Psychological therapies for the management of chronic pain (excluding headache) in adults Stable (no update expected for reasons given in 'What's new')
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.
Amanda C de C Williams, Christopher Eccleston, Stephen Morley
Plain language summary
Psychological therapy for adults with longstanding distressing pain and disability
Many people have pain that lasts for a long time, pain that is not relieved by drugs, surgery or physical therapy. The search for a diagnosis and for pain relief is often long, discouraging and even damaging. For some people, the pain leads to disability, depression, anxiety and social isolation. It is also associated with a tendency to experience much or all in life as ruined by pain, as a catastrophe that is impossible to control. These major life changes are not inevitable and are thought to be at least partly reversible using a treatment which aims to reduce disability and distress despite continuing pain. Treatment is based on robust psychological principles that have developed over 40 years of clinical use.
Our search found 42 trials of treatments which met our criteria, but only 35 provided data in a form that could be used. The two main types of psychological treatment are called cognitive behavioural therapy (CBT) and behaviour therapy. Both focus on helping people to change behaviour that maintains or worsens pain, disability, distress and catastrophic thinking; CBT also directly addresses the thoughts and feelings that are a problem for people with persistent pain. The effects of these two treatments on pain, disability, mood and catastrophic thinking were tested immediately after the treatment, and six months later.
Small to moderate benefits, more for disability, mood and catastrophic thinking than for pain, were found in trials which compared CBT with no treatment. Some of these were still positive six months later. Behaviour therapy showed few and only brief benefits. Psychological therapies can help people with chronic pain reduce negative mood (depression and anxiety), disability, catastrophic thinking, and in some cases, pain. Although the overall effect is positive, we do not know enough about exactly which type of treatment is best for which person.
Amanda C de C Williams, Christopher Eccleston, Stephen Morley
Implications for practice
Psychological interventions can reduce pain, disability, psychological distress and catastrophic ways of thinking about pain. Average effect sizes derived from collapsing data across trials are relatively small, as they are across pharmacological and physical treatments for chronic pain. Examination of what we think is feasible as the outcome of psychological treatment is appropriate: is it mere palliation, in which case effects will be small, or do we expect to move people who are stuck in trying to solve the unsolvable problem of pain to address instead the solvable problem of living more satisfactorily with chronic pain (Eccleston 2007), and starting to do so? Or to put it another way, do we believe that we effectively enable patients to manage the interruption of pain and to reduce its interference with their lives, and thereby to repair damaged identities (Morley 2011). These are substantial changes, unlikely to occur rapidly (within the timescale of some trials). What is evident from this review is the following:
- CBT is effective when delivered by experienced staff, those trained and supervised in the trial protocol, or both. The results cannot be extrapolated to CBT delivered by untrained staff.
- There is no clear benefit of adding further components to multicomponent CBT: it is unlikely that the extra component, such as two sessions on 'mindfulness', will make any measurable difference. The rationale given for such additions in trials in this review was often weak.
- Although trials do not tend to report adverse effects or deterioration (such as worsening of depression to a level of clinical concern), we know that such effects should be small (Fairbank 2005; Hellum 2011; Morley 2008), so the treatment can be considered to be safe, with the reservation that the reasons for discontinuing treatment are rarely given and may be due to hidden adverse effects.
- Average effects mask larger changes on the part of some patients and little or none for others. Better trial design and observational studies will help us to identify those patients for whom CBT can enable substantially better outcomes, and those who need current treatment to be adapted or who need other treatment to improve their quality of life with chronic pain. Clinicians can contribute significantly to generating hypotheses about how to distinguish these patients from one another.
- The way forward for psychological treatment lies not in more RCTs, unless the intervention is entirely novel, the patient population has not previously been studied, or the outcomes are truly innovative. Any new RCT needs to be designed and reported taking explicit account of the challenges identified and discussed in this review.
Implications for research
- We recommend the immediate cessation of new RCTs of CBT against simple alternatives, unless a strong case can be given for the novelty of the population or treatment under investigation. We include in this recommendation treatments of CBT with additional components: see Implications for practice, point 2. The evidence of weak to moderate effects across a range of outcomes is clear from our systematic reviews and from the others cited above, and is very unlikely to change as a result of further similar RCTs and systematic reviews. The average effects are small, as they are for all treatments of chronic pain (Moore 2010).
- The question addressed by psychological treatment for chronic pain is complex, conceptually and statistically. We no longer believe that it is possible to design a 'pure' trial of a single component of intervention (such as relaxation, operant reinforcement or acceptance), although that is not to deny that there is much to be learned from some of the trials which attempt it in this review. Suggested solutions in realistic and clinically informed evaluations of complex packages (Craig 2008; Shepperd 2009) will take us no further than the current review and, with pressure to economise on resources, there is so far no indication of which components should be cut or retained.
- Since we share these challenges with the larger field of pain medicine, we can usefully consider some current initiatives: running N of 1 trials (McMillan 2010); examining individual data for response trajectories (Lambert 2001; Moore 2005); pooling data for responder analyses (Moore 2010); or conducting clinical effectiveness trials (Moore 2010), where 'clinical effectiveness' is "the product of efficacy, tolerability, utility, cost, and speed" (Moore 2010, p174) so that trials focus on maximising benefit and minimising cost, including adverse events.
- We need better theory to generate hypotheses about processes and mechanisms of change, to be tested in terms of populations, treatment content, treatment process and outcomes.
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