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

Amanda C de C Williams, Christopher Eccleston, Stephen Morley, Amanda C de C Williams, Christopher Eccleston, Stephen Morley

Abstract

Background: Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review.

Objectives: To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking.

Search methods: We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators.

Selection criteria: Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20.

Data collection and analysis: Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25.

Main results: Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post-treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow-up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

Authors' conclusions: Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.

Conflict of interest statement

Following discussions with the Cochrane Funding Arbiter in 2015/16, we have revised and expanded our declarations of interest to fully comply with the updated Cochrane Commercial Sponsorship Policy (see http://community‐archive.cochrane.org/organisational‐policy‐manual/appendix‐5‐commercial‐sponsorship‐policy).

ACdeCW: UCL London received payment from Astellas Pharma Europe for her to speak about the psychology of pain at a general pain meeting in 2015. She is an author of an included study but was not involved in the data extraction or ratings of bias and quality.

CE attended a meeting of IMMPACT in 2011, an organisation that develops outcome measures and consults on analgesic trial design. IMMPACT receives arm's length funding from numerous pharmacological, charitable, and Governmental bodies (including the FDA). Research funding unrelated to this study was received by the University of Bath Centre for Pain Research from Reckitt Benckiser Healthcare during this review production. Since CE is an author as well as the PaPaS Co‐ordinating Editor at the time of writing, we acknowledge the input of Andrew Moore who acted as Sign Off Editor for this review. CE had no input into the editorial decisions or processes for this review.

SJM: none known.