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Cognitive behaviour therapy and behaviour therapy for chronic pain



Clinical bottom line: Diverse studies showed that cognitive behaviour therapy was effective in reducing pain experience, and improving positive behaviour expression, appraisal and coping in individuals with chronic pain.


Systematic review:

Morley S, Eccleston C, Williams A. systematic review and meta-analysis of randomised controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999; 80: 1-13.

 


Date review completed: 1996

Number of trials included: 25

Number of patients: (1672 total)

Control groups: Waiting list control, alternative therapy control.

Main outcomes: Pain experience, mood/affect depression or other, cognitive coping and appraisal, behaviour expression, behaviour activity, social role functioning.

Inclusion criteria were randomised clinical trial which assessed cognitive behaviour therapy or behaviour therapy in the treatment of chronic pain.

Medline, PsychLit, Embase and Social Science Citation Index were searched, using a combination of MeSH terms and relevant keywords, for trials which assessed cognitive behaviour therapy or behaviour therapy for the treatment of chronic pain. Bibliographies of retrieved reports and reviews were checked for additional citations. The Oxford Pain Relief Database was also searched. Papers were read by each reviewer. Authors were contacted for additional information if this was lacking from the individual studies. Information was pooled in a meta-analysis and effect size was calculated using Hedge's g. Corrections for small sample size were made. When mean or standard deviations were not presented other available statistics were used to determine the effect size.


Findings:

Information from 25 studies (1627 patients) was pooled in a meta-analysis; 19 were randomised and six were not. The average age of patients was 45.3 years and the mean chronicity was 12.3 years. Chronic low back pain, rheumatoid arthritis, osteoarthritis, mixed back pain, fibromyalgia, upper limb pain, and unspecified pain were assessed. Mean treatment duration was 6.7 weeks (range 3-10).

Pain experience (28 comparisons), mood/affect depression (24), mood/affect other (16), cognitive coping and appraisal negative (16), cognitive coping and appraisal positive (11), behaviour expression (12), behaviour activity (14), and social role functioning (25) were assessed in the trials.

Different treatments were grouped into three classes: cognitive behavioural therapy, behavioural therapy, and biofeedback.

 

Waiting list control:

Overall treatments were significantly more effective than waiting list control (Table 1). All three treatments were significantly more effective than waiting list control in changing pain experience, improving social functioning and in reducing negative appraisal and coping. The exception was a single comparison using behavioural therapy in reducing negative appraisal and coping.

 

Table 1

Treatment

Number of comparisons

Mean effect size (95% confidence interval)

Pain experience

28

0.40 (0.22 to 0.58)

Mood/affect depression

24

0.36 (0.13 to 0.59)

Mood/affect other

16

0.52 (0.19 to 0.84)

Cognitive coping & appraisal negative

16

0.50 (0.27 to 0.73)

Cognitive coping & appraisal positive

11

0.53 (0.28 to 0.78)

Behaviour expression

12

0.5 (0.22 to 0.78)

Behaviour activity

14

0.46 (0.25 to 0.72)

Social role functioning

25

0.60 (0.44 to 0.76)

 

Active control:

All three cognitive-behavioural treatments were compared with active alternative treatments (e.g. progressive or applied relaxation, routine care, education, occupational therapy). Pooled data showed that cognitive-behavioural treatments were significantly more effective than the alternative treatment controls for pain experience, cognitive coping and appraisal (increasing positive coping), and reducing the expression of pain (Table 2).

 

Table 2

Treatment

Number of comparisons

Mean effect size (95% confidence interval)

Pain experience

22

0.29 (0.11 to 0.46)

Mood/affect depression

15

-0.14 (-0.32 to 0.04)

Mood/affect other

16

0.05 (-0.27 to 0.37)

Cognitive coping & appraisal negative

14

0.17 (-0.08 to 0.42)

Cognitive coping & appraisal positive

15

0.40 (0.21 to 0.62)

Behaviour expression

11

0.27 (0.08 to 0.47)

Social role functioning

14

0.17 (-0.08 to 0.34)


Adverse effects

Adverse effects were not mentioned.

 

Comment

This systematic review is based mostly on information from randomised controlled trials, though six were not randomised because they used inappropriate methods to allocate patients to treatment groups. The reviewers' stated that most trials were statistically under powered, information could not be readily dichotomised, and that blinding was rarely possible in these types of studies. Blinding of the observer, but not the patient or therapist, would be possible in active treatment controlled trials. Bias could have occurred in these studies. The appropriateness of waiting list control is also debatable. Interpreting the results of the review is difficult because the reviewers' did not describe what cut-off point for effect size would make a clinically meaningful difference to a patient.


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Identifier

AT122 - 4823 COGNITIVE BEHAVIOUR THERAPY AND BEHAVIOUR THERAPY FOR CHRONIC PAIN: Sep-2000