Review: limited evidence that psychological therapies are of benefit for adults with chronic pain.

Question: Are psychological therapies effective for improving pain, disability and mood in adults with chronic pain? Outcomes: Any measurement of pain, disability or mood. Methods Design: Systematic review with meta-analysis. Data sources: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and Psychlit (from database inception to January 2008; an update search was later made up to August 2008). Study selection and analysis: Published randomised controlled trials (RCTs) comparing any psychological treatment with placebo, waiting list control, or medical or physical treatment for adults (aged >18 years) with chronic pain (>=3 months' duration; any site of the body). Exclusions: pain associated with malignancy; chronic headache or migraine. Two reviewers independently assessed quality and included studies based on consensus agreement. Studies were classified as cognitive behavioural therapy (CBT) or behavioural therapy (BT) compared with active control (AC) or treatment as usual (TAU). Outcomes were assessed immediately post-treatment or at follow-up (between 6 and 12 months post-treatment). Heterogeneity was assessed using the x2and I2 statistic. Main results Forty studies (n = 4781) met the inclusion criteria. Fourteen studies were of treatments for low back pain; 14 included mixed groups of musculoskeletal pain, including low back pain; nine were for rheumatoid arthritis; six were for fibromyalgia; four for temporomandibular joint pain; two for osteoarthritis of the knee; one for upper limb pain; and one for shoulder pain. Follow-up was complete for between 53% and 100% of subjects with an overall completion rate of 84%. Mean sample size for each trial was 81 (mean 75% female), mean age 48.7 years and chronic pain had been present for a median 9.9 months. Quality of the trial improved significantly with publication date. CBT was not effective compared with AC immediately post-treatment for treating chronic pain or mood but had a small effect on disability (12 RCTs, 728 participants; standardised mean difference (SMD) -0.16, 95% CI -0.31 to -0.02; p<0.05). At follow-up, CBT reduced pain compared with AC (12 RCTs, 935 participants; SMD -0.15, 95% CI -0.28 to 0.02; p<0.05), improved mood (12 RCTs, 934 participants; SMD -0.16 (95% CI -0.29 to -0.03; p<0.05) and reduced disability (11 RCTs, 876 participants; SMD -0.21 (95% CI -0.36 to -0.06; p<0.05). CBT reduced pain compared with TAU immediately post-treatment (23 studies, 1199 participants; SMD -0.19, 95% CI -0.32 to -0.05; p<0.05) but did not improve mood or affect disability. At follow-up, CBT was no longer effective compared with TAU for pain or disability but had a small significant effect on mood (nine RCTs, 684 participants; SMD -0.16 (95% CI -0.31 to -0.01; p<0.05). BT did not significantly reduce pain compared with AC either immediately post-treatment or at follow-up, improve mood or affect disability. Compared with TAU, BT reduced pain immediately post-treatment (nine RCTs, 430 participants; SMD -0.55, 95% CI -0.90 to -0.19; p<0.05) but had no effect on disability. At follow-up, BT had no significant effects on any outcome compared with TAU. Conclusions CBT may have a weak effect in improving pain, mood and disability in adults with chronic pain. There is an absence of evidence for BT, except for pain immediately following treatment, compared with TAU.