start of treatment)

Mean age = 46.3 (s.d. 7.5)

Source = community



Interventions “semi-intensive multidisciplinary rehabilitation”

“individual physiotherapy”

Outcomes Primary Pain Outcome: pain intensity 0-10

Primary Disability Outcome: Oswestry Disability Index 0-100

Primary Mood Outcome: (DEPS) depression 0-30

Low back pain intensity 0-10

Sciatic pain intensity 0-10

Oswestry Disability Index 0-100

subjective work capacity 0-10



Kaapa 2006 (Continued)

recent sick leave due to back pain

beliefs re working (2 year follow-up) 0-10

The Depression Scale (DEPS) 0-30

Healthcare consumption 12 months


Risk of bias





Keefe 1990

Methods RCT. Three arms. Assessed pre-treatment, post-treatment, six months.



Sex: 71F, 28M

Mean age = 64.0 (s.d. 11.5)

Source = rheumatology clinic

Diagnosis = Osteoarthritis of the knee


Interventions “coping skills training”

“arthritis education”

“standard care”

Outcomes Primary Pain Outcome: AIMS pain

Primary Disability Outcome: AIMS physical disability

Primary Mood Outcome: AIMS psychological disability

Arthritis Impact Measurement Scale (AIMS): pain

Arthritis Impact Measurement Scale (AIMS): psychological disability

Arthritis Impact Measurement Scale (AIMS): physical disability

Pain Behaviour (Keefe & Block) observation

Coping Strategy Questionnaire

Medication use



Keefe 1990 (Continued)



Risk of bias





Keefe 1996

Methods RCT. Three arms. Assessed at pre-treatment, post-treatment, six months, one year.



Sex: 54F, 34M

Mean age = 62.6 (s.d. 10.1)

Source = volunteer

Diagnosis = Osteoarthritis of knee


Interventions “spouse-assisted coping skills training”

“coping skills training”

“spouse-supported arthritis education”


Primary Disability Outcome: AIMS physical disability

Primary Mood Outcome: AIMS mental disability


Arthritis Impact Measurement Scale (AIMS): physical

Arthritis Impact Measurement Scale (AIMS): psychological

Coping Strategies Questionnaire coping

Coping Strategies pain control

Pain behaviour (Keefe & Block) observation

Notes CBT vs Active, post-treatment: analyses 1.1, 1.2, 1.3

Risk of bias




Keefe 1996 (Continued)




Kole-Snijders 1999



Start of treatment n =148

Sex: 94 F, 54 M

Mean age = 30.8 (s.d. 9.1)




Interventions “operant + cognitive coping skills”

“operant + group discussion”

“waiting list”




(all reduced by factor analysis to 3 scores: motoric, coping control, negative affect)

Pain Behaviour Scale

Checklist for Interpersonal Pain Behaviour

Behavioural approach test (walking distance)

Multi dimensional Locus of Control

Pain Cognition Checklist


Nijmegen Hyperventilation Questionnaire


McGill Pain Questionnaire pain

Notes

Risk of bias





Kole-Snijders 1999 (Continued)



Kraaimaat 1995




Sex: 52F, 25M (from the 77 who agreed to participate)

Mean age = 57.0 (s.d. 12.7)


Diagnosis = Rheumatoid arthritis


Interventions “Cognitive Behavioural Therapy”

“occupational therapy”

“waiting list”

Outcomes Primary Pain Outcome: IRGL pain

Primary Disability Outcome: IRGL function (Reversed)

Primary Mood Outcome: IRGL depression

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): function

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): self care

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): pain

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): anxiety

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): depression

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): potential support

Invloed van Reuma op Gezondheid en Leefwijze (IRGL): actual support

Invloed van Reuma op Gezondheid en Leefwijze (IRGL):mutual visits



Risk of bias







Marhold 2001

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, two-four months, four-six months.

Participants End of treatment n= 70


Sex: 72F, 0M

Mean age = 46.0 (s.d. 9.0)

Source = national sick leave register

Diagnosis = mixed chronic pain, 58% neck

Mean years of pain = not given, but half had been on sick leave 3 months, and half for 26

months.

Interventions “Cognitive Behaviour Therapy for return to work”

“Treatment as usual”




Days on sick leave

Multidimensional Pain Index


Beck Depression Index

Disability Rating Index

Pain and impairment rating scale (PAIRS)

Notes

Risk of bias





McCarberg 1999

Methods RCT. Two arms. Assessed pre-treatment, six months follow-up.



Sex: 264F, 89M

Mean age = 52.1 (s.d. 9.6)




McCarberg 1999 (Continued)

Diagnosis = mixed chronic pain, many Chronic Low Back Pain


Interventions “Cognitive Behaviour Therapy”

“minimal home study”

Outcomes Primary Pain Outcome: MPI pain severity



11pt box scale pain severity

pain discomfort scale: pain distress

Multidimensional Pain Inventory: pain severity

Multidimensional Pain Inventory: affective distress

Multidimensional Pain Inventory: self control


Multidimensional Pain Inventory: social support and spouse behaviour subscales

Notes CBT vs Active, follow-up: analyses 2.1, 2.2, 2.3

Risk of bias





Mishra 2000

Methods RCT. Four arms. Assessed at pre-treatment, post-treatment.



Sex: 77F, 7M

Mean age = 35.8 (s.d. 9.9)

Source = pain or rehabilitation clinic and volunteer

Diagnosis = temporomandibular joint disorder




Mishra 2000 (Continued)

Interventions “Biofeedback” (BT)

Cognitive behavioural skills training“ (CBT)

”Cognitive behavioural skills training + biofeedback“

”no treatment control“

Outcomes Primary Pain Outcome: CPI pain index

Primary Disability Outcome: none available


Characteristic Pain Index (CPI) pain severity 0-100

Graded Chronic Pain Score

Profile of Mood States total

Notes CBT vs TAU, post-treatment: analysis 3.1

BT vs TAU, post-treatment: analysis 7.1

Risk of bias





Moore 1985

Methods RCT. Three arms. Assessed at pre-treatment, post-treatment, three months, seven months.



Sex: 1F, 42M

Mean age = 49.3 (s.d. 13.2)




Interventions ”Cognitive Behaviour Therapy in couples group“

”Cognitive Behaviour Therapy in patient group“

”waiting list“

Outcomes Primary Pain Outcome: SIP pain


Primary Mood Outcome: MMPI depression



Moore 1985 (Continued)

Visual Analogue Scale pain severity

Visual Analogue Scale spouse rated pain

Sickness Impact Profile: pain

Minnesota Multiphasic Personality Inventory: depression

Minnesota Multiphasic Personality Inventory: somatization

Personal Adjustment and Role Skills: spouse

Marital satisfaction

Medical Visits


Risk of bias





Newton-John 1995




Sex: 27F, 17M

Mean age = 45.5 (s.d. 11.6)

Source = pain or rehabilitation clinic, community referral, volunteer



Interventions ”Cognitive Behaviour Therapy“

”biofeedback“

”waiting list“

Outcomes Primary Pain Outcome: pain diary

Primary Disability Outcome: MPI general activity


Pain diary

Pain disability

Multidimensional Pain Inventory: general activity

Coping Strategies Questionnaire modified



Newton-John 1995 (Continued)

Pain Beliefs Questionnaire


State-Trait Anxiety Index (STAI): state


BT vs TAU, post-treatment: analyses 7.1, 7.2, 7.3

Risk of bias





Nicassio 1997




Sex: 63F, 8M (at follow-up)

Mean age = 53.1 (s.d. no given)

Source = pain or rehabilitation clinic, support groups



Interventions ”behavioural treatment“

”education“

Outcomes Primary Pain Outcome: not available

Primary Disability Outcome: quality of well being

Primary Mood Outcome: CES-D Depression

pain index: composite of Fibromyalgia Impact Questionnaire pain scale, MPQ PRI, number

of body areas, and flare index

Pain Behavior Checklist self-reported pain behaviour



Rheumatology Attitudes Index helplessness subscale

Pain Management Inventory active and passive coping

Quality of Well being Scale QWB: structured interview on functional impairment



Nicassio 1997 (Continued)

Quality of Social Support Scale

myalgia score, nurse rated on examination

Notes BT vs Active, post-treatment and follow-up: analyses 5.2, 5.3, 6.2, 6.3

Risk of bias





O’Leary 1988

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment.



Sex: 30F, 0M

Mean age = 49.3 (s.d. not given)

Source = volunteers, specialist referrals, Arthritis Center

Diagnosis = rheumatoid arthritis


Interventions ”CBT“

”bibliotherapy“

Outcomes Primary Pain Outcome: Arthritis Self-Efficacy Scale: pain subscale (no data available)

Primary Disability Outcome: Perceived stress (no data available)

Primary Mood Outcome: Perceived stress: coping (no data available)

Average pain 0-100

Highest pain 0-100

Health Assessment Questionnaire disability

Joint impairment

Arthritis Self-Efficacy perceived ability to control pain, depression, and fatigue each 0-100

Arthritis Self-Efficacy to manage pain

Arthritis Self-Efficacy to be active despite pain

Zung Depression

Perceived Stress Scale: coping

University of California Los Angeles loneliness scale

Sleep quantity



O’Leary 1988 (Continued)

Sleep quality

Notes

Risk of bias





Parker 1988

Methods RCT. Three arms. Assessed at pre-treatment, six months, one year


Start of treatment n = not given

Sex: 3F, 80 M

Mean age = 60.6 (s.d. 7.7)

Source = hospital



Interventions ”cognitive behavioural pain management group“

”attention placebo group“

”control group“ (TAU)





McGill Pain Questionnaire pain dimensions


Arthritis Impact Measurement Scale (AIMS)


Symptom Checklist-90R psychological symptoms

Hassled Scale

Ways of Coping Questionnaire

Arthritis Helplessness Index

Disease status measures including walking speed.



Parker 1988 (Continued)

Notes

Risk of bias





Puder 1988

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, one month.



Sex: 49F, 20 M

Mean age = 52.7 (s.d. 14.4)

Source = community



Interventions ”Cognitive Behaviour Therapy“

”waiting list“

Outcomes Primary Pain Outcome: pain diary

Primary Disability Outcome: pain interference


Pain diary 0-5: highest and lowest ratings

Pain interference 0-5

Coping 0-5

Medication use


Risk of bias






Puder 1988 (Continued)


Radojevic 1992

Methods RCT. Four arms. Assessed at pre-treatment, post-treatment, two months.



Sex: 45F, 14M





Interventions ”cognitive behavior therapy with family“

”cognitive behavior therapy“ (CBT)

”education with family support“ (Active Control)

”waiting list“


Primary Disability Outcome: AIMS physical disability (Reversed)

Primary Mood Outcome: AIMS psychological disability


Arthritis Impact Measurement Scale (AIMS): physical disability

Arthritis Impact Measurement Scale (AIMS): psychological disability


Pain Management Inventory

Joint examination

Notes CBT vs Active, post-treatment: analyses 1.1, 1.2, 1.3

CBT vs TAU, post-treatment: analyses 3.1, 3.2, 3.3

Risk of bias







Redondo 2004

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, six months, one year.

Participants End of treatment n= 31


Sex: 40F, 0M





Interventions ”Cognitive Behavioural Therapy“

”physical exercise“

Outcomes Primary Pain Outcome: SF36 pain



tender point score

Fibromyalgia Impact Questionnaire (FIQ)

Short Form 36: physical role

Short Form 36: pain

Short Form 36: general health

Short Form 36: vitality

Short Form 36: social function

Short Form 36: emotional role

Short Form 36: mental health

Short Form 36: health change

Beck Depression Index

Beck Anxiety Inventory (BAI)

Arthritis Self Efficacy Scale pain management, physical function, symptoms

Chronic Pain Coping Inventory

functional capacity upper limb, lower limb, vertebral column

aerobic exercise capacity


Risk of bias







Smeets 2006

Methods RCT. Four arms. Assessed at pre-treatment, post-treatment.



Sex: 106F, 117M

Mean age = 41.6 (s.d. 10.0)


Diagnosis = CLBP

Mean years of pain = 4/6

Interventions ”Cognitive Behavioural Therapy + active physical treatment“

”Cognitive Behavioural Therapy“

”active physical treatment“

”waiting list“




Roland Morris Disability Questionnaire disability

Difficulty with 3 most limited activities: 0-100



Pain Cognitions List: catastrophizing, pain control subscales.

Notes

Risk of bias





Spence 1989

Methods RCT. Three arms. Assessed at pre-treatment, post-treatment, six months, two years.



Sex: 44F, 1M


Source = volunteer



Spence 1989 (Continued)

Diagnosis = chronic pain upper limb

Mean years of pain not given

Interventions ”group Cognitive Behavioural Therapy“

”individual Cognitive Behavioural Therapy“

”waiting list“


Primary Disability Outcome: SIP self rated


Pain Rating: Diary

Multidimensional Pain Questionnaire: Pain Rating Index

Interference: Diary

Distress: Diary


State Trait Anxiety Inventory

Sickness Impact Profile: Self

Sickness Impact Profile: Other-rated

Coping Strategies Questionnaire: modified


Risk of bias





Strauss 1986




Sex: 46F, 11M

Mean age = 54.0 (s.d. 13.0)

Source = rheumatology clinic


Mean years of pain not given



Strauss 1986 (Continued)

Interventions ”group psychotherapy“

”relaxation/assertion“

”no treatment“




4 aggregate outcome measures:functional status, social adaptation, psychological adaptation, psychological symptoms.

Measures contributing to these:Arthritis Impact Measurement Scale (AIMS)

Short Form 36

Rathus Assertive Behavior Scale

Rosenberg Self-Esteem Scale

Hostility Inventory

Wright’s Human Service Scale & Handicap Problems Inventory

Notes

Risk of bias





Strong 1998




Sex: not given

Mean age = 44.4 (s.d. 13.7)


Diagnosis = CLBP


Interventions ”CBT psychoeducation + usual management“

”placebo attention + usual management“



Strong 1998 (Continued)

Outcomes Primary Pain Outcome: MPI pain severity



3 factors derived from measures: illness behaviour, depressive/negative thinking, using pain strate-

gies

Contributing measures:Box pain scale

Pain Disability Index

Coping Strategies Questionnaire: multiple subscales

Survey of Pain Attitudes Revised: multiple subscales

Illness Behavior Questionnaire: several subscales

Notes CBT vs Active, post-treatment: analysis 1.3

Risk of bias





Thieme 2003

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, six months, 15 months.



Sex: 61F, 0M

Mean age = 47.3 (s.d. 8.3)

Source = hospital for rheumatic disorders



Interventions ”operant treatment“

”standard physical treatment“

Outcomes Primary Pain Outcome: MPI pain

Primary Disability Outcome: MPI interference


Diary pain intensity

Multidimensional Pain Inventory: pain



Thieme 2003 (Continued)


Multidimensional Pain Inventory: life control

Multidimensional Pain Inventory: affective distress

Multidimensional Pain Inventory: social support

Multidimensional Pain Inventory: self-efficacy

Multidimensional Pain Inventory: punishing responses, solicitous responses, distracting re-

sponses

Multidimensional Pain Inventory: total activities

doctor visits (from medical records)

hospital days (from medical records)

sleep hours diary

medication diary

Tubingen pain behaviour scale

Notes BT vs TAU, post-treatment and follow-up: analyses 7.1, 7.2, 7.3, 8.1, 8.2, 8.3

Risk of bias





Turner 1988




Sex: 30F, 51M



Diagnosis = CLBP


Interventions ”CBT“

”operant behavior therapy“

”waiting list“



Turner 1988 (Continued)


Primary Disability Outcome: SIP patient-rated


Multidimensional Pain Questionnaire: Pain Response Index

Sickness Impact Profile: patient-rated

Sickness Impact Profile: spouse-rated


Pain Behavior Checklist patient-rated

Pain Behavior Checklist spouse-rated

Cognitive Errors Questionnaire

Notes CBT vs TAU, post-treatment (waiting list not followed up): analyses 3.1, 3.2

BT vs TAU, post-treatment (waiting list not followed up):

analyses 7.1, 7.2

Risk of bias





Turner 1990

Methods RCT. Four arms. Assessed at pre-treatment, post-treatment, six months, one year.



Sex: 46F, 50M


Source = community

Diagnosis = CLBP


Interventions ”behavior therapy + aerobic exercise“

”behavior therapy“ (BT)

”aerobic exercise“ (Active Control)

”waiting list“






Primary Mood Outcome: CES-D depression

Multidimensional Pain Questionnaire: Pain Response Index


Sickness Impact Profile: spouse-rated

Pain Behavior CheckList patient-rated

Pain Behavior CheckList spouse-rated


Observed Pain Behaviour

Visual Analogue Scale pain spouse-rated

Strength

Flexibility

Pain Ways of Coping -150

Notes BT vs Active, post-treatment and follow-up: analyses 5.1, 5.2, 5.3, 6.1, 6.2, 6.3

BT vs TAU, post-treatment (waiting list not followed up): analyses 7.1, 7.2, 7.3

Risk of bias





Turner 1993

Methods RCT. Four arms. Assessed at pre-treatment, post-treatment, 6 months, one year.



Sex: 55F, 47M

Mean age = 42 (s.d. not given)

Source = pain or rehabilitation clinic, volunteer

Diagnosis = CLBP


Interventions ”cognitive therapy + relaxation“ (CBT)

”cognitive therapy“

”relaxation“ (BT)

”waiting list“







Visual Analogue Scale (VAS) Pain



Cognitive Errors Questionnaire


Notes CBT vs TAU, post-treatment (waiting list not followed up): analyses 3.1, 3.2, 3.3

BT vs TAU, post-treatment (waiting list not followed up): analyses 7.1, 7.2, 7.3

Risk of bias





Turner 2006

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, 6 months, one year.



Sex: 128F, 30M

Mean age = 37.4 (s.d. 11.3)


Diagnosis = temporomandibular joint pain


Interventions ”brief CBT: Pain Management Training“

”education/attention control: Self care control“

Outcomes Primary Pain Outcome: Graded Chronic Pain Scale: Pain Intensity



Graded Chronic Pain Scale: Activity Interference

Graded Chronic Pain Scale: Pain Intensity


Mandibular Function Impairment Questionnaire (MFIQ)




Survey of Pain Attitudes (SOPA)

TMD Self efficacy scale

CSQ catastrophizing subscale

Pain Catastrophizing Scale rumination subscale

Chronic Pain Coping Inventory (CPCI) task persistence, coping self-statements, relaxation,

rest

Notes CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.3, 2.1, 2.3

Risk of bias





Turner-Stokes 2003

Methods RCT. Two arms. Assessed at pre-treatment, post-treatment, 6 months, one year.



Sex: 87F, 39M





Interventions ”group programme“

”individual programme“

Outcomes Primary Pain Outcome: none available



McGill Pain Questionnaire

Multidimensional Pain Inventory (MPI)


State Trait Anxiety Index (STAI)

analgesic consumption

Notes



Turner-Stokes 2003 (Continued)

Risk of bias





Vlaeyen 1995

Methods RCT. Four arms. Assessed at pre-treatment, post-treatment, 6 months, one year.



Sex: 53F, 18M



Diagnosis = CLBP


Interventions ”cognitive treatment“

”operant treatment“

”respondent treatment“

”waiting list“



Primary Mood Outcome: BDI (data not available)

Visual Analogue Scale: pain

Behavioural Approach Test (BAT)

Checklist for interpersonal pain behaviour (CHIP)

Pain Cognition List (PCL)

walking distance, walk time


Notes CBT vs TAU, post-treatment (waiting list not followed up): analysis 3.1

BT vs TAU, post-treatment (waiting list not followed up): analysis 7.1

Risk of bias




Vlaeyen 1995 (Continued)




Vlaeyen 1996

Methods RCT. Three arms. Assessed at pre-treatment, post-treatment, 6 months, one year.



Sex: 110F, 15M

Mean age = 44.0 (s.d. 9.4)




Interventions ”cognitive + group discussion“

”education + group discussion“

”waiting list“

Outcomes Primary Pain Outcome: pain intensity score



Composite scores from factor analysis:Pain intensity, pain coping, pain control, relaxation, catastrophizing, pain behaviour, activ-

ity

Measures contributing to factors:Multidimensional Pain Questionnaire: Pain Response Index

Coping Strategies Questionnaire (CSQ)

Beck Depression Inventory (BDI) (none available)

Fear Survey Schedule

Arthritis knowledge

Maudsley Obsessive Compulsive Inventory

Pain behaviour scale

Multidimensional Pain Locus of Control Scale (MPCL)

Walking distance, walking time, cycling time

Notes CBT vs Active, post-treatment: analyses 1.1, 1.3

CBT vs TAU, post-treatment: analyses 3.1, 3.3

Risk of bias



Vlaeyen 1996 (Continued)





Williams 1996

Methods RCT. Three arms. Assessed at pre-treatment, post-treatment, 6 months, one year.



Sex: 68F, 53M

Mean age = 50.0 (s.d. 11.5)


Diagnosis = mixed chronic pain, low back commonest


Interventions ”inpatient CBT“

”outpatient CBT“

”waiting list“




Visual Analogue Scale (VAS): pain intensity

Visual Analogue Scale (VAS): pain distress

Sickness Impact Profile (SIP): patient-rated


State-Trait Anxiety Inventory (STAI)

Coping Strategies Questionnaire (CSQ): catastrophizing

Pain Self-Efficacy Questionnaire (PSEQ)

Pain Cognitions Questionnaire (PCQ)

walk distance

arm endurance

stair climb

standups

medication use

health care use

Notes CBT vs TAU, post-treatment (waiting list not followed up): analyses 3.1, 3.2, 3.3



Williams 1996 (Continued)

Risk of bias





Characteristics of excluded studies [ordered by study ID]

Alaranta 1994 Insufficient psychotherapeutic content

Appelbaum 1988 Inadequate n: The number of patients in any treatment arm was less than 10

Asenlof 2005 Not chronic pain

Bendix 1997 Insufficient psychotherapeutic content

Broderick 2004 Insufficient psychotherapeutic content

Brox 2003 Insufficient psychotherapeutic content

Corrado 2003 No primary psychological treatment for pain or non psychological comparator

Currie 2000 No primary psychological treatment for pain or non psychological comparator

Dahl 2004 Inadequate n: The number of patients in any treatment arm was less than 10

Dalton 2004 Not chronic pain

Dworkin 2002a Insufficient psychotherapeutic content

Edinger 2005 No primary psychological treatment for pain or non psychological comparator

Evans 2003 Not chronic pain

Fors 2000 Insufficient psychotherapeutic content



(Continued)

Haugstad 2006 Insufficient psychotherapeutic content

Keefe 2004 No primary psychological treatment for pain or non psychological comparator

Keller 2004 Insufficient psychotherapeutic content

Kerns 1986 Inadequate n: The number of patients in any treatment arm was less than 10

Linton 1984 Inadequate n: The number of patients in any treatment arm was less than 10

Linton 1985 Inadequate n: The number of patients in any treatment arm was less than 10

Linton 2001 Not chronic pain

Linton 2005 Not chronic pain

Moffett 2005 Insufficient psychotherapeutic content

Moore 2000 Not chronic pain

Nicholas 1991 Inadequate n: The number of patients in any treatment arm was less than 10

Nicholas 1992 Inadequate n: The number of patients in any treatment arm was less than 10

Parker 2003 No primary psychological treatment for pain or non psychological comparator

Peters 1990 Inadequate n: The number of patients in any treatment arm was less than 10

Schweikert 2006 Insufficient psychotherapeutic content

Sharpe 2001 Not chronic pain

Soderlund 2001 Insufficient psychotherapeutic content

Spence 1995 Insufficient psychotherapeutic content

Turner 1982 Inadequate n: The number of patients in any treatment arm was less than 10

Van den Hout 2003 Not chronic pain

Van Lankveld 2004 No primary psychological treatment for pain or non psychological comparator



Characteristics of studies awaiting classification [ordered by study ID]

Babu 2007

Methods Not yet assessed

Participants Diagnosis = Fibromyalgia

Other details of participants not yet assessed

Interventions ”EMG Biofeedback“

”Sham Biofeedback“

Outcomes Not yet assessed

Notes New study

Change data only

Bliokas 2007


Participants Diagnosis = Mixed chronic pain


Interventions ”Graded exposure in vivo and outpatient multidisciplinary chronic Pain management group program“

”outpatient multidisciplinary chronic Pain management group program“

”Waiting list control“


Notes New study

Ersek 2008


Participants Diagnosis = Mixed sample older adults


Interventions ”pain self-management training group (SMG) intervention“

”education only control condition“


Notes New study



Leeuw 2008


Participants Diagnosis = Chronic Low Back Pain (CLBP)


Interventions ”Exposure in vivo“

”Operant graded activity“


Notes New study

Linton 2008


Participants Diagnosis = spinal pain


Interventions ”exposure plus usual treatment“

”waiting list control plus usual treatment“


Notes New study

Lorig 2008


Participants Diagnosis = rheumatoid arthritis, osteoarthritis, or fibromyalgia


Interventions ”Internet-based Arthritis Self-Management Program (ASMP)“

”Usual care“


Notes New study



Morone 2008




Interventions ”Mindfulness Meditation“

”Wait-list control“


Notes New study

Smeets 2008




Interventions ”active physical treatment; APT“

”graded activity plus problem solving training; GAP“

”combination treatment; CT“


Notes New study

Woods 2008




Interventions ”graded in vivo exposure,“

”graded activity“

”Wait-list control“

Outcomes not yet assessed

Notes New study



Zautra 2008


Participants Diagnosis = Rheumatoid Arthritis


Interventions ”cognitive behavioral therapy for pain“

”mindfulness meditation and emotion regulation therapy“

”education-only group“

Outcomes not yet assessed

Notes New study



D A T A A N D A N A L Y S E S

Comparison 1. Cognitive behavioural vs active control post-treatment

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Pain 14 861 Std. Mean Difference (IV, Random, 95% CI) -0.14 [-0.33, 0.04]

2 Disability 12 728 Std. Mean Difference (IV, Random, 95% CI) -0.16 [-0.31, -0.02]

3 Mood 15 890 Std. Mean Difference (IV, Random, 95% CI) -0.11 [-0.29, 0.06]

Comparison 2. Cognitive behavioural vs active control follow-up


studies

No. of


1 Pain 12 935 Std. Mean Difference (IV, Random, 95% CI) -0.15 [-0.28, -0.02]

2 Disability 11 876 Std. Mean Difference (IV, Random, 95% CI) -0.21 [-0.36, -0.06]

3 Mood 12 934 Std. Mean Difference (IV, Random, 95% CI) -0.16 [-0.29, -0.03]

Comparison 3. Cognitive behavioural vs treatment as usual


studies

No. of



2 Disability 18 972 Std. Mean Difference (IV, Random, 95% CI) -0.08 [-0.27, 0.12]


Comparison 4. Cognitive behavioural vs treatment as usual follow-up


studies

No. of




3 Mood 9 684 Std. Mean Difference (IV, Random, 95% CI) -0.16 [-0.31, -0.01]



Comparison 5. Behavioural vs active control post-treatment


studies

No. of





Comparison 6. Behavioural vs active control follow-up


studies

No. of


1 Pain 1 39 Std. Mean Difference (IV, Random, 95% CI) 0.30 [-0.34, 0.93]



Comparison 7. Behavioural vs treatment as usual post-treatment


studies

No. of





Comparison 8. Behavioural vs treatment as usual follow-up


studies

No. of







Analysis 1.1. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 1 Pain.

Review: Psychological therapies for the management of chronic pain (excluding headache) in adults

Comparison: 1 Cognitive behavioural vs active control post-treatment

Outcome: 1 Pain

Study or subgroup CBT Active treatment control Std. Mean Difference Weight Std. Mean Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

Astin 2003 32 60.2 (17.7) 33 59.2 (18.7) 8.0 % 0.05 [ -0.43, 0.54 ]

Bradley 1987 16 3.05 (1.65) 18 3.79 (1.65) 5.2 % -0.44 [ -1.12, 0.24 ]

Cook 1998 11 2.9 (1.5) 10 4.8 (2.1) 3.3 % -1.01 [ -1.93, -0.09 ]

Ersek 2003 19 3.7 (1.6) 20 5.1 (1.9) 5.5 % -0.78 [ -1.43, -0.13 ]

Greco 2004 32 1.98 (0.87) 33 1.97 (0.91) 8.0 % 0.01 [ -0.48, 0.50 ]

Jensen 1997 29 42.5 (25.5) 25 41 (21.8) 7.1 % 0.06 [ -0.47, 0.60 ]

Kaapa 2006 59 3.3 (2.5) 61 3.4 (2.4) 10.6 % -0.04 [ -0.40, 0.32 ]

Keefe 1990 31 4.61 (1.73) 35 5.67 (1.65) 7.8 % -0.62 [ -1.12, -0.13 ]

Keefe 1996 28 4.21 (1.48) 27 5.22 (2.06) 7.1 % -0.56 [ -1.10, -0.02 ]

Kraaimaat 1995 24 14.8 (4.3) 28 15.4 (4.6) 7.0 % -0.13 [ -0.68, 0.41 ]

Radojevic 1992 15 5.17 (2.12) 15 5.3 (3.04) 4.9 % -0.05 [ -0.76, 0.67 ]

Redondo 2004 21 67 (19.5) 19 60.2 (14.8) 5.8 % 0.38 [ -0.24, 1.01 ]

Turner 2006 72 5.2 (1.9) 76 5.2 (2.1) 11.5 % 0.0 [ -0.32, 0.32 ]

Vlaeyen 1996 42 1 (1.8) 30 0.4 (1.8) 8.2 % 0.33 [ -0.14, 0.80 ]

Total (95% CI) 431 430 100.0 % -0.14 [ -0.33, 0.04 ]

Heterogeneity: Tau2 = 0.05; Chi2 = 22.68, df = 13 (P = 0.05); I2 =43%

Test for overall effect: Z = 1.52 (P = 0.13)

-2 -1 0 1 2

Favours experimental Favours control



Analysis 1.2. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 2 Disability.



Outcome: 2 Disability



Astin 2003 32 48.8 (15.4) 33 50.1 (18.3) 9.0 % -0.08 [ -0.56, 0.41 ]

Cook 1998 11 5.1 (3.5) 10 7.1 (3.6) 2.8 % -0.54 [ -1.42, 0.33 ]

Ersek 2003 19 61.3 (27) 20 57.6 (19.8) 5.4 % 0.15 [ -0.48, 0.78 ]

Greco 2004 32 47.82 (22.88) 33 50.87 (26.72) 9.0 % -0.12 [ -0.61, 0.37 ]

Hammond 2001 63 1.43 (1.8) 58 1.9 (2.18) 16.7 % -0.23 [ -0.59, 0.12 ]

Jensen 1997 29 37.9 (18.1) 25 42.2 (12.8) 7.4 % -0.27 [ -0.80, 0.27 ]

Kaapa 2006 59 20.9 (10.1) 61 21.6 (11.4) 16.7 % -0.06 [ -0.42, 0.29 ]

Keefe 1990 31 2.06 (1.29) 35 2.34 (1.28) 9.1 % -0.22 [ -0.70, 0.27 ]

Keefe 1996 28 1.72 (0.71) 27 1.53 (0.95) 7.6 % 0.22 [ -0.31, 0.75 ]

Kraaimaat 1995 24 5.8 (5.1) 28 10.1 (5.7) 6.6 % -0.78 [ -1.35, -0.21 ]

Radojevic 1992 15 12.27 (9.43) 15 14.72 (11.61) 4.1 % -0.23 [ -0.94, 0.49 ]

Redondo 2004 21 50.7 (20.6) 19 52.9 (19.3) 5.5 % -0.11 [ -0.73, 0.51 ]

Total (95% CI) 364 364 100.0 % -0.16 [ -0.31, -0.02 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 9.12, df = 11 (P = 0.61); I2 =0.0%


-2 -1 0 1 2




Analysis 1.3. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 3 Mood.



Outcome: 3 Mood



Astin 2003 31 13.1 (7.9) 33 14.3 (8.4) 7.5 % -0.15 [ -0.64, 0.35 ]

Bradley 1987 16 43.48 (31.43) 18 52.05 (31.45) 4.9 % -0.27 [ -0.94, 0.41 ]

Cook 1998 11 8.1 (4.8) 10 11.6 (6.7) 3.3 % -0.58 [ -1.46, 0.30 ]

Ersek 2003 19 7.6 (4.7) 20 8.8 (6.8) 5.4 % -0.20 [ -0.83, 0.43 ]

Greco 2004 32 14.86 (10.07) 33 16.52 (11.53) 7.6 % -0.15 [ -0.64, 0.34 ]

Jensen 1997 29 9 (6.7) 25 9.9 (6.8) 6.8 % -0.13 [ -0.67, 0.40 ]

Kaapa 2006 59 5.5 (5.5) 61 5.7 (5.2) 10.5 % -0.04 [ -0.40, 0.32 ]

Keefe 1990 31 2.59 (1.65) 35 2.09 (0.94) 7.6 % 0.37 [ -0.11, 0.86 ]

Keefe 1996 28 1.7 (0.97) 27 2.48 (1.57) 6.7 % -0.59 [ -1.13, -0.05 ]

Kraaimaat 1995 24 3.1 (3.5) 28 2.2 (2.9) 6.6 % 0.28 [ -0.27, 0.83 ]

Radojevic 1992 15 6.05 (3.33) 15 4.62 (3.64) 4.4 % 0.40 [ -0.32, 1.12 ]

Redondo 2004 21 15.4 (8.8) 19 16.8 (10.2) 5.5 % -0.14 [ -0.77, 0.48 ]

Strong 1998 15 -0.36 (0.89) 15 0.66 (0.76) 3.9 % -1.20 [ -1.99, -0.41 ]

Turner 2006 72 8.8 (9.3) 76 11 (10.6) 11.4 % -0.22 [ -0.54, 0.10 ]

Vlaeyen 1996 42 13.4 (5.8) 30 11.9 (5.8) 7.9 % 0.26 [ -0.21, 0.73 ]

Total (95% CI) 445 445 100.0 % -0.11 [ -0.29, 0.06 ]



-2 -1 0 1 2




Analysis 2.1. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 1 Pain.


Comparison: 2 Cognitive behavioural vs active control follow-up

Outcome: 1 Pain

Study or subgroup Experimental Control Std. Mean Difference Weight Std. Mean Difference


Astin 2003 32 58.4 (22.2) 33 57.6 (22.5) 7.0 % 0.04 [ -0.45, 0.52 ]

Bradley 1987 16 3.61 (2.23) 18 3.78 (2.24) 3.7 % -0.07 [ -0.75, 0.60 ]

Cook 1998 11 4.9 (2) 10 5.9 (2.5) 2.2 % -0.43 [ -1.29, 0.44 ]

Ersek 2003 19 4.2 (2.1) 20 5.1 (2.4) 4.1 % -0.39 [ -1.02, 0.24 ]

Greco 2004 32 2.05 (0.94) 33 1.87 (0.95) 7.0 % 0.19 [ -0.30, 0.68 ]

Jensen 1997 29 46.1 (19.8) 25 48.7 (28.3) 5.8 % -0.11 [ -0.64, 0.43 ]

Kaapa 2006 53 3.3 (2.5) 54 3.4 (2.5) 11.6 % -0.04 [ -0.42, 0.34 ]

Keefe 1990 30 5.22 (2.08) 35 5.91 (1.95) 6.9 % -0.34 [ -0.83, 0.15 ]

Kraaimaat 1995 24 14.7 (4.7) 28 16.6 (4.6) 5.5 % -0.40 [ -0.95, 0.15 ]

McCarberg 1999 113 3.63 (1.36) 132 3.79 (1.39) 26.3 % -0.12 [ -0.37, 0.14 ]

Redondo 2004 21 66.2 (30.7) 19 65.7 (24.2) 4.3 % 0.02 [ -0.60, 0.64 ]

Turner 2006 72 3.9 (2.6) 76 4.7 (2.3) 15.8 % -0.32 [ -0.65, 0.00 ]

Total (95% CI) 452 483 100.0 % -0.15 [ -0.28, -0.02 ]



-2 -1 0 1 2




Analysis 2.2. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 2 Disability.




Study or subgroup CBT Active control Std. Mean Difference Weight Std. Mean Difference


Astin 2003 32 46.4 (29.5) 33 50 (18.2) 8.2 % -0.15 [ -0.63, 0.34 ]

Cook 1998 11 5.8 (2.9) 10 8.9 (3.6) 2.6 % -0.92 [ -1.83, -0.01 ]

Ersek 2003 19 61.6 (19) 20 57 (23.7) 5.2 % 0.21 [ -0.42, 0.84 ]

Greco 2004 32 49.52 (25.53) 33 49.78 (23.86) 8.3 % -0.01 [ -0.50, 0.48 ]

Hammond 2001 63 1.33 (1.82) 60 2.13 (2.46) 13.8 % -0.37 [ -0.73, -0.01 ]

Jensen 1997 29 45.6 (16.2) 25 46.7 (14.5) 7.0 % -0.07 [ -0.61, 0.46 ]

Kaapa 2006 53 18.9 (12.8) 54 18.5 (12.4) 12.5 % 0.03 [ -0.35, 0.41 ]

Keefe 1990 30 1.69 (1.16) 35 2.63 (1.5) 7.8 % -0.69 [ -1.19, -0.18 ]

Kraaimaat 1995 24 8.1 (5.6) 28 10.1 (6.6) 6.7 % -0.32 [ -0.87, 0.23 ]

McCarberg 1999 113 3.62 (1.36) 132 3.81 (1.36) 22.7 % -0.14 [ -0.39, 0.11 ]

Redondo 2004 21 47.8 (18.4) 19 56.1 (18.4) 5.2 % -0.44 [ -1.07, 0.19 ]

Total (95% CI) 427 449 100.0 % -0.21 [ -0.36, -0.06 ]



-2 -1 0 1 2




Analysis 2.3. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 3 Mood.



Outcome: 3 Mood

Study or subgroup CBT Active control Std. Mean Difference Weight Std. Mean Difference


Astin 2003 31 12.3 (7.6) 33 14 (9.2) 6.9 % -0.20 [ -0.69, 0.29 ]

Bradley 1987 16 55.06 (30.93) 18 70.03 (30.95) 3.5 % -0.47 [ -1.16, 0.21 ]

Cook 1998 11 8.3 (3.5) 10 11 (7) 2.2 % -0.48 [ -1.35, 0.40 ]

Ersek 2003 19 8 (5.3) 20 9.6 (6.5) 4.2 % -0.26 [ -0.89, 0.37 ]

Greco 2004 32 15.01 (10.5) 33 14.17 (11.64) 7.0 % 0.07 [ -0.41, 0.56 ]

Jensen 1997 29 10.1 (6.8) 25 10.1 (8.9) 5.8 % 0.0 [ -0.53, 0.53 ]

Kaapa 2006 53 5.7 (4.6) 54 5.8 (5.7) 11.6 % -0.02 [ -0.40, 0.36 ]

Keefe 1990 30 2.51 (1.33) 35 2.92 (1.94) 6.9 % -0.24 [ -0.73, 0.25 ]

Kraaimaat 1995 24 3.3 (3.4) 28 4 (4.2) 5.6 % -0.18 [ -0.73, 0.37 ]

McCarberg 1999 113 3.63 (1.37) 132 3.79 (1.25) 26.3 % -0.12 [ -0.37, 0.13 ]

Redondo 2004 21 13 (8) 19 13.6 (11.7) 4.3 % -0.06 [ -0.68, 0.56 ]

Turner 2006 72 8.3 (9.1) 76 11.4 (10.1) 15.8 % -0.32 [ -0.64, 0.00 ]

Total (95% CI) 451 483 100.0 % -0.16 [ -0.29, -0.03 ]



-2 -1 0 1 2




Analysis 3.1. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 1 Pain.


Comparison: 3 Cognitive behavioural vs treatment as usual

Outcome: 1 Pain

Study or subgroup CBT usual treatment/waitlist Std. Mean Difference Weight Std. Mean Difference


Altmaier 1992 21 2.05 (0.74) 21 2 (0.89) 3.9 % 0.06 [ -0.55, 0.66 ]

Basler 1997 36 4.08 (2.11) 40 4.18 (1.37) 6.0 % -0.06 [ -0.51, 0.39 ]

Becker 2000 49 52 (24) 42 65 (24) 6.5 % -0.54 [ -0.96, -0.12 ]

Buhrman 2004 22 2.4 (1.1) 29 3.2 (0.8) 4.1 % -0.84 [ -1.42, -0.26 ]

Carson 2005 18 4.86 (1.88) 25 5.14 (2.04) 3.8 % -0.14 [ -0.75, 0.47 ]

Evers 2002 30 14.93 (5.32) 29 15.35 (4.55) 5.0 % -0.08 [ -0.59, 0.43 ]

Flor 1993 26 2.32 (1.37) 26 2.52 (1.5) 4.5 % -0.14 [ -0.68, 0.41 ]

Greco 2004 32 1.98 (0.87) 27 1.65 (0.89) 4.9 % 0.37 [ -0.15, 0.89 ]

Jensen 2001 49 70.2 (11.75) 48 71.48 (15.72) 7.0 % -0.09 [ -0.49, 0.31 ]

Johansson 1998 18 49.3 (21.9) 19 51.2 (21.9) 3.5 % -0.08 [ -0.73, 0.56 ]

Keefe 1990 31 4.61 (1.73) 28 5.68 (1.62) 4.8 % -0.63 [ -1.15, -0.10 ]

Kraaimaat 1995 24 14.8 (4.3) 19 14.6 (4.4) 3.9 % 0.05 [ -0.56, 0.65 ]

Mishra 2000 24 42.5 (15.11) 25 42.53 (23.56) 4.3 % 0.00 [ -0.56, 0.56 ]

Moore 1985 11 4.73 (1.85) 12 6.5 (1.83) 2.1 % -0.93 [ -1.80, -0.06 ]

Newton-John 1995 16 10.38 (11.37) 12 17.56 (9.05) 2.6 % -0.67 [ -1.44, 0.10 ]

Puder 1988 31 3.19 (0.89) 38 3.26 (0.66) 5.5 % -0.09 [ -0.56, 0.38 ]

Radojevic 1992 15 5.17 (2.12) 15 5.5 (2.38) 2.9 % -0.14 [ -0.86, 0.57 ]

Spence 1989 12 23.17 (13.73) 14 23.29 (11.28) 2.6 % -0.01 [ -0.78, 0.76 ]

Turner 1988 24 15.91 (11.63) 21 22.14 (12.35) 3.9 % -0.51 [ -1.11, 0.08 ]

Turner 1993 21 44.33 (28.45) 18 48.06 (20.97) 3.6 % -0.14 [ -0.77, 0.49 ]

Vlaeyen 1995 18 63.17 (22.14) 13 68.39 (15.98) 2.9 % -0.26 [ -0.97, 0.46 ]

Vlaeyen 1996 42 1 (1.8) 39 0.4 (1.8) 6.2 % 0.33 [ -0.11, 0.77 ]

Williams 1996 38 60 (21.7) 31 68.1 (20.7) 5.5 % -0.38 [ -0.86, 0.10 ]

Total (95% CI) 608 591 100.0 % -0.19 [ -0.32, -0.05 ]



-2 -1 0 1 2




Analysis 3.2. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 2 Disability.






Altmaier 1992 21 57.43 (15.06) 21 57.67 (16.37) 5.2 % -0.01 [ -0.62, 0.59 ]

Basler 1997 36 1.63 (0.87) 40 1.84 (0.62) 6.6 % -0.28 [ -0.73, 0.17 ]

Becker 2000 49 49 (26) 42 51 (24) 7.1 % -0.08 [ -0.49, 0.33 ]

Buhrman 2004 22 3.2 (1.4) 29 3.5 (1.2) 5.6 % -0.23 [ -0.79, 0.33 ]

Evers 2002 30 2.46 (0.47) 29 2.4 (0.38) 6.0 % 0.14 [ -0.37, 0.65 ]

Flor 1993 26 1.7 (1.27) 26 2.03 (1.46) 5.7 % -0.24 [ -0.78, 0.31 ]

Greco 2004 32 47.82 (22.88) 27 39.02 (25.63) 6.0 % 0.36 [ -0.16, 0.88 ]

Jensen 2001 49 44.16 (16.31) 48 41.82 (19.55) 7.2 % 0.13 [ -0.27, 0.53 ]

Johansson 1998 18 3 (0.7) 19 2.6 (0.7) 4.7 % 0.56 [ -0.10, 1.22 ]

Keefe 1990 31 2.06 (1.29) 28 1.96 (1.26) 6.0 % 0.08 [ -0.43, 0.59 ]

Kraaimaat 1995 24 22.2 (5.1) 19 19.5 (6.6) 5.1 % 0.46 [ -0.15, 1.07 ]

Newton-John 1995 16 2.86 (0.89) 12 2.4 (0.86) 4.0 % 0.51 [ -0.25, 1.27 ]

Puder 1988 31 2.62 (0.81) 38 2.97 (0.68) 6.3 % -0.47 [ -0.95, 0.01 ]

Radojevic 1992 15 12.27 (9.43) 15 16.24 (9.68) 4.2 % -0.40 [ -1.13, 0.32 ]

Spence 1989 12 15.79 (8.89) 14 18.83 (7.79) 3.9 % -0.35 [ -1.13, 0.42 ]

Turner 1988 24 5.39 (3.91) 21 5.75 (6.9) 5.3 % -0.06 [ -0.65, 0.52 ]

Turner 1993 21 9.53 (8.22) 18 9.64 (7.32) 5.0 % -0.01 [ -0.64, 0.62 ]

Williams 1996 38 15.81 (11.2) 31 29.65 (10.82) 5.9 % -1.24 [ -1.76, -0.72 ]

Total (95% CI) 495 477 100.0 % -0.08 [ -0.27, 0.12 ]



-2 -1 0 1 2




Analysis 3.3. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 3 Mood.



Outcome: 3 Mood



Altmaier 1992 21 14.19 (5.61) 21 14 (5.92) 5.8 % 0.03 [ -0.57, 0.64 ]

Becker 2000 49 6.3 (5.2) 42 5.8 (5.6) 8.6 % 0.09 [ -0.32, 0.50 ]

Buhrman 2004 22 6 (4.7) 29 5.4 (4) 6.5 % 0.14 [ -0.42, 0.69 ]

Evers 2002 30 9.98 (4.62) 29 12.85 (7.87) 7.0 % -0.44 [ -0.96, 0.08 ]

Flor 1993 26 2.55 (1.2) 26 2.29 (1.02) 6.6 % 0.23 [ -0.32, 0.78 ]

Greco 2004 32 14.86 (10.07) 27 20.33 (14.14) 6.9 % -0.45 [ -0.97, 0.07 ]

Jensen 2001 49 36.68 (21.79) 48 34.67 (18.71) 8.9 % 0.10 [ -0.30, 0.50 ]

Keefe 1990 31 2.59 (1.65) 28 3.42 (1.8) 6.9 % -0.48 [ -0.99, 0.04 ]

Kraaimaat 1995 24 3.1 (3.5) 19 2.5 (2.5) 5.8 % 0.19 [ -0.41, 0.79 ]

Moore 1985 11 76.2 (18) 12 82.1 (14.4) 3.8 % -0.35 [ -1.18, 0.47 ]

Newton-John 1995 16 9.18 (7.67) 12 11.42 (5.21) 4.4 % -0.32 [ -1.08, 0.43 ]

Radojevic 1992 15 6.05 (3.33) 15 6.18 (3.58) 4.7 % -0.04 [ -0.75, 0.68 ]

Spence 1989 12 11.75 (9.1) 14 18.57 (9.42) 4.0 % -0.71 [ -1.51, 0.09 ]

Turner 1993 21 9.81 (6.5) 18 7.22 (4.87) 5.5 % 0.44 [ -0.20, 1.07 ]

Vlaeyen 1996 42 13.4 (5.8) 39 13.2 (5.8) 8.2 % 0.03 [ -0.40, 0.47 ]

Williams 1996 38 9.5 (7.8) 21 17.3 (7) 6.3 % -1.02 [ -1.59, -0.46 ]

Total (95% CI) 439 400 100.0 % -0.14 [ -0.32, 0.05 ]



-2 -1 0 1 2




Analysis 4.1. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 1 Pain.


Comparison: 4 Cognitive behavioural vs treatment as usual follow-up

Outcome: 1 Pain



Altmaier 1992 21 2.33 (0.8) 21 2 (0.95) 8.0 % 0.37 [ -0.24, 0.98 ]

Becker 2000 49 52 (24) 43 67 (19) 12.7 % -0.68 [ -1.10, -0.26 ]

Evers 2002 30 14.99 (5.12) 29 15.79 (4.98) 10.1 % -0.16 [ -0.67, 0.35 ]

Flor 1993 23 2.3 (1.36) 24 2.94 (1.45) 8.6 % -0.45 [ -1.03, 0.13 ]

Greco 2004 32 2.05 (0.94) 27 1.69 (1.15) 10.0 % 0.34 [ -0.17, 0.86 ]

Haldorsen 1998 93 48.2 (27.4) 94 52.1 (28.9) 17.9 % -0.14 [ -0.42, 0.15 ]

Jensen 2001 49 66.91 (16.09) 48 68.09 (19.41) 13.5 % -0.07 [ -0.46, 0.33 ]

Keefe 1990 30 5.22 (2.08) 28 5.64 (1.79) 10.0 % -0.21 [ -0.73, 0.30 ]

Kraaimaat 1995 24 14.7 (4.7) 28 15.9 (5.4) 9.3 % -0.23 [ -0.78, 0.31 ]

Total (95% CI) 351 342 100.0 % -0.15 [ -0.36, 0.05 ]



-2 -1 0 1 2




Analysis 4.2. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 2 Disability.






Flor 1993 23 1.6 (1.23) 24 2.47 (1.32) 9.3 % -0.67 [ -1.26, -0.08 ]

Becker 2000 49 48 (27) 42 54 (24) 17.8 % -0.23 [ -0.65, 0.18 ]

Keefe 1990 30 1.69 (1.16) 28 1.96 (1.43) 11.9 % -0.21 [ -0.72, 0.31 ]

Jensen 2001 49 41.88 (18.89) 48 41.57 (23.97) 19.0 % 0.01 [ -0.38, 0.41 ]

Altmaier 1992 21 52.19 (19.58) 21 50.71 (25.95) 8.9 % 0.06 [ -0.54, 0.67 ]

Evers 2002 30 2.42 (0.47) 29 2.37 (0.4) 12.2 % 0.11 [ -0.40, 0.62 ]

Kraaimaat 1995 24 19.9 (5.6) 19 18.8 (7.7) 8.9 % 0.16 [ -0.44, 0.77 ]

Greco 2004 32 49.52 (25.53) 27 43.05 (27.3) 12.0 % 0.24 [ -0.27, 0.76 ]

Total (95% CI) 258 238 100.0 % -0.06 [ -0.25, 0.12 ]



-2 -1 0 1 2




Analysis 4.3. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 3 Mood.



Outcome: 3 Mood



Altmaier 1992 21 16.24 (4.22) 21 15 (6.15) 6.2 % 0.23 [ -0.38, 0.84 ]

Becker 2000 49 6.1 (5.4) 43 6.4 (5) 13.5 % -0.06 [ -0.47, 0.35 ]

Evers 2002 30 9.51 (5.35) 29 13.07 (7.51) 8.4 % -0.54 [ -1.06, -0.02 ]

Flor 1993 23 2.52 (1.12) 24 2.89 (0.76) 6.8 % -0.38 [ -0.96, 0.20 ]

Greco 2004 32 15.01 (10.5) 27 16.99 (12.94) 8.6 % -0.17 [ -0.68, 0.35 ]

Haldorsen 1998 93 35.4 (10.3) 94 36.9 (9.9) 27.6 % -0.15 [ -0.43, 0.14 ]

Jensen 2001 49 39.19 (22.4) 48 37.71 (26.05) 14.3 % 0.06 [ -0.34, 0.46 ]

Keefe 1990 30 2.51 (1.33) 28 3.06 (1.52) 8.4 % -0.38 [ -0.90, 0.14 ]

Kraaimaat 1995 24 3.3 (3.4) 19 4.1 (3.8) 6.2 % -0.22 [ -0.82, 0.38 ]

Total (95% CI) 351 333 100.0 % -0.16 [ -0.31, -0.01 ]



-2 -1 0 1 2


Analysis 5.1. Comparison 5 Behavioural vs active control post-treatment, Outcome 1 Pain.


Comparison: 5 Behavioural vs active control post-treatment

Outcome: 1 Pain

Study or subgroup Behavioural treatment Active control Std. Mean Difference Weight Std. Mean Difference


Turner 1990 18 14.78 (11.44) 21 17.52 (10.2) 100.0 % -0.25 [ -0.88, 0.38 ]

Total (95% CI) 18 21 100.0 % -0.25 [ -0.88, 0.38 ]

Heterogeneity: not applicable


-2 -1 0 1 2




Analysis 5.2. Comparison 5 Behavioural vs active control post-treatment, Outcome 2 Disability.






Turner 1990 18 3.63 (2.98) 21 5.49 (6.79) 35.1 % -0.34 [ -0.97, 0.30 ]

Nicassio 1997 36 0.4 (0.08) 35 0.42 (0.08) 64.9 % -0.25 [ -0.71, 0.22 ]

Total (95% CI) 54 56 100.0 % -0.28 [ -0.66, 0.10 ]



-2 -1 0 1 2


Analysis 5.3. Comparison 5 Behavioural vs active control post-treatment, Outcome 3 Mood.



Outcome: 3 Mood



Nicassio 1997 36 15.47 (12.13) 35 20.69 (9.83) 60.5 % -0.47 [ -0.94, 0.00 ]

Turner 1990 18 7.36 (5.89) 21 7.38 (4.57) 39.5 % 0.00 [ -0.63, 0.63 ]

Total (95% CI) 54 56 100.0 % -0.28 [ -0.73, 0.16 ]



-2 -1 0 1 2




Analysis 6.1. Comparison 6 Behavioural vs active control follow-up, Outcome 1 Pain.


Comparison: 6 Behavioural vs active control follow-up

Outcome: 1 Pain



Turner 1990 18 18.21 (13.31) 21 14.94 (7.96) 100.0 % 0.30 [ -0.34, 0.93 ]

Total (95% CI) 18 21 100.0 % 0.30 [ -0.34, 0.93 ]

Heterogeneity: not applicable


-4 -2 0 2 4


Analysis 6.2. Comparison 6 Behavioural vs active control follow-up, Outcome 2 Disability.






Nicassio 1997 36 0.4 (0.11) 35 0.42 (0.09) 64.6 % -0.20 [ -0.66, 0.27 ]

Turner 1990 18 4.75 (3.4) 21 4.73 (7.85) 35.4 % 0.00 [ -0.63, 0.63 ]

Total (95% CI) 54 56 100.0 % -0.13 [ -0.50, 0.25 ]



-2 -1 0 1 2




Analysis 6.3. Comparison 6 Behavioural vs active control follow-up, Outcome 3 Mood.



Outcome: 3 Mood



Nicassio 1997 36 13.7 (10.06) 35 17.72 (11.32) 60.9 % -0.37 [ -0.84, 0.10 ]

Turner 1990 18 10 (7.57) 21 9.31 (7.73) 39.1 % 0.09 [ -0.54, 0.72 ]

Total (95% CI) 54 56 100.0 % -0.19 [ -0.63, 0.25 ]



-2 -1 0 1 2


Analysis 7.1. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 1 Pain.


Comparison: 7 Behavioural vs treatment as usual post-treatment

Outcome: 1 Pain



Flor 1993 26 1.85 (1.027) 26 2.524 (1.5) 12.0 % -0.52 [ -1.07, 0.04 ]

Jensen 2001 54 69.25 (15.22) 48 71.75 (15.72) 14.1 % -0.16 [ -0.55, 0.23 ]

Mishra 2000 23 40 (22.25) 25 42.53 (23.56) 11.8 % -0.11 [ -0.68, 0.46 ]

Newton-John 1995 16 8.42 (6.05) 12 17.56 (9.05) 8.9 % -1.19 [ -2.01, -0.37 ]

Thieme 2003 40 3.82 (0.96) 21 5.47 (1.06) 11.3 % -1.64 [ -2.24, -1.03 ]

Turner 1988 17 37.88 (20.07) 18 48.06 (12.35) 10.4 % -0.60 [ -1.28, 0.08 ]

Turner 1990 18 14.78 (11.44) 19 20.95 (10.62) 10.7 % -0.55 [ -1.21, 0.11 ]

Turner 1993 17 37.88 (20.07) 18 48.06 (20.97) 10.5 % -0.48 [ -1.16, 0.19 ]

Vlaeyen 1995 19 71.32 (20.9) 13 68.39 (15.98) 10.1 % 0.15 [ -0.56, 0.86 ]

Total (95% CI) 230 200 100.0 % -0.55 [ -0.90, -0.19 ]



-2 -1 0 1 2




Analysis 7.2. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 2 Disability.






Flor 1993 40 1.73 (0.84) 21 2.03 (1.47) 14.9 % -0.27 [ -0.80, 0.26 ]

Jensen 2001 54 43.71 (20.53) 48 41.82 (19.55) 16.0 % 0.09 [ -0.30, 0.48 ]

Newton-John 1995 16 2.76 (0.91) 12 2.4 (0.86) 13.0 % 0.39 [ -0.36, 1.15 ]

Thieme 2003 40 3.29 (1.02) 21 5.28 (0.86) 14.0 % -2.03 [ -2.67, -1.38 ]

Turner 1988 29 3.96 (4.7) 21 5.74 (6.9) 14.6 % -0.31 [ -0.87, 0.26 ]

Turner 1990 18 3.63 (2.98) 19 5.37 (5.93) 13.9 % -0.36 [ -1.01, 0.29 ]

Turner 1993 17 4.75 (3.97) 18 9.64 (7.32) 13.6 % -0.80 [ -1.50, -0.11 ]

Total (95% CI) 214 160 100.0 % -0.46 [ -1.00, 0.08 ]

Heterogeneity: Tau2 = 0.44; Chi2 = 36.36, df = 6 (P<0.00001); I2 =83%


-2 -1 0 1 2




Analysis 7.3. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 3 Mood.



Outcome: 3 Mood



Flor 1993 40 2.11 (1.31) 21 2.29 (1.02) 17.0 % -0.15 [ -0.67, 0.38 ]

Jensen 2001 54 38.94 (19.67) 48 34.67 (18.71) 18.3 % 0.22 [ -0.17, 0.61 ]

Newton-John 1995 40 6.18 (4.87) 21 11.42 (5.21) 16.7 % -1.04 [ -1.60, -0.48 ]

Thieme 2003 40 2.54 (1.03) 21 4.46 (1.48) 16.3 % -1.58 [ -2.18, -0.98 ]

Turner 1990 18 7.36 (5.89) 19 7.03 (5.02) 15.9 % 0.06 [ -0.59, 0.70 ]

Turner 1993 17 6.24 (3.36) 18 7.22 (4.87) 15.7 % -0.23 [ -0.89, 0.44 ]

Total (95% CI) 209 148 100.0 % -0.44 [ -1.01, 0.13 ]



-2 -1 0 1 2


Analysis 8.1. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 1 Pain.


Comparison: 8 Behavioural vs treatment as usual follow-up

Outcome: 1 Pain



Flor 1993 26 1.8 (1.26) 24 2.94 (1.45) 28.0 % -0.83 [ -1.41, -0.25 ]

Jensen 2001 54 67.1 (20.48) 48 68.09 (19.41) 37.3 % -0.05 [ -0.44, 0.34 ]

Thieme 2003 40 3.66 (182) 40 4.85 (0.86) 34.7 % -0.01 [ -0.45, 0.43 ]

Total (95% CI) 120 112 100.0 % -0.25 [ -0.71, 0.20 ]



-2 -1 0 1 2




Analysis 8.2. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 2 Disability.






Flor 1993 24 1.42 (1.04) 24 2.47 (1.32) 32.7 % -0.87 [ -1.46, -0.27 ]

Jensen 2001 54 46.91 (21.77) 48 41.57 (23.97) 34.1 % 0.23 [ -0.16, 0.62 ]

Thieme 2003 40 2.96 (1.18) 40 4.83 (0.72) 33.2 % -1.89 [ -2.43, -1.36 ]

Total (95% CI) 118 112 100.0 % -0.83 [ -2.14, 0.47 ]



-2 -1 0 1 2


Analysis 8.3. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 3 Mood.



Outcome: 3 Mood



Flor 1993 24 1.65 (0.91) 24 2.89 (0.76) 32.0 % -1.45 [ -2.10, -0.81 ]

Jensen 2001 54 39.15 (22.56) 48 37.71 (26.05) 34.5 % 0.06 [ -0.33, 0.45 ]

Thieme 2003 40 2.38 (1.29) 40 4.47 (1.65) 33.6 % -1.40 [ -1.89, -0.91 ]

Total (95% CI) 118 112 100.0 % -0.91 [ -1.98, 0.16 ]



-2 -1 0 1 2




A P P E N D I C E S

Appendix 1. MEDLINE search strategy (via OVID)

1. PAIN explode all trees (MeSH)

2. (chronic* near pain*)

3. (#1 and (chronic* near pain*))

4. (chronic* near discomfort)

5. (chronic* near ache*)

6. (chronic* near fibromyalgia:ab)

7. (chronic* near fibromyalgia:ti)

8. (chronic* near neuralgi*:ab)

9. (chronic* near neuralgi*:ti)

10. (chronic* near dysmenorrhea:ti)

11. (chronic* near dysmenorrhea:ab)

12. (chronic* near dysmenorrhoea:ti)

13. (chronic* near dysmenorrhoea:ab)

14. (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13)

15. PSYCHOTHERAPY explode tree 1 (MeSH)

16. COGNITIVE THERAPY single term (MeSH)

17. BEHAVIOR THERAPY explode tree 1 (MeSH)

18. BIOFEEDBACK (PSYCHOLOGY) single term (MeSH)

19. ((behaviour* next therapy) or (behaviour* next therapies))

20. ((cognitive next therapy) or (cognitive next therapies))

21. (relax* near technique*)

22. ((relax* near therapy) or (relax* near therapies))

23. meditat*

24. psychotherap*

25. (psychological next treatment)

26. ((psychological next therapy) or (psychological next therapies))

27. (group next therapy)

28. (self-regulation next training)

29. (coping next skill*)

30. (pain-related next thought*)

31. (behaviour* near rehabilitat*)

32. (psychoeducation* next group)

33. (psychoeducation* next groups)

34. (psycho-education* next groups)

35. (psycho-education* next group)

36. (mind and (body next relaxation next technique*))

37. MIND-BODY AND RELAXATION TECHNIQUES explode tree 1 (MeSH)

38. (#15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32

or #33 or #34 or #35 or #36 or #37)

39. (#14 and #38)



H I S T O R Y

Protocol first published: Issue 4, 2008

Review first published: Issue 2, 2009

C O N T R I B U T I O N S O F A U T H O R S

CE oversaw the review and authoring of the manuscript, and authored sections of the manuscript. AW authored sections of the

manuscript and extracted data from papers. SM managed the review process, extracted data and advised on statistical strategy. All

authors contributed to conceptualisation of the review, selection of papers, and judging the quality of the studies.

D E C L A R A T I O N S O F I N T E R E S T

All authors have received research support from charities, government, and industry sources at various times. This review was supported

by a Department of Health Cochrane Incentive Grant that assisted authors in meeting costs. CE has consulted for various pharmaceutical

and associated companies related to the psychology of analgesic behaviour, and the measurement of patient outcomes in trials. No

direct or indirect industrial funding supported this study or its authors.

S O U R C E S O F S U P P O R T

Internal sources

• No sources of support supplied

External sources

• Department of Health, UK.

Incentive Scheme Grant

D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W

1. No data were available in the trials on adverse events, withdrawal, and escape or emergency analgesia.

2. No dichotomous outcomes were reported so no NNTs were calculated.

3. No adjustment for reliability of measures was made.

4. Planned sub-group analyses were not possible to undertake due to lack of data.



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