Key message: Cognitive behavioural therapy (CBT), when delivered by experienced staff, can be helpful in the management of chronic pain, though it is not known which components of CBT work best for different types of patients and for which outcomes
Chronic pain is a common problem and one which is responsible for significant distress and disability. Psychological therapies have been in use to help people manage chronic pain for many years. They aim to help people change behaviour that worsens pain and the distress and disability that can accompany it.
The Cochrane Pain, Palliative and Supportive Care Group has now updated its review on the use of psychological therapies for chronic pain (excluding headache and pain due to malignant disease such as cancer) in adults. People receiving two classes of psychological therapy – cognitive behavioural therapy (CBT) and behaviour therapy – were compared with people in ‘active control’ groups, receiving medical or physical treatments, or ‘waiting list’ or ‘treatment as usual’ control groups. The review authors were interested in the impact of these therapies on pain experience, disability, negative mood and catastrophic thinking, both immediately after treatment and at 6-12 months follow-up.
The review includes 42 randomized controlled trials (RCTs) (16 of which are newly added in this update) with usable data from 35 RCTs involving 4788 people. The largest analysis was of CBT versus active control, with 1258 participants. Most of the studies evaluated CBT.
What did they find?
- Compared with active control, CBT showed positive effects on disability immediately after treatment and at follow-up and on catastrophic thinking at the end of treatment
- Compared with doing nothing (‘treatment as usual’ or ‘waiting list’), CBT showed small positive effects on pain and disability immediately after treatment but not at follow-up and on mood which were maintained at follow-up; there were moderate effects on catastrophic thinking at the end of treatment but insufficient data to evaluate this at follow-up
- Compared with doing nothing (‘treatment as usual’ or ‘waiting list’), behaviour therapy had no effect on pain, disability or mood immediately post-treatment, but a small effect on catastrophic thinking; there were insufficient data at follow-up except for disability, where there was no effect
- Compared to the earlier version of this review, the effect sizes in favour of CBT have been maintained and extended with the addition of catastrophic thinking as an outcome of interest, while those for behaviour therapy are reduced
How good was the evidence?
- People in ‘waiting list’ or ‘treatment as usual’ control groups may have received no treatment or sought treatment elsewhere, as some of the included trials allowed this. Some may have received treatments like those in the active control groups
- Many studies were at high risk of bias and the most common problem was reporting bias
- The authors note that there are problems with interpreting the data and give a full discussion of these along with implications for future research into these treatments