Psychological therapies for the management of chronic pain

(excluding headache) in adults (Review)

Eccleston C, Williams ACDC, Morley S

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2009, Issue 3
http://www.thecochranelibrary.com

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1.
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Figure 2.
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RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 3.
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Figure 4.
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Figure 5.
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Figure 6.
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Figure 7.
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Figure 8.
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Figure 9.
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Figure 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 26. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
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REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 1 Pain. . .
Analysis 1.2. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 2 Disability.
Analysis 1.3. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 3 Mood. .
Analysis 2.1. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 1 Pain. . . .
Analysis 2.2. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 2 Disability. . .
Analysis 2.3. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 3 Mood. . . .
Analysis 3.1. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 1 Pain. . . . . .
Analysis 3.2. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 2 Disability. . . . .
Analysis 3.3. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 3 Mood. . . . . .
Analysis 4.1. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 1 Pain. . .
Analysis 4.2. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 2 Disability.
Analysis 4.3. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 3 Mood. .
Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 5.1. Comparison 5 Behavioural vs active control post-treatment, Outcome 1 Pain. . . .

Analysis 5.2. Comparison 5 Behavioural vs active control post-treatment, Outcome 2 Disability. .
Analysis 5.3. Comparison 5 Behavioural vs active control post-treatment, Outcome 3 Mood. . . .
Analysis 6.1. Comparison 6 Behavioural vs active control follow-up, Outcome 1 Pain. . . . . .
Analysis 6.2. Comparison 6 Behavioural vs active control follow-up, Outcome 2 Disability. . . .
Analysis 6.3. Comparison 6 Behavioural vs active control follow-up, Outcome 3 Mood. . . . .
Analysis 7.1. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 1 Pain. . .
Analysis 7.2. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 2 Disability.
Analysis 7.3. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 3 Mood. .
Analysis 8.1. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 1 Pain. . . .
Analysis 8.2. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 2 Disability. . .
Analysis 8.3. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 3 Mood. . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . .
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . .

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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ii

[Intervention Review]

Psychological therapies for the management of chronic pain

(excluding headache) in adults
Christopher Eccleston1 , Amanda C de C Williams2 , Stephen Morley3
1

Cochrane Pain, Palliative and Supportive Care Review Group, Centre for Pain Research, University of Bath, Bath, UK. 2 Research
Department of Clinical, Educational & Health Psychology, University College London, London, UK. 3 Leeds Institute of Health
Sciences, University of Leeds, Leeds, UK

Contact address: Christopher Eccleston, Cochrane Pain, Palliative and Supportive Care Review Group, Centre for Pain Research,
University of Bath, Claverton Down, Bath, BA2 7AY, UK. [email protected]. [email protected]. (Editorial group: Cochrane
Pain, Palliative and Supportive Care Group.)
Cochrane Database of Systematic Reviews, Issue 3, 2009 (Status in this issue: Unchanged)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD007407.pub2
This version first published online: 15 April 2009 in Issue 2, 2009.
Last assessed as up-to-date: 3 February 2009. (Help document - Dates and Statuses explained)
This record should be cited as: Eccleston C, Williams ACDC, Morley S. Psychological therapies for the management of
chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007407. DOI:
10.1002/14651858.CD007407.pub2.

ABSTRACT
Background
Psychological treatments are designed to treat pain, distress and disability, and are in common practice. No comprehensive systematic
review has been published since 1999.
Objectives
To evaluate the effectiveness of psychological therapies on pain, disability, and mood.
Search strategy
Randomised controlled trials (RCTs) of psychological therapy were identified by searching MEDLINE, EMBASE and Psychlit and
CENTRAL from the beginning of each abstracting service until January 2008. A further search was undertaken from January 2008 to
August 2008. Additional studies were identified 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. Studies
were excluded if the pain was primarily headache, or was associated with a malignant disease. Studies were also excluded if the number
of patients in any treatment arm was less than 10.
Data collection and analysis
Fifty-two studies were examined with a quality rating scale specifically designed for use with these studies. Data were extracted from
40 studies (4781 participants) by two authors. Two main classes of treatment (Cognitive Behavioural Therapy (CBT) and Behaviour
Therapy (BT)), were compared with two control conditions (Treatment as Usual (TAU) and Active control (AC)), at two assessment
points (immediately following treatment and six months following treatment), giving eight comparisons. For each comparison, treatment
effectiveness was assessed on three outcomes: pain, disability, and mood giving a total of 24 analyses.
Main results
Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Overall there is an absence of evidence for BT, except for pain immediately following treatment compared with TAU. CBT has some
small positive effects for pain, disability and mood. At present there is insufficient data on 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
CBT and BT have weak effects in improving pain. CBT and BT have minimal effects on disability associated with chronic pain. CBT
and BT are effective in altering mood outcomes, and there is some evidence that these changes are maintained at six months.

PLAIN LANGUAGE SUMMARY

Psychological therapy for adults with longstanding distressing pain and disability
Many people have pain that lasts for a long time, and pain that is not relieved or cured by physical therapy or medicines. The search
for a diagnosis and for pain relief is often long, discouraging, and even damaging. For some people the pain leads to physical disability,
changes in mood such as depression and anxiety, and social isolation. These are not inevitable and are thought to be reversible, at least
to some extent, using a rehabilitation approach which aims to reduce disability and distress despite continuing pain. The treatments
are based on robust psychological principles and practices and have been in use and developing for about 40 years.
The search found 52 trials of treatments, but only 40 provided data in a form that could be used. The two main types of psychological
treatment were Cognitive Behavioural Therapy (CBT), and Behaviour Therapy (BT). Both focus on trying to help people change
behaviour that makes pain, disability and distress worse. CBT also works directly on the thoughts and feelings that are a problem
for people with persistent pain. The effects of these two treatments on pain, disability, and mood were tested immediately after the
treatment, and six months later.
Psychological therapies can help people with chronic pain reduce negative mood (depression and anxiety), disability, and in some cases
pain, but guidance is still required on the best content, duration, intensity, and format of treatment.

BACKGROUND
Chronic pain is a common problem causing significant distress
and disability. Behavioural and cognitive treatments designed to
ameliorate pain, distress and disability were first introduced over
40 years ago and are now well established (Fordyce 1968; Keefe
2004). There are many uncontrolled trials, case studies, observations, and clinical reports of treatment methods. Narrative reviews
generally report positive effects of psychological treatments on a
range of outcomes. In addition there have been periodic publication of meta-analyses and systematic reviews (Flor 1992; Morley
1999) and many recent studies have focused on specific patient
groups such as those with musculoskeletal pain syndromes (Dixon
2007; Guzman 2001; Hoffman 2007; Ostelo 2005).
There is a broad family of treatments included in the general term
psychological. In essence, treatments have been developed that
are specifically designed to alter psychological processes thought
to underlie or significantly contribute to pain, distress, and/or
disability. The design of psychological treatments is normally informed by specific theories of the etiology of human behaviour,
or have developed pragmatically through observation and study
of response to intervention. Although in practice there is variety

in the types of interventions used, not all have been evaluated for
their effectiveness. The evidence base for psychological therapies
is over-represented by studies of programmatic and protocolised
treatments from a behavioural or cognitive-behavioural tradition
of clinical psychology. Psychological therapies are commonly presented as being offered after orthodox treatments have failed when
the treatment goal shifts from one of removing or alleviating pain
to one of managing pain and its myriad adverse consequences
on quality of life. A typical treatment protocol for cognitive behavioural therapy (CBT) will involve methods aimed directly at assessing the thoughts associated with pain, and the extent of avoidance of unpleasant thoughts and of painful experiences, and the
consequences of these. A common focus is on strongly held beliefs
about pain and their relationship with behaviour, which typically
worsens the situation in the shorter or longer term. Behavioural
methods focus on the identification of behaviour that is contingent upon pain, or upon events which provide pain relief or comfort, and the development of behaviour that is contingent instead
upon goal achievement related to the values of the individual with
pain. Most therapies involve education, and many are incorporated within larger treatment programmes involving physical and

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

occupational therapy.
In an earlier published review on this topic (Morley 1999), we
searched for all published randomised controlled trials (RCTs)
of interventions described as psychological in nature, and recovered trials principally of behaviour therapy (BT) or CBT (Morley
1999). RCTs of interventions for headache were excluded in the
previous review as a Cochrane review on this topic is underway (
Nicholson 2004). We also note two more recent completed publications on the efficacy of biofeedback treatments for tension and
migraine headaches (Nestoriuc 2007; Nestoriuc 2008). In the earlier published review 33 papers were recovered that described 30
trials (Morley 1999). Twenty-five had data that could be entered
into a meta-analysis. Compared with waiting list controls, the findings were that CBT had a compound effect size of 0.5 (a median
figure across the range of outcomes). However, comparison with
active treatments produced smaller effect sizes for some outcomes
(such as coping) but no differences on key outcome variables such
as negative affect. The (Morley 1999) review is now out of date
and in need of updating (Shojania 2007). Other developments in
psychological science have led to new forms of treatments being
promoted, and the quality of trials and trial reporting is thought to
be improving (Morley 2006). The aim of this review is to establish
the published evidence on the efficacy of psychological treatments
for chronic pain in adults. Further, key variables that are thought
to influence the effectiveness of many psychological interventions
will also be assessed and evaluated if possible.

OBJECTIVES
To determine the clinical effectiveness of psychological therapy
for non-malignant chronic pain (excluding headache) for adults
compared with medical or physical treatments, placebo or waiting
list controls.

METHODS

Studies were included if they:

were available as a full publication or report of a RCT;
had a design that placed a psychological treatment as an
active treatment of primary interest;
had a psychological treatment with definable psychotherapeutic content;
were published (or electronically pre-published) in a
peer reviewed science journal;
were with participants reporting chronic pain (i.e. at
least three months duration); and
had ten or more participants in each treatment arm at
the end of the treatment assessment.
Types of participants
Adults (aged 18 years or older) reporting pain of at least three
months duration in any body site, not associated with a malignant
disease process. Patients with headache or migraine were excluded
but those with neck, facial or dental pain, or looking at all of these
together, were included. Studies of participants with headache or
migraine, or both, were excluded because the psychological treatments for headache and migraine are sufficiently different, have a
separate history, and a separate audience, and for that reason are
the subject of a separate review (Nicholson 2004).
Types of interventions
Studies were included if at least one trial arm consisted of a psychology intervention, and a comparator arm using placebo, other
active treatment, treatment as usual, or waiting list control.
Types of outcome measures
Data were collected on descriptive characteristics of participants and characteristics of the treatments, including treatment setting, mode of delivery and therapist.
Following the Morley 1999 review, data were collected
on outcomes in the domains of pain experience, negative mood, and disability for this review; all outcomes
were recorded and described.

Criteria for considering studies for this review

Types of studies
RCTs comparing a credible psychological treatment, or a compound treatment with primary psychological content, with
placebo, other active treatment, treatment as usual, or waiting list
control, in chronic pain. Studies were excluded if they were concerned with headache or associated with a malignant life-threatening disease. A psychological treatment was judged credible if it
was based on an extant psychological model or framework, and its
delivery was from, or was supervised by, a health care professional
qualified in psychology.

Search methods for identification of studies

Electronic searches
RCTs of any psychological therapy were identified by MEDLINE,
EMBASE and Psychlit from their inception to January 2008. The
Cochrane Central Register of Controlled Trials (CENTRAL) was
also searched. Additional studies were identified from the reference lists of retrieved papers and from discussion with investigators. Searching was performed in two sets. The first was undertaken prior to the previously published systematic review (Morley

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

1999). The second was undertaken focusing on the ten years since
that review using the same search strategy but taking account of
changes in search architecture and terminology. No language restrictions were applied and no unpublished studies were included
(see Appendix 1). All abstracts were reviewed by at least two review
authors and were included on the basis of consensus agreement
and discussion with the third review author when necessary. An
update search was later undertaken from January 2008 to August
2008.

Data collection and analysis

of the study, the participants, primary diagnosis, method of treatment and outcome measurement tools used.
Data were extracted by two review authors for each paper and
recorded on a standard data extraction form. Data suitable for
pooling were entered into RevMan 5.
The primary data type was measurement using continuous scales.
We estimated treatment effects using standardized mean differences by extracting means, standard deviations, and sample size at
post-treatment and follow-up. When data were not available we
did not infer any parameters. Studies were excluded because it was
not possible to extract the necessary data. Dichotomous outcome
data based on clinical improvement were not extracted. These data
were rarely reported.

Selection of studies
The trials used in the previous (non-Cochrane) systematic review
and meta-analysis (Morley 1999) were automatically included,
although a few were subsequently excluded by the stricter criteria
adopted here. The search of the literature since the end of the
previous search produced 519 possible abstracts. From these 44
were selected by one or more of four raters for examination of
the full paper. Over the same period, search of reviews and other
sources revealed several relevant RCTs which had not been found
by the search, so the search was repeated. The final total of papers
from the previous systematic review and from the two (duplicate)
searches was 98 papers which reported on 89 separate RCTs. All
these papers were read in full.
Data extraction and management
A data extraction book was devised jointly by review authors based
on that used in Morley 1999 and Eccleston 2002. It includes definitions of information to be extracted that relate to the design

Assessment of risk of bias in included studies

The quality rating scale was applied (Yates 2005). All studies were
scored by two of the three review authors and a consensus reached
after initial comparison or ratings and calculation of reliability.
The quality rating scale was designed specifically for application
to psychological treatment studies in pain. It provides an overall total score (0 to 35) consisting of two subscales: first a treatment quality scale (0 to 9) covering stated rationale for treatment,
manualisation, therapist training, and patient engagement. The
second subscale is a design and methods scale (0 to 26) covering
inclusion/exclusion criteria, attrition, sample description, minimization of bias (randomisation method, allocation bias, blinding
of assessment, and equality of treatment expectations), selection
of outcomes, length of follow-up, analyses, and choice of control.
This comprehensive quality assessment method was used in place
of the single item of allocation bias, and is represented in the risk
of bias figures (Figure 1; Figure 2).

Figure 1. Methodological quality graph: review authors judgements about each methodological quality
item presented as percentages across all included studies.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Figure 2. Methodological quality summary: review authors judgements about each methodological quality
item for each included study.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Measures of treatment effect

Two classes of psychological treatment were investigated and labelled Cognitive Behavioural Therapy (CBT) and Behavioural
Therapy (BT). CBT involves treatments that include specific direct cognitive therapeutic content. BT includes treatments that are
purely behavioural technologies such as biofeedback. Two classes
of comparator treatments are investigated and labelled Active Control (AC) and Treatment as Usual (TAU). The active comparator involves a treatment designed to change pain behaviour such
as physical therapy, education, or medical regime. Patients randomised to the AC within each trial are selected to all receive the
same treatment. Patients in TAU conditions are either selected to
a waiting list on which they are restricted from accessing other
care, or they are selected to no other structured treatment but are
not restricted from seeking care. Two assessment time points are
also selected: Post-treatment and Follow-up. Post-treatment is the
assessment point immediately following treatment, and follow-up
is the assessment point at least six months after the end of treatment, but not more than 12 months, and the longer of the two
if there were two follow-up assessments within this timeframe.
Therefore eight separate comparisons were designed comprising of
two classes of psychological treatment under investigation (CBT,
BT), two forms of comparator (AC, TAU), and two assessment
time points (post-treatment and follow-up). They are labelled:
1. Cognitive behavioural vs active control post-treatment.
2. Cognitive behavioural vs active control follow-up.
3. Cognitive behavioural vs treatment as usual post-treatment.
4. Cognitive behavioural vs treatment as usual follow-up.
5. Behavioural vs active control post-treatment.
6. Behavioural vs active control follow-up.
7. Behavioural vs treatment as usual post-treatment.
8. Behavioural vs treatment as usual follow-up.
Multiple measurement tools are typically used in each trial. For
each comparison three outcomes were identified and labelled
Pain, Disability, and Mood. Although standard trial reporting
guidance promotes the definition of primary outcomes (Boutron
2008) most trials do not state a single or preferred a priori primary outcome, so a judgement must be made. From each trial we
selected the measure considered most appropriate for each of the
three outcomes. When there was more than one measure for an
outcome we gave preference to the measure that has documented
frequent usage in the field as opposed to a novel measure. Also,
when there was a choice between single item and multi-item selfreport tools, longer tools were chosen on the basis of inferred increased reliability. Not all trials reported data on all three outcomes
of pain, disability and mood, and not all trials reported follow-up
data.
Assessment of heterogeneity
Heterogeneity was assessed according to the standard method using the Chi-squared and the I-squared statistic, calculated for each

comparison on each outcome. I-Squared values above 50% indicate high heterogeneity, between 25% and 50% medium heterogeneity, and below 25% low heterogeneity.

RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies; Characteristics of studies awaiting classification.
Results of the search
A total of 97 publications reported on 87 RCTs. Of these 35 studies
(36 papers) did not meet the inclusion criteria and were excluded
(Alaranta 1994; Appelbaum 1988; Asenlof 2005; Bendix 1997;
Broderick 2004; Brox 2003; Corrado 2003; Currie 2000; Dahl
2004; Dalton 2004; Dworkin 2002a; Edinger 2005; Evans 2003;
Fors 2000; Haugstad 2006; Keefe 2004; Keller 2004; Kerns 1986;
Linton 1984; Linton 1985; Linton 2001; Linton 2005; Moffett
2005; Moore 2000; Nicholas 1991; Nicholas 1992; Parker 2003;
Peters 1990; Schweikert 2006; Sharpe 2001; Soderlund 2001;
Spence 1995; Turner 1982; Van den Hout 2003; Van Lankveld
2004). Sixty-two publications reported on the remaining 52 RCTs
that met the inclusion criteria. Data were not provided in a form
that allowed extraction for quantitative analysis in 12 of these
52 studies (reported in 17 articles) (Buckelew 1998; Dworkin
1994; Dworkin 2002b; Fairbank 2005; Freeman 2002; Geraets
2005; Kole-Snijders 1999; Marhold 2001; Parker 1988; Smeets
2006; Strauss 1986; Turner-Stokes 2003): these presented data
as mean differences without a standard deviation, as graphs, or
subgrouped in a way which cut across the trial conditions. Therefore a total of 40 RCTs (with a total of 4781 participants) reported in 43 separate publications provided data for analysis in at
least one of the comparisons (Altmaier 1992; Astin 2003; Basler
1997; Becker 2000; Bradley 1987; Buhrman 2004; Carson 2005;
Cook 1998; Ersek 2003; Evers 2002; Flor 1993; Greco 2004;
Haldorsen 1998; Hammond 2001; Jensen 1997; Jensen 2001;
Johansson 1998; Kaapa 2006; Keefe 1990; Keefe 1996; Kraaimaat
1995; McCarberg 1999; Mishra 2000; Moore 1985; NewtonJohn 1995; Nicassio 1997; OLeary 1988; Puder 1988; Radojevic
1992; Redondo 2004; Spence 1989; Strong 1998; Thieme 2003;
Turner 1988; Turner 1990; Turner 1993; Turner 2006; Vlaeyen
1995; Vlaeyen 1996; Williams 1996).
Included studies
Almost half of the studies are new since the review that was published in 1999 (Morley 1999), with 50% of the trials published
being published before 1997, and 75% by 2002, producing a
steady increase in publication of trials over these years. Six of the
25 studies from Morley 1999 were excluded from the current
analysis, primarily for reasons of small sample size, and because

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Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

of the lack of descriptive data for use in computing effect sizes

(Appelbaum 1988; Kerns 1986; Nicholas 1991; Nicholas 1992;
Peters 1990; Turner 1982). Of the 52 included studies, 29 had
just two arms; 15 had three, and eight had four. The quality of
trial design improved markedly with the publication date of the
trial (Spearmans rho = 0.475, P < 0.01), as did the sample size.
The total number of patients entered in to these studies was 5679
(with a mean of 109 per study). The total number of patients
giving data immediately post-treatment was 4781 (with a mean
of 92 per study). Study Completion Rates (from entry to posttreatment assessment) ranged from 53 % to 100%. The overall
completion rate was 84%; the overall attrition rate is therefore
16%. Overall, the mean number of patients from each trial was
91.4 (range 21 to 387) but the improvement in sample size over
the years is evident from the difference between trials up to 1997
with a mean number entering of 81 (s.d. 34), and for those studies
from 1998 onwards the number entering was a mean of 133 (s.d.
107). Women usually outnumbered men, with a mean of 73%
(range 2 to 100%). The mean age was 48.7 (s.d. 10.5), and the
median years of pain (from the 42 studies which provided data)
was 9.9 (range four months to 25 years).
Participants were recruited from a range of healthcare and other
sources. Thirty-nine studies (75%) came from hospital based clinics: 23 pain clinics, nine rheumatology clinics, one orthopaedic
clinic, and six mixed. Five trials recruited exclusively from volunteers. Six trials recruited exclusively from community based services. Finally, two studies recruited using national government or
insurance based databases.
Fourteen studies (26%) were solely of treatments for patients with
low back pain and 14 were for treatments of mixed groups of
musculoskeletal pain patients in which back pain was usually the
most common complaint. Nine studies had patient groups with
rheumatoid arthritis (in one case specifically in the hand) and one
had Systemic Lupus Erythematosus; six had fibromyalgia; four
had temporomandibular joint pain; two had osteoarthritis of the
knee; one had upper limb pain; and one was a trial of patients with
shoulder pain.
Treatment arms were classified on the basis of their content and of
the label given by the authors as cognitive behavioural treatment
or as behavioural treatment. Control conditions were classified as
active control when there was a protocolised treatment which
engaged the patient, such as an exercise programme, a medical
procedure, an education programme, a support group, or a selfinstruction booklet, and as waiting list or treatment as usual. We
did not distinguish between these because for some patients treatment as usual is elective treatment which may be none at all and
therefore equivalent to being on a waiting list. We are aware that
there might be a grey area of classification where treatment as usual
involves some active and regular physiotherapy or pharmacotherapy, but when available information did not allow us to assign to
an active control, we classified a condition as treatment as usual.
Excluded studies

Thirty-five studies (36 papers) did not meet the inclusion criteria
and were excluded. Thirty-five studies may seem a large proportion of the total 88 RCTs to exclude, but seven of these did not
concern chronic pain but sub-chronic or acute pain, and another
five targeted a problem other than non-cancer chronic pain, albeit that some or all patients had a pain problem. The fact that
these studies survived the search strategies and filters is evidence of
the diversity of terminology used to describe pain and treatments,
which necessitated a broad search to maximise yield.
Of the remaining 23 RCTs, two compared two versions of a treatment which were equally psychological in content (Keefe 2004;
Van Lankveld 2004). Nine studies had an insufficient number of
participants (n < 10) in one or more arms at the end of treatment (Appelbaum 1988; Dahl 2004; Kerns 1986; Linton 1984
Linton 1985; Nicholas 1991; Nicholas 1992; Peters 1990; Turner
1982). Twelve had content which, even if described in psychological terms, appeared to us from the description of treatment to
lack the definable psychotherapeutic content specified in our criteria, approximating to education, instruction, or nonspecific support (Alaranta 1994; Bendix 1997; Broderick 2004; Brox 2003;
Dworkin 2002a; Fors 2000; Haugstad 2006; Keller 2004; Moffett
2005; Schweikert 2006; Soderlund 2001; Spence 1995). This
judgement was difficult to apply in some cases and led to extended
discussion between the review authors to reach a decision.

Risk of bias in included studies

For the 52 studies which met the inclusion criteria, the mean
overall quality of the studies was 19.3 (s.d. 4.8, range nine to 28).
The mean design quality score was 14.4 (s.d. 3.7, range seven
to 23) and the mean treatment quality score was 4.9 (s.d. 2.2,
range one to eight). A Spearmans correlation was conducted to
investigate the association between year of study and treatment
quality score, design quality score, and total quality score (sum of
treatment quality and design quality). This was conducted on all
trials providing an n for end of treatment reducing the number
of available studies from 52 to 42. Treatment quality was not
associated with year of study: rho = -0.073, P > 0.1. However,
design quality was associated with the year of study, as was the
total: rho = 0.453, P < 0.01; 0.344, P < 0.01 respectively. Design
quality was weakly associated with treatment quality: rho = 0.306,
P = 0.05. n at the end of treatment was strongly associated with
design quality score and with total quality score (rho = 0.592, P <
0.01; rho = 0.460, P = 0.01).
Of the 24 analyses reported (CBT or BT vs Active control or Treatment as usual, post-treatment and follow-up, for pain, disability,
and mood), 10 showed low heterogeneity (I-Squared < 25%),
five showed modest heterogeneity (I-Squared > = 25% to <50%)
and seven showed large heterogeneity (I-Squared > = 50%) and
for two comparisons there was only one study. Large heterogeneity
was primarily associated with analyses of BT.

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Effects of interventions
Cognitive behavioural vs active control posttreatment
Fourteen studies of 861 participants were entered into an analysis
of the effects of CBT on pain. The overall effect of CBT on pain
was not significant (Z = 1.52, P > 0.05) (Analysis 1.1; Figure 3).
Twelve studies of 728 participants were entered into an analysis of
the effects of CBT on disability. The overall effect was significant
(Z = 2.20, P < 0.05) with a small effect size of -0.16 (CI -0.31 to
-0.02) (Analysis 1.2; Figure 4). Fifteen studies of 890 participants
were entered into a study of the effects of CBT on mood. The
overall effects of CBT on mood was not significant (Z = 1.27, P
> 0.05) (Analysis 1.3; Figure 5).
Figure 3. Forest plot of comparison: 1 Cognitive Behavioural vs Active Control Post-treatment, outcome:
1.1 Pain.

Figure 4. Forest plot of comparison: 1 Cognitive Behavioural vs Active Control Post-treatment, outcome:
1.2 Disability.

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Figure 5. Forest plot of comparison: 1 Cognitive Behavioural vs Active Control Post-treatment, outcome:
1.3 Mood.

Cognitive behavioural vs active control follow-up

Twelve studies with 935 participants were entered into an analysis
of the effects of CBT on pain at follow-up. The overall effect of
CBT on pain at follow-up was significant (Z = 2.27, P < 0.05)
with a small effect size of -0.15 (CI -0.28 to -0.02) (Analysis 2.1;
Figure 6). Eleven studies, with 876 participants, were entered into
an analysis of the effects of CBT on disability at follow-up. The
overall effect of CBT at follow-up was significant, (Z = 2.71, P <
0.05) with a small effect size of -0.21 (CI -0.36 to -0.06) (Analysis
2.2; Figure 7). Twelve studies, with 934 participants, were entered
into an analysis of the effects of CBT on mood at follow-up. The
overall effect of CBT on mood at follow-up was significant (Z =
2.44, P < 0.05) with a small effect size of -0.16 (CI -0.29 to -0.03)
(Analysis 2.3 Figure 8).
Figure 6. Forest plot of comparison: 2 Cognitive Behavioural vs Active Control Follow-up, outcome: 2.1
Pain.

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Figure 7. Forest plot of comparison: 2 Cognitive Behavioural vs Active Control Follow-up, outcome: 2.2
Disability.

Figure 8. Forest plot of comparison: 2 Cognitive Behavioural vs Active Control Follow-up, outcome: 2.3
Mood.

Cognitive behavioural vs treatment as usual posttreatment

Twenty three studies of 1199 participants were entered into an
analysis of the effects of CBT on pain. The overall effect of CBT
on pain was significant (Z = 2.71, P < 0.05) with an effect size of 0.19 (CI -0.32 to -0.05) (Analysis 3.1; Figure 9). Eighteen studies
of 972 participants were entered into an analysis of the effects
of CBT on disability. The overall effect was not significant (Z =
0.76, P > 0.05) (Analysis 3.2; Figure 10). Sixteen studies of 839
participants were entered into an analysis of the effects of CBT on
mood. The overall effect of CBT on mood was not significant (Z
= 1.43, P > 0.05) (Analysis 3.3; Figure 11).

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Figure 9. Forest plot of comparison: 3 Cognitive Behavioural vs Treatment as Usual, outcome: 3.1 Pain.

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Figure 10. Forest plot of comparison: 3 Cognitive Behavioural vs Treatment as Usual, outcome: 3.2
Disability.

Figure 11. Forest plot of comparison: 3 Cognitive Behavioural vs Treatment as Usual, outcome: 3.3 Mood.

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Cognitive behavioural vs treatment as usual follow-up

Nine studies with 693 participants were entered into analysis of
the effects of CBT on pain at follow-up. The overall effect of CBT
on pain at follow-up was not significant (Z = 1.48, P> 0.05) (
Analysis 4.1; Figure 12). Eight studies, with 496 patients, were
entered into analysis of the effects of CBT on disability at followup. The overall effect of CBT at follow up was not significant (Z =
0.66, P > 0.05) (Analysis 4.2; Figure 13). Nine studies, with 684
patients, were entered into analysis of the effects of CBT on mood
at follow-up. The overall effect of CBT on mood at follow-up was
significant (Z = 2.04, P < 0.05) with a small effect size of -0.16 (0.31 to -0.01) (Analysis 4.3; Figure 14).
Figure 12. Forest plot of comparison: 4 Cognitive Behavioural vs Treatment as Usual Follow-up, outcome:
4.1 Pain.

Figure 13. Forest plot of comparison: 4 Cognitive Behavioural vs Treatment as Usual Follow-up, outcome:
4.2 Disability.

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Figure 14. Forest plot of comparison: 4 Cognitive Behavioural vs Treatment as Usual Follow-up, outcome:
4.3 Mood.

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Behavioural vs active control post-treatment

One study of 39 participants was analysed for the effects of BT
on pain. The overall effect of BT on pain was not significant (Z
= 0.77, P > 0.05) (Analysis 5.1; Figure 15. Two studies of 110
participants were entered into an analysis of the effects of BT on
disability. The overall effect was not significant (Z = 1.46, P >
0.05) (Analysis 5.2; Figure 16). Two studies of 110 participants
were entered into an analysis of the effects of BT on mood. The
overall effects of BT on mood was not significant (Z = 1.26, P >
0.05) (Analysis 5.3; Figure 17).
Figure 15. Forest plot of comparison: 5 Behavioural vs Active Control Post-treatment, outcome: 5.1 Pain.

Figure 16. Forest plot of comparison: 5 Behavioural vs Active Control Post-treatment, outcome: 5.2
Disability.

Figure 17. Forest plot of comparison: 5 Behavioural vs Active Control Post-treatment, outcome: 5.3 Mood.

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Behavioural vs active control follow-up

One study with 39 participants was entered into an analysis of the
effects of BT on pain at follow-up. The overall effect of BT on pain
at follow-up was not significant (Z = 0.92, P > 0.05) (Analysis 6.1;
Figure 18). Two studies with 110 participants were entered into an
analysis of the effects of BT on disability at follow-up. The overall
effect of BT at follow-up was not significant (Z = 0.66, P > 0.05) (
Analysis 6.2; Figure 19). Two studies, with 110 participants, were
entered into analysis of the effects of BT on mood at follow-up.
The overall effect of BT on mood at follow-up was not significant
(Z = 0.85, P > 0.05) (Analysis 6.3; Figure 20).
Figure 18. Forest plot of comparison: 6 Behavioural vs Active Control Follow-up, outcome: 6.1 Pain.

Figure 19. Forest plot of comparison: 6 Behavioural vs Active Control Follow-up, outcome: 6.2 Disability.

Figure 20. Forest plot of comparison: 6 Behavioural vs Active Control Follow-up, outcome: 6.3 Mood.

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Behavioural vs treatment as usual post-treatment

Nine studies of 430 participants were entered into an analysis of
the effects of BT on pain. The overall effect of BT on pain was
significant (Z = 3.03, P = < 0.05) with a moderate effect size of
0.55 (CI -0.90 to -0.19) (Analysis 7.1; Figure 21). Seven studies of
374 participants were entered into an analysis of the effects of BT
on disability. The overall effect was not significant (Z = 1.67, P =
< 0.05) (Analysis 7.2; Figure 22). Six studies of 357 participants
were entered into a study of the effects of BT on mood. The overall
effects of BT on mood was not significant (Z = 1.52, P > 0.05) (
Analysis 7.3; Figure 23).
Figure 21. Forest plot of comparison: 7 Behavioural vs Treatment as Usual Post-treatment, outcome: 7.1
Pain.

Figure 22. Forest plot of comparison: 7 Behavioural vs Treatment as Usual Post-treatment, outcome: 7.2
Disability.

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Figure 23. Forest plot of comparison: 7 Behavioural vs Treatment as Usual Post-treatment, outcome: 7.3
Mood.

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Behavioural vs treatment as usual follow-up

Three studies, with 232 participants, were entered into a study
of the effects of BT on pain at follow-up. The overall effect of
BT on pain at follow-up was not significant (Z = 1.09, P > 0.05)
(Analysis 8.1; Figure 24). Three studies, with 230 participants,
were entered into an analysis of the effects of BT on disability at
follow-up: the overall effect of BT at follow-up was not significant
(Z = 1.25, P > 0.05) (Analysis 8.2; Figure 25). Three studies, with
230 participants, were entered into a study of the effects of BT on
mood at follow-up. The overall effect of BT on mood at followup was not significant (Z = 1.68, P > 0.5) (Analysis 8.3; Figure
26).
Figure 24. Forest plot of comparison: 8 Behavioural vs Treatment as Usual Follow-up, outcome: 8.1 Pain.

Figure 25. Forest plot of comparison: 8 Behavioural vs Treatment as Usual Follow-up, outcome: 8.2
Disability.

Figure 26. Forest plot of comparison: 8 Behavioural vs Treatment as Usual Follow-up, outcome: 8.3 Mood.

Pain outcomes
CBT and BT appear to have a small to moderate effect on pain
measured immediately post-treatment when compared with doing

nothing (TAU or Waiting List); that is, randomly assigning them

to a wait list or usual treatment arm. There is no effect at follow-up.
When compared with another active treatment CBT appears to

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have a small effect on pain at follow-up, but not immediately posttreatment. There are too few studies for a meaningful conclusion
on the effects of BT on pain, immediately post-treatment or at
follow-up.
Disability outcomes
CBT has a small effect on disability immediately post-treatment
and at follow-up, compared with an active control. There were
no effects of CBT compared with doing nothing (TAU or Waiting List) immediately post-treatment or at follow-up. BT had no
effect on disability in comparison with doing nothing (TAU or
Waiting List) immediately post-treatment or at follow-up. There
are too few studies for a meaningful conclusion on the effects of
BT on disability compared with an active control, immediately
post-treatment or at follow-up.
Mood outcomes
CBT has no effect on mood immediately post-treatment compared with either active control or doing nothing (TAU or Waiting
List). There is a small effect at follow-up for both comparisons in
improving mood outcomes compared to waiting list or treatment
as usual, immediately post-treatment, and at follow-up. BT had
no effect on mood in comparison with doing nothing (TAU or
Waiting List) immediately post-treatment or at follow-up. There
are too few studies for a meaningful conclusion on the effects of
BT on mood compared with an active control, immediately posttreatment or at follow-up.
Heterogeneity inspection
In the seven analyses showing high heterogeneity of study samples
(I-squared > 50%) further exploratory analyses were undertaken.
By visual inspection we removed the outliers to test for their influence on the overall effect. In analyses 8.1, 8.2 and 8.3 the samples
were made up of only three studies reporting different findings.
In the analyses 7.1, 7.2, and 7.3 the high heterogeneity appeared
to be caused largely by two studies (Newton-John 1995; Thieme
2003) which in all cases were extreme positive outliers. Their removal reduced heterogeneity to acceptable levels without affecting
the overall result. Finally, in analysis 3.2 there was one positive
outlier (Williams 1996) the removal of which again reduced heterogeneity to acceptable levels without affecting the overall result.
Effects of quality ratings
Three further analyses were undertaken to assess the potential
effects of quality. Studies below the median total quality score
were excluded from the analyses. This had no effect on the overall
findings making only minor changes to effect sizes, and so are
not reported further. The lack of any major effect is due largely
to the over-representation of studies with higher quality in the
analyses, and the fact that the n at the end of treatment was strongly
associated with design quality score and with total quality score

(rho = 0.592, P <0.001; rho = 0.460, P = 0.002), and these analyses

are already weighted by sample size.

DISCUSSION
Evidence base
There is a large evidence base for estimating the effectiveness of
psychological treatments in chronic pain: 52 included RCTs involving 5679 participants. All trials are of specific behavioural
technologies such as relaxation and biofeedback or of programmatic versions of CBT. There were no trials of other psychological
treatments such as psychodynamic, psychotherapy, interpersonal,
or dialectical BT. There was only one small ineligible trial of an acceptance based intervention (Dahl 2004). A moderate number of
trials were inadequate by our criteria or did not provide analysable
data, and a few were eligible but provided data in a form which
could not be used.
In total, 40 trials (16 from the previous systematic review and 22
new) were entered into a full analysis. CBT and BT dominate
the evidence base. This allowed for greater power in the analyses,
with the largest analysis being of 1199 participants (CBT vs TAU
for Pain at post-treatment) and the smallest of 39 participants
(BT vs AC for Pain immediately post-treatment and at followup). An analysis of the quality rating scores showed that the quality of the design and reporting of trials has clearly improved over
the years, perhaps as a consequence of the emphasis of Cochrane
and other evidence-focused organisations concerned with methodological standards such as CONSORT (Boutron 2008). However,
the quality of treatments, or of their reporting, or both, does not
appear to have improved over time.

Summary of results
The evidence of effectiveness of CBT and BT is weak. For BT
in particular, the evidence is sparse. There were too few trials to
draw any conclusions about the effects of BT compared with active control. Compared with doing nothing (TAU or waiting list
controls), however, BT has a small but robust effect on pain immediately post-treatment but not at follow-up. There are no other
effects on disability or mood.
The majority of studies were of CBT. Of the six relevant comparisons of CBT versus active control, three outcomes (pain, disability, mood) at two time points (immediately post-treatment and six
to 12 months follow-up), four were positive. There were positive
effects of CBT on disability immediately post-treatment and at
follow-up. There were also positive effects on pain and mood at
follow-up but not immediately post-treatment. Compared with
doing nothing (TAU or Waiting List control) the only two effects

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were on pain immediately post-treatment and on mood at followup.

Both CBT and BT appear to have effects on pain outcomes immediately post-treatment when compared with no treatment, and
at follow-up for CBT compared with active control. However, for
the majority of the trials pain was not a primary outcome, and
was not necessarily expected to change as a direct result of therapy.
Most trials are concerned with adjustment in terms of function or
mental health outcomes despite continuing pain.
There is no evidence for the effectiveness of BT in altering disability. There is evidence for the effectiveness of CBT in altering disability when compared with an active control immediately posttreatment and at follow-up.
There is no evidence for the effectiveness of BT in altering mood.
There is evidence for the effectiveness of CBT in altering mood
when compared with an active control and treatment as usual but
only for longer term outcomes, at follow-up.

Issues for consideration

Psychological therapies for the management of chronic pain are
potentially useful treatments. However, there are some caveats.
There is an insufficient evidence base for those therapies we have
labelled BT in improving non-pain outcomes such as mood or
disability. Despite many trials of programmes of CBT, there remains an inconsistent picture. Half of the comparisons show no
effect of CBT, and half show weak effect sizes of unknown clinical
significance on pain, mood and disability outcomes. A number of
issues arise from this analysis for further consideration:
1. We strongly suspect that as a field we have underestimated the complexity of behaviour change and the social and psychological influences that maintain disability in chronic pain patients (Blyth 2007). The typical
chronic pain patient has well established behavioural
patterns reinforced over a long period of failed attempted adjustment to pain and distress. The hypothesis that the psychotherapeutic content of existing trials aimed at achieving reduction in long standing disability or depression is either absent, insufficient, or has
become dilute merits further investigation, but is outside the remit of this particular review. We plan to address it in a further analysis, but even where authors
give full details of treatment content, quantity does not
imply proportional quality, and while in psychological treatments there appeared for some time to be a
dose effect (a positive relationship between the number of treatment sessions and the extent of gain) both
the finding and the rationale currently lack evidence
(e.g., Barkham 2006). We speculate, however, that good
clinical outcomes should perhaps not be expected from
dilute and brief treatments delivered by inexperienced
staff to severely distressed patients.

2. After multiple readings of these papers, we would propose that the next generation of studies pay particular
attention to four main issues. First, therapy needs to be
based on an explicit theoretical model that guides choice
of content, dose, timing and quality. Many of the trials
reviewed are pragmatic mixes of various content, but
without an adequate rationale, and with apparent disjunction between stated aims of treatment, actual treatment content, and outcomes measured. Second, trials
of targeted therapies focused on specific treatments for
specific outcomes (e.g. Vlaeyen 2002) should replace
large programmes of multicomponent therapies with
multiple targets. Third, criticism of the heterogeneity
of patients with chronic pain led to treatment of specific diagnostic groups of patients. However, the diagnostic group is unlikely to be as important as psychological variables in defining patients needs. A more psychologically-informed subgrouping of patients, rather
than by diagnostic group, should allow better targeted
and more effective treatment, although it is still not
clear on what basis patients should be grouped (Morley
2006). Matching patients to treatment components according to baseline problem severity misses the demonstrated impact of, for instance, the behavioural component on emotional problems, or the cognitive component on physical activity. Component dismantling
studies likewise offer an illusion of identifying active ingredients of the total package when we do not yet have
the power of numbers, nor the statistics, to calculate the
effects of each component on each outcome (Grimshaw
1995). Fourth, the field should seriously consider developing measures which are capable of indexing clinical
improvement to replace or augment statistical change (
Morley 2006) and which have ecological validity. Broad
spectrum measures of the disability domain, such as
quality of life (e.g. Short Form 36 Health Survey) may
have validity problems when applied to trials of the effectiveness of therapies, caused largely by the inclusion
of content either irrelevant to the patient and/or not
the target of treatment (Bowling 1997; Dworkin 2005).
As a consequence, sensitivity of measures may be compromised. In addition, we did not distinguish in our
analysis of disability measures with a focus on physical
function and those with a focus on other aspects such
as social role functioning. In future analyses it may be
possible to analyze sub-categories of the broad concept
of disability.
3. Twelve studies had insufficient psychotherapeutic content to enter analyses, and nine studies were seriously
underpowered. Some of these 21 trials were recent and
represent wasted effort in that they could not add anything to existing knowledge. RCTs are expensive and

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difficult to undertake, particularly where treatment is

intensive, requires trained and experienced staff from
multiple professions, and follow-up is extended. Collaborative effort of multiple sites working with the same
protocol and same treatment manual offer a better
chance of producing reliable data to inform the field.
Indeed, we note that in contrast to many other fields
there is a complete absence of large scale multi-site studies. Although such studies are complex to organise and
manage to completion the advantages which they confer
with regard to size/power and generalizability are considerable. There are precedents for conducting multisite trials with complex behavioural interventions (e.g.,
Dimidjian 2006).
4. Trials report results in terms of statistical rather than
clinical significance, which may have led to earlier optimistic summaries of effectiveness. Rarely do trials report binary outcomes based on a clinical significance
criteria (Morley 2006; Morley 2008). As a consequence
we have no basis on which to estimate the number of
people who are successfully treated by CBT or BT.
Therefore there is a need for the field to develop methods to identify treatment responders (Dworkin 2005;
Dworkin 2008). In addition, no trial reported adverse
events, and drop-outs from treatment were rarely investigated further. The absence of consideration of adverse
effects of psychological therapy is unacceptable: we note
that a recent study of effectiveness observed evidence
of deterioration in a small proportion of patients using statistically defined criteria for clinically significant
change (Morley 2008).
5. The design of adequate control groups remains problematic in this field, particularly given potentially large
group effects (Moos 2003). The debate about specificity
or nonspecificity of effects is a familiar and unresolved
issue in psychology more broadly (Roth 2005). In this
review we had separate comparisons between treatment
with an active comparator, and treatment with TAU.
An ideal control is structurally equivalent to the active
treatment. Without such placebic controls we remain
unable to determine whether the differences between
the treatment and control arms of the trial are specific
to treatment. This may be particularly true of studies that rely on mean data from continuous measures (
Hrobarjtsson 2001; Hrobarjtsson 2004).
6. Relatively few trials provided outcome data on health
care use, although many gave unnecessary health care
use by chronic pain patients among their reasons for
attempting treatment. However, rather than being able
to analyse high quality trials which also collect data on
health care use and costs, many more recent trials appear
to have made economies by reducing treatment length,

the level of training or experience of personnel, or other

variables which might contribute to better outcome. Of
course, where treatment appears not to be effective, data
on costs become irrelevant.
7. The field is already changing. The updated search conducted in August 2008 identified ten additional studies
for possible inclusion and these will be added to the next
update (Babu 2007; Bliokas 2007; Ersek 2008; Leeuw
2008; Linton 2008; Lorig 2008; Morone 2008; Smeets
2008; Woods 2008; Zautra 2008) as it was not possible to add these to the current publication due to time
constraints. We suspect that not all of these trials will
become included studies, or will give data in an analyzable form. However, it is interesting to note the emergence of trials on more specific, theoretically informed
therapies such as exposure for low back pain.

AUTHORS CONCLUSIONS
Implications for practice
This large portmanteau analysis shows that there is overall promise
in CBT as an effective treatment for chronic pain in adults. However, it covers a diverse range of treatment content, quality, length,
and assessment procedures. We are not able to conclude which specific features of therapy may be critical for outcome. It is important
to note that CBT for other disorders such as anxiety or depression
draws on a functional analysis of cognition and behaviour which
forms the basis for repeated behavioural experiment (i.e., guided
behavioural change). It is not clear how far this essential principle
has been pursued in the field of chronic pain. Similarly it is difficult
to understand how very brief group interventions might have any
specific effects on cognitive, emotional or behavioural outcomes
for a group. Broad implications from these analyses do suggest that
immediate improvements in longstanding pain related mood disorders may be unrealistic, and follow-up assessment is necessary.

Implications for research

The field would benefit from a change of research direction away
from multicomponent and dismantling studies, which cannot
identify processes of change, towards simpler treatment modalities, with a secure foundation in theory, and with some monitoring
between the beginning and end of treatment for treatment engagement (as opposed merely to patient presence). There appears to be
little point in conducting further trials of generic CBT in which
a range of sometimes poorly specified interventions are included.
Better specification of each treatment component is required such
that the effects of that component on both the intended outcomes
and hypothesised mediators of those outcomes is clearly defined
and measured.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

22

Additionally, the outcome measures selected should be as closely

related as possible to the aims and methods of the intervention;
they should minimise multiple measurement of the same variable
and try to sample from the major outcome domains (Dworkin
2005); and they should include measures of health care use such
as doctor and hospital visits and analgesic use. Additionally, and
perhaps first, debate is necessary on what constitutes an acceptable outcome of treatment by patients and other stakeholders (
Dworkin 2008; Turk 2008).
Finally, the quality of the studies, or of the reporting of studies (or
both), could be improved with authors paying significant attention to issues concerning power, randomization procedures, control of measurement bias, and the inclusion of intention-to-treat
analyses (present in only a minority of studies). With regard to
treatment implementation, trialists will need to pay more attention to ensuring therapist adherence to protocol, and to the provision of evidence of the competence of the person delivering the
treatment (Kerns 2008).

ACKNOWLEDGEMENTS
We thank Malcolm Adams and Shona Yates for earlier contributions to the protocol, in particular for discussion on coding. We
thank also the PaPaS review group, and the referees for their detailed and helpful feedback.

REFERENCES

References to studies included in this review

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Bradley 1987 {published data only}

Bradley LA, Young LD, Anderson KO, Turner RA, Agudelo CA,
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Buhrman 2004 {published data only}
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Carson 2005 {published data only}
Carson JW, Keefe FJ, Lynch TR, Carson KM, Goli V, Fras AM,
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Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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23

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Dworkin SF, Turner JA, Wilson L, Massoth D, Whitney C, Huggins
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Dworkin 2002b {published data only}
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D, et al.A randomized clinical trial using research diagnostic criteria
for temporomandibular disorders-axis II to target clinic cases for a
tailored self-care TMD treatment program. Journal of Orofacial Pain
2002;16:4863.

Haldorsen 1998 {published data only}

Haldorsen EM, Kronholm K, Skouen JS, Ursin H. Multimodal cognitive behavioral treatment of patients sicklisted for musculoskeletal pain: a randomized controlled study. Scandinavian Journal of
Rheumatology 1998;27:1625.

Ersek 2003 {published data only}

Ersek M, Turner JA, McCurry SM, Gibbons L, Kraybill BM. Efficacy
of a self-management group intervention for elderly persons with
chronic pain. Clinical Journal of Pain 2003;19:15667.

Hammond 2001 {published data only}

Hammond A, Freeman K. One-year outcomes of a randomized

controlled trial of an educational-behavioural joint protection programme for people with rheumatoid arthritis. Rheumatology 2001;
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Hammond A, Freeman K. The long-term outcomes from a randomized controlled trial of an educational-behavioural joint protection
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Evers 2002 {published data only}

Evers AW, Kraaimaat FW, van Riel PL, de Jong AJ. Tailored cognitivebehavioral therapy in early rheumatoid arthritis for patients at risk:
A randomized controlled trial. Pain 2002;100:14153.

Jensen 1997 {published data only}

Jensen IB, Bergstrom G, Ljungquist T, Bodin L. A 3-year follow-up
of a multidisciplinary rehabilitation programme for back and neck
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Fairbank 2005 {published data only}

Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K,

Collins R. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme
for patients with chronic low back pain: the MRC spine stabilisation
trial. BMJ 2005;330:17.
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Jensen 2001 {published data only}

Jensen IB, Bergstroem G, Ljungquist T, Bodin L, Nygren AL. A

randomized controlled component analysis of a behavioral medicine
rehabilitation program for chronic spinal pain: Are the effects dependent on gender?. Pain 2001;91:6578.
Jensen IB, Bergstrom G, Ljungquist T, Bodin L. A 3-year follow-up
of a multidisciplinary rehabilitation programme for back and neck
pain. Pain 2005;115:27383.

Flor 1993 {published data only}

Flor H, Birbaumer N. Comparison of the efficacy of electromyographic biofeedback, cognitive-behavioral therapy, and conservative
medical interventions in the treatment of chronic musculoskeletal
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Freeman 2002 {published data only}
Freeman K, Hammond A, Lincoln N. Use of cognitive-behavioural
arthritis education programmes in newly diagnosed rheumatoid
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Geraets 2005 {published data only}
Geraets J, Goossens M, De Bruijn CPC, De Groot IJM, Koke AJS,
Pelt R, et al.Cost-effectiveness of a graded exercise therapy program
for patients with chronic shoulder complaints. International Journal
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Geraets J, Goossens M, de Groot IJM, de Bruijn, CPC, de Bie RA,
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Geraets JJ, Goossens ME de Bruijn CP, Koke AJ, de Bie RA,

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of Physiotherapy 2005;50:338.
Greco 2004 {published data only}
Greco CM, Rudy TE, Manzi S. Effects of a stress-reduction program
on psychological function, pain, and physical function of systemic
lupus erythematosus patients: a randomized controlled trial. Arthritis & Rheumatism 2004;51:62534.

Johansson 1998 {published data only}

Johansson C, Dahl J, Jannert M, Melin L, Andersson G. Effects of a
cognitive-behavioral pain-management program. Behaviour Research
& Therapy 1998;36:91530.
Kaapa 2006 {published data only}
Kaapa EH, Frantsi K, Sarna S, Malmivaara A. Multidisciplinary
group rehabilitation versus individual physiotherapy for chronic nonspecific low back pain: a randomized trial. Spine 2006;31:3716.
Keefe 1990 {published data only}
Keefe FJ, Caldwell DS, Williams DA, Gil KM, Mitchell D, Robertson C, et al.Pain coping skills training in the management of osteoarthritic knee pain: II. Follow-up results. Behavior Therapy 1990;
21:43547.

Keefe FJ, Caldwell DS, Williams DA, Gil KM, Mitchell D, Robertson C, Martinez S, et al.Pain coping skills training in the management of osteoarthritic knee pain: A comparative study. Behavior
Therapy 1990;21:4962.
Keefe 1996 {published data only}
Keefe FJ, Caldwell DS, Baucom D, Salley A, Robinson E, Timmons
K, et al.Spouse-assisted coping skills training in the management of
knee pain in osteoarthritis: long-term follow up results. Pain 1999;
12:4962.

Keefe FJ, Caldwell DS, Baucom D, Salley A, Robinson E, Timmons

K, et al.Spouse-assisted coping skills training in the management of
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Kole-Snijders 1999 {published data only}

Kole-Snijders AM, Vlaeyen JW, Goossens ME, Rutten-van

Moelken MP, Heuts PH. van Breukelen G, et al.Chronic low-back
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Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

24

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Consulting & Clinical Psychology 1999;67:93144.
Spinhoven P, ter Kuile M, Kole-Snijders AMJ, Mansfield MH, den
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Kraaimaat 1995 {published data only}
Kraaimaat FW, Brons MR, Geenen R, Bijlsma JWJ. The effect of
cognitive behavior therapy in patients with rheumatoid arthritis. Behaviour Research & Therapy 1995;33:48795.
Marhold 2001 {published data only}
Marhold C, Linton SJ. Melin L. A cognitive-behavioral return-towork program: Effects on pain patients with a history of long-term
versus short-term sick leave. Pain 2001;91:15563.
McCarberg 1999 {published data only}
McCarberg B, Wolf J. Chronic pain management in a health maintenance organization. Clinical Journal of Pain 1999;15:507.
Mishra 2000 {published data only}
Mishra KD, Gatchel RJ, Gardea MA. The relative efficacy of three
cognitive-behavioral treatment approaches to temporomandibular
disorders. Journal of Behavioral Medicine 2000;23:293309.
Moore 1985 {published data only}
Moore JE, Chaney EF. Outpatient group treatment of chronic pain:
Effects of spouse involvement. Journal of Consulting & Clinical Psychology 1985;53:32634.
Newton-John 1995 {published data only}
Newton-John TO, Spence SH, Schotte D. Cognitive-behavioral
therapy versus EMG biofeedback in the treatment of chronic low
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Nicassio 1997 {published data only}
Nicassio PM, Radojevic V, Weisman MH, Schuman C, Kim J,
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24:20007.
OLeary 1988 {published data only}
OLeary A, Shoor S, Lorig K, Holman HR. A cognitive-behavioral
treatment for rheumatoid arthritis. Health Psychology 1988;7:527
44.
Parker 1988 {published data only}
Parker JC, Frank RG, Beck NC, Smarr KL, Buesher KL, Phillips LR,
et al.Pain management in rheumatoid arthritis patients. A cognitive
behavioural approach. Arthritis and Rheumatism 1988;31:593601.
Puder 1988 {published data only}
Puder RS. Age analysis of cognitive-behavioral group therapy for
chronic pain outpatients. Psychology & Aging 1988;3:2047.
Radojevic 1992 {published data only}
Radojevic V, Nicassio PM, Weisman MH. Behavioral intervention
with and without family support for rheumatoid arthritis. Behavior
Therapy 1992;23:1330.
Redondo 2004 {published data only}
Redondo JR, Justo CM, Moraleda FV, Velayos YG, Puche JJ, Zubero
JR, et al.Long-term efficacy of therapy in patients with fibromyalgia: a physical exercise-based program and a cognitive-behavioral approach. Arthritis & Rheumatism 2004;51:18492.

Smeets 2006 {published data only}

Smeets R, Vlaeyen JWS, Hidding A, Kester ADM, Van Der Heijden G, Van Geel ACM, et al.Active rehabilitation for chronic low
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Cognitive-Behavioral Treatment in Chronic Low Back Pain. Journal
of Pain 2006;7:26171.
Spence 1989 {published data only}

Spence SH. Cognitive-behavior therapy in the management of

chronic, occupational pain of the upper limbs. Behaviour Research &
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Spence SH. Cognitive-behaviour therapy in the treatment of chronic,
occupational pain of the upper limbs: A 2 yr follow-up. Behaviour
Research & Therapy 1991;29:5039.
Strauss 1986 {published data only}
Strauss GD, Spiegel JS, Daniels M, Speigel T, Landsverk J, Roy-Byne
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of two approaches. Arthritis and Rheumatism 1986;29:120.312.9.
Strong 1998 {published data only}
Strong J. Incorporating cognitive-behavioral therapy with occupational therapy: A comparative study with patients with low back
pain. Journal of Occupational Rehabilitation 1998;8:6171.
Thieme 2003 {published data only}
Thieme K, Gromnica-Ihle E, Flor H. Operant behavioral treatment
of fibromyalgia: a controlled study. Arthritis & Rheumatism 2003;
49:31420.
Turner 1988 {published data only}
Turner JA, Clancy S. Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain. Journal
of Consulting & Clinical Psychology 1988;56:2616.
Turner 1990 {published data only}
Turner JA, Clancy S, McQuade KJ, Cardenas DD. Effectiveness of
behavioral therapy for chronic low back pain: A component analysis.
Journal of Consulting & Clinical Psychology 1990;58:5739.
Turner 1993 {published data only}
Turner JA, Jensen MP. Efficacy of cognitive therapy for chronic low
back pain. Pain 1993;52:16977.
Turner 2006 {published data only}
Turner JA, Mancl L, Aaron LA. Short- and long-term efficacy of
brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial.. Pain
2006;121:18194.
Turner-Stokes 2003 {published data only}
Turner-Stokes L, Erkeller-Yuksel F, Miles A, Pincus T, Shipley M,
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versus an individual therapy model. Archives of Physical Medicine &
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Vlaeyen 1995 {published data only}
Vlaeyen JW, Haazen IW, Schuerman JA, Kole-Snijders AM, van Eek
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Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

25

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1995;34:95118.

from stress and pain symptoms: A preliminary randomized trial.

Behavior Therapy 2004;35:785801.

Vlaeyen 1996 {published data only}

Vlaeyen JW, Teeken-Gruben NJ, Goossens ME, Rutten-van Molken
MP, Pelt RA, van Eek H, et al.Cognitive-educational treatment of
fibromyalgia: a randomized clinical trial. I. Clinical effects. Journal
of Rheumatology 1996;23:123745.

Dalton 2004 {published data only}

Dalton JA, Keefe FJ, Carlson J, Youngblood R. Tailoring cognitivebehavioral treatment for cancer pain. Pain Management Nursing
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Williams 1996 {published data only}

Williams A, Richardson P, Nicholas M, Pither C, Harding VR, Ridout KL, et al.Inpatient vs. outpatient pain management: Results of
a randomised controlled trial. Pain 1996;66:1322.

References to studies excluded from this review

Alaranta 1994 {published data only}
Alaranta H, Rytokoski U, Rissanen A, Talo S, Ronnemaa T, Puukka P,
et al.Intensive physical and psychosocial training program for patients
with chronic low back pain. A controlled clinical trial. Spine 1994;
19:133949.
Appelbaum 1988 {published data only}
Appelbaum KA, Blanchard EB, Hickling EJ, Alfonso M. Cognitive
behavioral treatment of a veteran population with moderate to severe
rheumatoid arthritis. Behavior Therapy 1988;19:489502.
Asenlof 2005 {published data only}
Asenlof P, Denison E, Lindberg P. Individually tailored treatment
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Bendix 1997 {published data only}
Bendix A, Bendix T, Lund C, Kirkbak S, Ostenfeld S. Comparison
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Brox 2003 {published data only}
Brox J, Sorensen I, Friis R, Nygaard A, Indahl O, Keller A, et
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Corrado PE, Gottlieb H, Abdelhamid MH. The effect of biofeedback
and relaxation training on anxiety and somatic complaints in chronic
pain patients. American Journal of Pain Management 2003;13:133
9.
Currie 2000 {published data only}
Currie SR, Wilson KG, Pontefract AJ, deLaplante L. Cognitive-behavioral treatment of insomnia secondary to chronic pain. Journal
of Consulting & Clinical Psychology 2000;68:40716.
Dahl 2004 {published data only}
Dahl J, Wilson K G, Nilsson A. Acceptance and commitment therapy
and the treatment of persons at risk for long-term disability resulting

Dworkin 2002a {published data only}

Dworkin SF, Turner JA, Mancl L, Wilson L, Massoth D, Huggins
KH, et al.A randomized clinical trial of a tailored comprehensive
care treatment program for temporomandibular disorders. Journal
of Orofacial Pain 2002;16:25976.
Edinger 2005 {published data only}
Edinger JD, Wohlgemuth WK, Krystal AD, Rice JR. Behavioral
insomnia therapy for fibromyalgia patients: A randomized clinical
trial. Archives of Internal Medicine 2005;165:252735.
Evans 2003 {published data only}
Evans S, Fishman B, Spielman L, Haley A. Randomized trial of cognitive behavior therapy versus supportive psychotherapy for HIVrelated peripheral neuropathic pain. Psychosomatics 2003;44:4450.
Fors 2000 {published data only}
Fors EA, Gotestam KG. Patient education, guided imagery and pain
related talk in fibromyalgia coping. European Journal of Psychiatry
2000;14:23340.
Haugstad 2006 {published data only}
Haugstad GK, Haugstad TS, Kirste UM, Leganger S, Klemmetsen
I, Malt UF. Mensendieck somatocognitive therapy as treatment approach to chronic pelvic pain: results of a randomized controlled intervention study. American Journal of Obstetrics & Gynecology 2006;
194:130310.
Keefe 2004 {published data only}
Keefe FJ, Blumenthal J, Baucom D, Affleck G, Waugh R, Caldwell
DS, et al.Effects of spouse-assisted coping skills training and exercise
training in patients with osteoarthritic knee pain: a randomized controlled study. Pain 2004;110:53949.
Keller 2004 {published data only}
Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikeras O. Trunk
muscle strength, cross-sectional area, and density in patients with
chronic low back pain randomized to lumbar fusion or cognitive
intervention and exercises. Spine 2004;29:38.
Kerns 1986 {published data only}
Kerns RD, Turk DC, Holzman AD, Rudy TE. Comparison of cognitive-behavioral and behavioral approaches to the outpatient treatment of chronic pain. Clinical Journal of Pain 1986;1:195203.
Linton 1984 {published data only}
Linton SJ, Gotestam KG. A controlled study of the effects of applied
relaxation plus operant procedures in the regulation of chronic pain.
British Journal of Clinical Psychology 1984;23:2919.
Linton 1985 {published data only}
Linton SJ, Melin L, Stjernlof K. The effects of applied relaxation and
operant activity on chronic pain. Behavioural Psychotherapy 1985;
13:87100.
Linton 2001 {published data only}
Linton SJ, Ryberg M. A cognitive-behavioral group intervention as
prevention for persistent neck and back pain in a non-patient population: a randomized controlled trial. Pain 2001;90:8390.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

26

Linton 2005 {published data only}

Linton SJ, Boersma K, Jansson M, Svard L, Botvalde M. The effects of
cognitive behavioural and physical therapy preventive interventions
on pain related sick leave. Clinical Journal of Pain 2005;21:10919.

Turner 1982 {published data only}

Turner JA. Comparison of group progressive-relaxation training and
cognitive-behavioral group therapy for chronic low back pain. Journal of Consulting & Clinical Psychology 1982;50:75765.

Moffett 2005 {published data only}

Moffett JAK, Jackson DA, Richmond S, Hahn S, Coulton S, Farrin
A. Randomised trial of a brief physiotherapy intervention compared
with usual physiotherapy for neck pain patients: Outcomes and patients preference. British Medical Journal 2005;330:758.

Van den Hout 2003 {published data only}

van den Hout JH, Vlaeyen JW, Heuts PH, Zijlema JH, Wijnen JA.
Secondary prevention of work-related disability in nonspecific low
back pain: does problem-solving therapy help? A randomized clinical
trial. Clinical Journal of Pain 2003;19:8796.

Moore 2000 {published data only}

Moore JE, Von Korff M, Cherkin D, Saunders K, Lorig K. A randomized trial of a cognitive-behavioral program for enhancing back
pain self care in a primary care setting. Pain 2000;88:14553.

Van Lankveld 2004 {published data only}

van Lankveld W, van Helmond T, Naring G, de Rooij DJ, van den
Hoogen F. Partner participation in cognitive-behavioral self-management group treatment for patients with rheumatoid arthritis. Journal
of Rheumatology 2004;31:173845.

Nicholas 1991 {published data only}

Nicholas MK, Wilson PH, Goyen J. Operant-behavioural and cognitive-behavioural treatment for chronic low back pain.. Behaviour
Research & Therapy 1991;29:22538.
Nicholas 1992 {published data only}
Nicholas MK, Wilson PH, Goyen J. Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain. Pain 1992;48:33947.
Parker 2003 {published data only}
Parker JC, Smarr KL, Slaughter JR, Johnston SK, Priesmeyer ML,
Hanson KD, et al.Management of depression in rheumatoid arthritis: a combined pharmacologic and cognitive-behavioral approach.
Arthritis & Rheumatism 2003;49:76677.
Peters 1990 {published data only}
Peters J, Large RG, Elkind G. Follow-up results from a randomised
controlled trial evaluating in- and outpatient pain management programmes. Pain 1992;50:4150.

Peters JL, Large RG. A randomised control trial evaluating in- and
outpatient pain management programmes. Pain 1990;41:28393.
Schweikert 2006 {published data only}
Schweikert B, Jacobi E, Seitz R, Cziske R, Ehlert A, Knab J, et
al.Effectiveness and cost-effectiveness of adding a cognitive-behavioral treatment to the rehabilitation of chronic low back pain. Journal
of Rheumatology 2006;33:251926.
Sharpe 2001 {published data only}
Sharpe L, Sensky T, Timberlake N, Ryan B, Brewin C, Allard S. A
blind, randomized, controlled trial of cognitive-behavioural intervention for patients with recent onset rheumatoid arthritis: Preventing psychological and physical morbidity. Pain 2001;89:27583.
Soderlund 2001 {published data only}
Soderlund A, Lindberg P. Cognitive behavioural components in physiotherapy management of chronic whiplash associated disorders
(WAD) -- a randomized group study. Physiotherapy Theory & Practice
2001;17:22938.
Spence 1995 {published data only}
Spence SH, Sharpe L, Newton-John T, Champion D. Effect of EMG
biofeedback compared to applied relaxation training with chronic,
upper extremity cumulative trauma disorders. Pain 1995;63:199
206.

References to studies awaiting assessment

Babu 2007 {published data only}
Babu AS, Mathew E, Danda D, Prakesh H. Management of patients
with fibromyalgia using biofeedback: A randomized control trial.
Indian Journal of Medical Sciences 2007;61:44561.
Bliokas 2007 {published data only}
Bliokas VV, Cartmill TK, Nagy BJ. Does systematic graded exposure
in vivo enhance outcomes in multidisciplinary chronic pain management groups?. Clinical Journal of Pain 2007;23:36174.
Ersek 2008 {published data only}
Ersek M, Turner JA, Cain KC, Kemp CA. Results of a randomized
controlled trial to examine the efficacy of a chronic pain self-management group for older adults [ISRCTN11899548]. Pain 2008;138:
2940.
Leeuw 2008 {published data only}
Leeus M, Goossens MEJB, van Breukelen GJP, de Jong JR, Heuts
PHTG, Smeets RJEM, et al.Exposure in vivo versus operant graded
activity in chronic low back pain patients: Results of a randomized
controlled trial. Pain 2008;138(1):192207.
Linton 2008 {published data only}
Linton SJ, Boersma K, Jansson M, Overmeer T, Lindblom K, Vlaeyen
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Lorig 2008 {published data only}
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Morone 2008 {published data only}
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the treatment of chronic low back pain in older adults: a randomized
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Smeets 2008 {published data only}
Smeets RJEM, Vlaeyen JWS, Hidding A, Kester ADM, van der Heijden GJMG, Knottnerus JA. Chronic low back pain: Physical training, graded activity with problem solving training, or both? The oneyear post-treatment results of a randomized controlled trial. Pain
2008;134:26376.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

27

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A, Parrish B. Comparison of cognitive behavioral and mindfulness
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Consulting and Clinical Psychology 2008;76:40821.

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Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

28

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Indicates the major publication for the study

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

29

CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Altmaier 1992
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, six months.

Participants

End of treatment n = 42
Start of treatment n = 45
Sex: 12F, 33M
Mean age = 39.9 (sd 8.9)
Source = pain and rehabilitation clinic
Diagnosis = Chronic Low Back Pain
Mean years of pain = not given

Interventions

Psychology based programme: multicomponent CBT

Standard inpatient rehabilitation

Outcomes

Primary Pain Outcome: MPQ PRI

Primary Disability Outcome: WHYMPI pain interference
Primary Mood Outcome: WHYMPI distress
1. Primary Aerobic impairment
2. Self-efficacy
3. West Haven Yale Multidimensional Pain Inventory (WHYMPI) self control
4. West Haven Yale Multidimensional Pain Inventory (WHYMPI) pain interference
5. West Haven Yale Multidimensional Pain Inventory (WHYMPI) Mood
6. Disability
7. Melzack Pain Questionnaire Pain Response Index (MPQ PRI)

Notes

CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3,3, 4.1, 4.2, 4.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 15/35

Is the Design Quality adequate?

No

Design Quality = 11/26

Is the Treatment Quality adequate?

No

Treatment Quality = 4/9

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Astin 2003
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, six weeks, four months

Participants

End of treatment n = 78
Start of treatment n = 128
Sex: 127F, 1M (data from start of treatment)
Mean age = 47.7 (sd 10)
Source = volunteer
Diagnosis = Fibromyalgia
Mean years of pain = 3.5

Interventions

mindfulness meditation Qiqong

education

Outcomes

Primary Pain Outcome: SF36 Pain (Reversed)

Primary Disability Outcome: Fibromyalgia Impact Questionnaire
Primary Mood Outcome: BDI Depression
1. Fibromyalgia Impact Questionnaire
2. Short Form 36 (Pain)
3. Beck Depression Index (BDI)
4. Six minute Walk Test
5. Physician Rated Tender Point Score

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 18/35

Is the Design Quality adequate?

Yes

Design Quality = 14/26

Is the Treatment Quality adequate?

No

Treatment Quality = 4/9

Basler 1997
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, six months.

Participants

End of treatment n =76

Start of treatment n = 94
Sex: 57F, 19M
Mean age = 49.3 (sd 9.7)
Source = Pain or Rehabilitation Clinic
Diagnosis = Chronic Low Back Pain
Mean years of pain = 10.8

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Basler 1997

(Continued)

Interventions

CBT added to Medical Treatment

Medical Treatment

Outcomes

Primary Pain Outcome: NRS 0-10 Pain

Primary Disability Outcome: Disability in physical function from Dusseldorf Disability
Scale
Primary Mood Outcome: none
1. Pain Intensity Numerical Rating Scale (0-10)
2. Control over pain Numerical Rating Scale (0-10)
3. Days per week pain free
4. Days per week pain medication use
5. Use of cognitive strategies (self report)
6. Use of avoidance behaviour (self report)
7. Pleasant activities (self report)
8. Social support (self report)
9. Philosophical beliefs (self report)
10. Catastrophizing (bespoke scale)
11. Active coping (bespoke scale)
12. Disability in social relationships from Dusseldorf Disability Scale
13. Disability in social roles from Dusseldorf Disability Scale
14. Disability in physical function from Dusseldorf Disability Scale
15. Disability in mental performance from Dusseldorf Disability Scale
16. Disability in physical performance from Dusseldorf Disability Scale

Notes

CBT vs TAU, post-treatment: analyses 3.1, 3.2

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 18/35

Is the Design Quality adequate?

No

Design Quality = 12/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 6/9

Becker 2000
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six months.

Participants

End of treatment n = 134

Start of treatment n =166
Sex: 106F, 60M (at start of treatment)
Mean age = 56.5 (s.d. 15)

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Becker 2000

(Continued)
Source = Pain or Rehabilitation Clinic
Diagnosis = Mixed chronic pain
Mean years of pain = 9.3

Interventions

Multidisciplinary pain treatment

Primary Care medical treatment
Waiting List

Outcomes

Primary Pain Outcome: NRS 0-10 Pain

Primary Disability Outcome: SF36 physical function (reversed)
Primary Mood Outcome: HADS Depression
1. Pain Numerical Rating Scale (NRS) (0-10)
2. Pain Visual Rating Scale (VRS)
3. Psychological general well being
4. Hospital Anxiety and Depression Scale (Anxiety)
5. Hospital Anxiety and Depression Scale (Depression)
6. Short Form 36 Role Physical
7. Short Form 36 Physical Function
8. Short Form 36 Pain
9. Short Form 36 General Health
10. Short Form 36 Vitality
11. Short Form 36 Social Function
12. Short Form 36 Role Emotional
13. Short Form 36 Mental Health
14. Sleep
15. Mean opioid Dose

Notes

CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 18/35

Is the Design Quality adequate?

Yes

Design Quality = 17/26

Is the Treatment Quality adequate?

No

Treatment Quality = 1/9

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Bradley 1987
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six month follow up.

Participants

End of treatment n = 55
Start of treatment n = 68
Sex: 43F, 10M (given at 6 month f/u)
Mean age = 50.1 (sd 12.4)
Source = Rheumatology Clinic
Diagnosis = Rheumatoid Arthritis
Mean years of pain = 11.5 years

Interventions

cognitve-behavioral group therapy

structured group social support therapy
no adjunct treatment (TAU)

Outcomes

Primary Pain Outcome: VAS pain intensity

Primary Disability Outcome: none
Primary Mood Outcome: DACL depression
Pain Intensity Visual Analogue Scale
Pain Unpleasantness Visual Analogue Scale
Observed pain behaviour
Rheumatoid activity
Subjective global assessment
Professional global assessment
Articular index
Grip strength
Rheumatoid Factor
Erythrocyte sedimentation rate (ESR)
State-Trait Anxiety Index: Trait (STAI )
Depression Adjective Checklist (DACL)
Skin temperature change
Health Locus of Control
Arthritis helplessness
Notes

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.3, 2.1, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 18/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

No

Treatment Quality = 3/9

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Buckelew 1998
Methods

RCT. Four arms. Assessed at pre-treatment, post-treatment, three months, one year, two years.

Participants

End of treatment n = 109

Start of treatment n = 119
Sex: 108F, 11M
Mean age = 44 (sd 10)
Source = mainly community
Diagnosis = fibromyalgia
Mean years of pain = 11.5

Interventions

Biofeedback + relaxation + exercise

Biofeedback + relaxation
Exercise
Education attentional control

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
Arthritis Impact Measurement Scale: Physical Activity subscale (AIMS)
Symptom Checklist (SCL-90R) distress
Center for Epidemiologic Studies Depression Scale (CES-D)
Arthritis Self-Efficacy Scale
sleep rating 0-12
Tender Point Index
Myalgic score
Physicians VAS rating of disease severity
Keefe & Block Pain Behaviour: observation

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 20/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 5/9

Buhrman 2004
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Buhrman 2004

(Continued)

Participants

End of treatment n = 51
Start of treatment n = 56
Sex: 35F, 21M (at start of treatment)
Mean age = 44.6 (sd 10.4)
Source = Volunteers
Diagnosis = Chronic Low Back Pain
Mean years of pain = 10.1

Interventions

Internet based self help

Waiting list

Outcomes

Primary Pain Outcome: MPI pain intensity

Primary Disability Outcome: MPI pain interference
Primary Mood Outcome: HADS Depression
Pain Diary (Highest intensity)
Pain Impairment Rating Scale
Coping Strategies Questionnaire
Hospital Anxiety and Depression Scale (HADS Anxiety)
Hospital Anxiety and Depression Scale (HADS Depression)
Multidimensional Pain Inventory: Pain Intensity
Multidimensional Pain Inventory: Pain Interference
Multidimensional Pain Inventory: Life Control
Multidimensional Pain Inventory: Affective Distress
Multidimensional Pain Inventory: support
Multidimensional Pain Inventory: Punishing responses
Multidimensional Pain Inventory: Solicitous responses
Multidimensional Pain Inventory: distracting responses

Notes

CBT vs TAU, post-treatment: analyses 3.1, 3.2, 3.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 19/35

Is the Design Quality adequate?

Yes

Design Quality = 14/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 5/9

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Carson 2005
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, three months.

Participants

End of treatment n = 43
Start of treatment n = 43
Sex: 26F, 17M
Mean age = 51.1 (no sd given)
Source = Pain or rehabilitation clinic
Diagnosis = Chronic Low Back Pain
Mean years of pain = 12.3

Interventions

Loving kindness meditation

Usual care

Outcomes

Primary Pain Outcome: BPI 0-10 usual pain

Primary Disability Outcome: none
Primary Mood Outcome: BSI (Distress) (No data available)
McGill Pain Questionnaire
Brief Pain Inventory: usual pain
Brief Pain Inventory: worse pain
The State Trait Anger Expression Inventory (STAXI)
Brief Symptom Inventory: psychological distress

Notes

CBT vs TAU post-treatment:: analysis 3.1

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 24/35

Is the Design Quality adequate?

Yes

Design Quality = 16/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 8/9

Cook 1998
Methods

RCT. Two arms. Assessed pre-treatment, post-treatment.

Participants

End of treatment n = 21
Start of treatment n = 28
Sex: 13F, 8M (at end of treatment)
Mean age = 77.6 (no sd given)
Source = elderly community
Diagnosis = mixed chronic pain
Mean years of pain = 25.3

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Cook 1998

(Continued)

Interventions

CBT
Education attention control

Outcomes

Primary Pain Outcome: NRS Pain

Primary Disability Outcome: Roland & Morris Disability Questionnaire subset 0-16
Primary Mood Outcome: Geriatric Depression Scale
McGill Pain Questionnaire Pain Rating Index
Pain Numerical Rating Scale
Roland Morris Disability Questionnaire
Geriatric Depression Scale
Pain Medication

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 21/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 6/9

Dworkin 1994
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, three months, one year.

Participants

End of treatment n = 139

Start of treatment n=185
Sex: 118F, 21M (at three months)
Mean age = 37.1 (s.d. 10.2)
Source = community and volunteer
Diagnosis = TMD
Mean years of pain = not given

Interventions

CBT followed by usual treatment

Usual Treatment

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
Pain Visual Analogue Scale
Pain Interference 0-10
Mandibular range of motion

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Dworkin 1994

(Continued)
Symptom Checklist-90R
Chronic pain grade

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 25/35

Is the Design Quality adequate?

Yes

Design Quality = 18/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 7/9

Dworkin 2002b
Methods

RCT. 2 arms. Assessed pre-treatment, post-treatment, six months, one year.

Participants

End of treatment n = 99
Start of treatment n = 124
Sex: 105F, 19M
Mean age = 37.5 (s.d. 4.0)
Source = pain clinic
Diagnosis = temporomandibular joint pain (TMD)
Mean years of pain = not given

Interventions

Structured self-care
Specialist treatment as usual

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
Characteristic pain intensity 0-10
Pain interference 0-10
Pain-related disability days
Symptom Checklist-90R depression and other symptoms
Chronic pain grade
Jaw movement measures

Notes
Risk of bias

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Dworkin 2002b

(Continued)

Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 24/35

Is the Design Quality adequate?

Yes

Design Quality = 16/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 8/9

Ersek 2003
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, three months.

Participants

End of treatment n = 42
Start of treatment n = 45
Sex: 39F, 6M (at start of treatment)
Mean age = 82 (no sd given)
Source = elderly community
Diagnosis = mixed chronic pain
Mean years of pain = not given

Interventions

Self Management
Educational booklet

Outcomes

Primary Pain Outcome: Graded Pain Scale pain

Primary Disability Outcome: SF-36 (Reversed)
Primary Mood Outcome: Geriatric Depression Scale
Graded Pain Scale (Pain Intensity)
Graded Pain Scale (activity interference)
Short Form 36 (Physical Function)
Short Form 36 Role Physical
Geriatric Depression Scale
Survey of Pain Attitudes: Control belief
Survey of Pain Attitudes: Harm belief
Survey of Pain Attitudes: Medical Care beliefs

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 20/35

Is the Design Quality adequate?

No

Design Quality = 12/26

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Ersek 2003

(Continued)

Is the Treatment Quality adequate?

Yes

Treatment Quality = 8/9

Evers 2002
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, six months follow up.

Participants

End of treatment n = 59
Start of treatment n = 64
Sex: 42F, 17M
Mean age = 54.1 (s.d. 11.4)
Source = Rheumatology clinic
Diagnosis = Rheumatoid Arthritis
Mean years of pain = 3.1

Interventions

Tailor made CBT

Treatment as Usual

Outcomes

Primary Pain Outcome: IRGL Pain

Primary Disability Outcome: IRGL Functional Disability (Composite Z score)
Primary Mood Outcome: BDI depression
Disease Activity
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): Functional Disability
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): Pain
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): Anxiety
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): Perceived support
Social network
Illness Cognitions: Helplessness
Illness Cognitions: Acceptance
Active Coping with Pain
Passive Coping with pain
Active Coping with Stress
Passive Coping with Stress
Fatigue
Beck Depression Inventory
Negative Mood (ZwartSpooren)
Medication compliance

Notes

CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 24/35

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

41

Evers 2002

(Continued)

Is the Design Quality adequate?

Yes

Design Quality = 16/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 6/9

Fairbank 2005
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, six months, one year, two years.

Participants

End of treatment n = 290

Start of treatment n= 349
Sex: 172F, 173M
Mean age = not given
Source = orthopaedic referral
Diagnosis = CLBP
Mean years of pain = 8

Interventions

CBT intensive rehabilitation

Surgical stabilisation

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
Shuttle Walk
Short Form 36 Physical subscale
Short Form 36 Mental subscale
Oswestry Disability Scale
Modified Somatic Questionnaire
Zung Depression Scale
Mean Cost

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 24/35

Is the Design Quality adequate?

Yes

Design Quality = 21/26

Is the Treatment Quality adequate?

No

Treatment Quality = 3/9

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Flor 1993
Methods

RCT. Three arms. Assessed pre-treatment, post-treatment, six months, two years.

Participants

End of treatment n = 57
Start of treatment n = 90
Sex: 50F, 28M (at end of treatment)
Mean age = 42.4 (s.d. 9.7)
Source = Pain or rehab clinic, and volunteer
Diagnosis = Mixed (mostly Chronic Low Back Pain)
Mean years of pain = 9.4

Interventions

CBT
Biofeedback
WLC

Outcomes

Primary Pain Outcome: MPI pain intensity

Primary Disability Outcome: MPI pain interference
Primary Mood Outcome: MPI affective distress
Multidimensional Pain Inventory: pain intensity
Multidimensional Pain Inventory: interference
Multidimensional Pain Inventory: Affective distress
Multidimensional Pain Inventory: Life control
Pain-related Self Statements Scale (PRSS): catastrophizing
Pain-related Self Statements Scale (PRSS): active coping
Pain behaviour
Use of health care
Electromyography baseline
Electromyography reactivity

Notes

CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3
BT vs TAU, post-treatment and follow-up: analyses 7.1, 7.2, 7.3, 8.1, 8.2, 8.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 17/35

Is the Design Quality adequate?

Yes

Design Quality = 14/26

Is the Treatment Quality adequate?

No

Treatment Quality = 3/9

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Freeman 2002
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, three months, six months.

Participants

End of treatment n = 54
Start of treatment n = 54
Sex: 46F, 8M
Mean age = 51.4 (s.d. 11.3)
Source = rheumatology clinics
Diagnosis = Rheumatoid Arthritis
Mean years of pain = 4.5 months since diagnosis

Interventions

Cognitive Behavioural Arthritis Education Programme

Arthritis Education Programme

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
Arthritis Impact Measurement Scale (AIMS) 2
Visual Analogue Scale pain
Arthritis Impact Measurement Scale: Physical Activity subscale Affect
Rheumatology Attitudes Index: helplessness, internality
Arthritis Self-Efficacy Scale
Erythrocyte sedimentation rate (ESR)
morning stiffness
28 joint score

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 17/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

No

Treatment Quality = 2/9

Geraets 2005
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, one year.

Participants

End of treatment n = 158

Start of treatment n = 176
Sex: 109F, 83M (at start of treatment)
Mean age = 52.5 (s.d. 12.4)

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Geraets 2005

(Continued)
Source = mixed community and volunteer
Diagnosis = Shoulder pain
Mean years of pain = not given

Interventions

Graded exercise
Primary Care TAU

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: none
Shoulder disability questionnaire
Shoulder pain
Pain intensity NRS
Quality of life
Fear avoidance
Kinesiophobia (2 items)
Pain Coping and Cognition List: catastrophizing
Pain Coping and Cognition List: Coping
General Practitioner visits
Physician visits
Physiotherapy visits
Number of drug prescriptions
Number of days work absence
Total cost of Health Care (Euros)

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 26/35

Is the Design Quality adequate?

Yes

Design Quality = 20/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 6/9

Greco 2004
Methods

RCT. Three arms. Assessed pre-treatment, post-treatment, six/nine months.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Greco 2004

(Continued)

Participants

End of treatment n = 80
Start of treatment n = 92
Sex: 87F, 5M (at start of treatment)
Mean age = 47.3 (s.d. 10.4)
Source = volunteers
Diagnosis = SLE
Mean years of pain = 11

Interventions

CBT with Biofeedback

Symptom monitoring and support
Treatment as Usual

Outcomes

Primary Pain Outcome: AIMS2 pain 0-10

Primary Disability Outcome: SF36 physical function (reversed)
Primary Mood Outcome: CES-D Depression
Arthritis Impact Measurement Scale (AIMS) 2: Pain
Multidimensional Pain Inventory: interference
Center for Epidemiologic Studies Depression Scale (CES-D)
Arthritis Self-efficacy
Perceived Stress
Short Form 36 Physical function
Fatigue severity
Global self assessment
Disease activity systemic lupus activity measure-revised (SLAM-R)
Systemic Lupus Erythematosus Disease Activity Index (SLEDAI).

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3
CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 24/35

Is the Design Quality adequate?

Yes

Design Quality = 19/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 5/9

Haldorsen 1998
Methods

RCT. Two arms. Assessed pre-treatment, one year.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Haldorsen 1998

(Continued)

Participants

End of treatment n = 387

Start of treatment n = 469
Sex: 298F, 171M
Mean age = 43 (s.d. 10.6)
Source = National Insurance system contact
Diagnosis = mixed chronic pain
Mean years of pain = not given

Interventions

Cognitive Behaviour Therapy

Treatment As Usual

Outcomes

Primary Pain Outcome: VAS pain

Primary Disability Outcome: none
Primary Mood Outcome: HSCL distress
Visual Analogue Scale Pain (in afternoon)
Physical training
Hopkins Checklist (HSCL) Distress (Norwegian version)
Attribution style
Work Satisfaction
Ergonomic performance
Subjective health rating

Notes

CBT vs TAU post-treatment: analyses 4.1, 4.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 12/35

Is the Design Quality adequate?

No

Design Quality = 10/26

Is the Treatment Quality adequate?

No

Treatment Quality = 2/9

Hammond 2001
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, one year.

Participants

End of treatment n = 121

Start of treatment n = 127
Sex: 97F, 30M
Mean age = 50.5 (s.d. 10.6)
Source = Rheumatology clinic
Diagnosis = Rheumatoid Arthritis (hand)

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Hammond 2001

(Continued)
Mean years of pain = 1.6

Interventions

Joint protection arthritis education

Standard arthritis education

Outcomes

Primary Pain Outcome: none available

Primary Disability Outcome: AIMS2 activities of daily living
Primary Mood Outcome: none available
Adherence to joint protection
Hand pain Visual Analogue Scale
Overall pain Visual Analogue Scale
Tender count (28 joints)
Swollen joint count (28 joints)
Early morning stiffness
Grip strength
hand joint alignment
Arthritis Impact Measurement Scale (AIMS) 2: ADL
Arthritis Impact Measurement Scale (AIMS) 2: upper limb function
Arthritis Impact Measurement Scale (AIMS) 2: lower limb function
Arthritis Impact Measurement Scale (AIMS) 2: current health status
Arthritis Self Efficacy (Pain)
Arthritis Self Efficacy (Other)
Rheumatoid attitude index (helplessness)
Rheumatoid attitude index (internality)
Satisfaction with health

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.2, 2.2

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 18/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

No

Treatment Quality = 3/9

Jensen 1997
Methods

RCT. Two arms. Assessed pre-treatment, post-treatment, six months, 18 months.

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Jensen 1997

(Continued)

Participants

End of treatment n = 59
Start of treatment n = 63
Sex: 63F, 0 M (at start of treatment)
Mean age = 43.4 (s.d. 8.4)
Source = Pain or rehabilitation clinic
Diagnosis = non specific back or neck pain
Mean years of pain = 4.2

Interventions

Woman-specific CBT
Regular CBT

Outcomes

Primary Pain Outcome: VAS pain intensity

Primary Disability Outcome: Disability Rating Index
Primary Mood Outcome: BDI depression
Pain intensity Visual Analogue Scale
Beck Depression Inventory (BDI)
Anxiety Visual Analogue Scale
Disability Rating Index
Health Perception Numerical Rating Scale
Coping Strategies Questionnaire (CSQ)
Rheumatoid attitudes index (helplessness)

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 17/35

Is the Design Quality adequate?

Yes

Design Quality = 14/26

Is the Treatment Quality adequate?

No

Treatment Quality =3/9

Jensen 2001
Methods

RCT. Four arms. Assessed at pre-treatment, post-treatment, six months, 18 months, three years.

Participants

End of treatment n = 186

Start of treatment n = 214
Sex: 117F, 93M
Mean age = 43.3 (s.d. 10.4)
Source = pain or rehabilitation clinic
Diagnosis = Mixed (mostly Chronic Low Back Pain)

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Jensen 2001

(Continued)
Mean years of pain = 2.7

Interventions

CBT
Behavioural medicine rehabilitation
Behaviourally orientated physical therapy (BT)
Treatment As Usual

Outcomes

Primary Pain Outcome: SF36 pain (reversed)

Primary Disability Outcome: SF36 physical function (reversed)
Primary Mood Outcome: SF36 mental health (reversed)
Short Form 36 Pain
Short Form 36 Physical Function
Short Form 36 Mental Health

Notes

CBT vs TAU, post-treatment and follow-up (six months): analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3
BT vs TAU, post-treatment and follow-up (six months): analyses 7.1, 7.2, 7.3, 8.1, 8.2, 8.3
Baseline N used as N unavailable for post-treatment and follow-up results

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 27/35

Is the Design Quality adequate?

Yes

Design Quality = 20/26

Is the Treatment Quality adequate?

Yes

Treatment Quality =7/9

Johansson 1998
Methods

RCT. Two arms. Assessed pre-treatment, post-treatment, one month.

Participants

End of treatment n = 36
Start of treatment n = 42
Sex: 28F, 8M (at end of treatment)
Mean age = 43.5 (s.d. 7.6)
Source = Pain or Rehabilitation clinic
Diagnosis = chronic musculoskeletal pain
Mean years of pain = 11

Interventions

CBT
WLC

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Johansson 1998

(Continued)

Outcomes

Primary Pain Outcome: VAS pain intensity

Primary Disability Outcome: MPI Activity
Primary Mood Outcome: none available
Visual Analogue Scale: pain intensity
Visual Analogue Scale: pain interference
Sick leave %
Hours of occupational training per day
Multidimensional Pain Index
Coping Strategies Questionnaire CSQ

Notes

CBT vs TAU, post-treatment:analyses 3.1, 3.2

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 17/35

Is the Design Quality adequate?

No

Design Quality = 11/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 6/9

Kaapa 2006
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, 6 months, one year, two years.

Participants

End of treatment n = 120

Start of treatment n = 132
Sex: 120F, 12M (start of treatment)
Mean age = 46.3 (s.d. 7.5)
Source = community
Diagnosis = Chronic Low Back Pain
Mean years of pain = 1.3

Interventions

semi-intensive multidisciplinary rehabilitation

individual physiotherapy

Outcomes

Primary Pain Outcome: pain intensity 0-10

Primary Disability Outcome: Oswestry Disability Index 0-100
Primary Mood Outcome: (DEPS) depression 0-30
Low back pain intensity 0-10
Sciatic pain intensity 0-10
Oswestry Disability Index 0-100
subjective work capacity 0-10

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Kaapa 2006

(Continued)
recent sick leave due to back pain
beliefs re working (2 year follow-up) 0-10
The Depression Scale (DEPS) 0-30
Healthcare consumption 12 months

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 23/35

Is the Design Quality adequate?

Yes

Design Quality = 20/26

Is the Treatment Quality adequate?

No

Treatment Quality = 3/9

Keefe 1990
Methods

RCT. Three arms. Assessed pre-treatment, post-treatment, six months.

Participants

End of treatment n = 94
Start of treatment n = 99
Sex: 71F, 28M
Mean age = 64.0 (s.d. 11.5)
Source = rheumatology clinic
Diagnosis = Osteoarthritis of the knee
Mean years of pain = 12.0

Interventions

coping skills training

arthritis education
standard care

Outcomes

Primary Pain Outcome: AIMS pain

Primary Disability Outcome: AIMS physical disability
Primary Mood Outcome: AIMS psychological disability
Arthritis Impact Measurement Scale (AIMS): pain
Arthritis Impact Measurement Scale (AIMS): psychological disability
Arthritis Impact Measurement Scale (AIMS): physical disability
Pain Behaviour (Keefe & Block) observation
Coping Strategy Questionnaire
Medication use

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Keefe 1990

(Continued)

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3
CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 26/35

Is the Design Quality adequate?

Yes

Design Quality = 18/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 8/9

Keefe 1996
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six months, one year.

Participants

End of treatment n = 82
Start of treatment n = 88
Sex: 54F, 34M
Mean age = 62.6 (s.d. 10.1)
Source = volunteer
Diagnosis = Osteoarthritis of knee
Mean years of pain = 10.7

Interventions

spouse-assisted coping skills training

coping skills training
spouse-supported arthritis education

Outcomes

Primary Pain Outcome: AIMS pain

Primary Disability Outcome: AIMS physical disability
Primary Mood Outcome: AIMS mental disability
Arthritis Impact Measurement Scale (AIMS): pain
Arthritis Impact Measurement Scale (AIMS): physical
Arthritis Impact Measurement Scale (AIMS): psychological
Coping Strategies Questionnaire coping
Coping Strategies pain control
Pain behaviour (Keefe & Block) observation

Notes

CBT vs Active, post-treatment: analyses 1.1, 1.2, 1.3

Risk of bias
Item

Authors judgement

Description

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Keefe 1996

(Continued)

Is the Study Quality adequate?

Yes

Total Quality = 25/35

Is the Design Quality adequate?

Yes

Design Quality = 17/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 8/9

Kole-Snijders 1999
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six months, one year.

Participants

End of treatment n = 133

Start of treatment n =148
Sex: 94 F, 54 M
Mean age = 30.8 (s.d. 9.1)
Source = pain or rehabilitation clinic
Diagnosis = Chronic Low Back Pain
Mean years of pain = 9.8

Interventions

operant + cognitive coping skills

operant + group discussion
waiting list

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
(all reduced by factor analysis to 3 scores: motoric, coping control, negative affect)
Pain Behaviour Scale
Checklist for Interpersonal Pain Behaviour
Behavioural approach test (walking distance)
Multi dimensional Locus of Control
Pain Cognition Checklist
Coping Strategies Questionnaire
Nijmegen Hyperventilation Questionnaire
Visual Analogue Scale pain
McGill Pain Questionnaire pain

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 24/35

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Kole-Snijders 1999

(Continued)

Is the Design Quality adequate?

Yes

Design Quality = 20/26

Is the Treatment Quality adequate?

No

Treatment Quality = 4/9

Kraaimaat 1995
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six months.

Participants

End of treatment n = 52
Start of treatment n = 58
Sex: 52F, 25M (from the 77 who agreed to participate)
Mean age = 57.0 (s.d. 12.7)
Source = rheumatology clinics
Diagnosis = Rheumatoid arthritis
Mean years of pain = 15.6

Interventions

Cognitive Behavioural Therapy

occupational therapy
waiting list

Outcomes

Primary Pain Outcome: IRGL pain

Primary Disability Outcome: IRGL function (Reversed)
Primary Mood Outcome: IRGL depression
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): function
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): self care
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): pain
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): anxiety
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): depression
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): potential support
Invloed van Reuma op Gezondheid en Leefwijze (IRGL): actual support
Invloed van Reuma op Gezondheid en Leefwijze (IRGL):mutual visits

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3
CBT vs TAU, post-treatment and follow-up: analyses 3.1, 3.2, 3.3, 4.1, 4.2, 4.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 21/35

Is the Design Quality adequate?

Yes

Design Quality = 14/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 7/9

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Marhold 2001
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, two-four months, four-six months.

Participants

End of treatment n= 70
Start of treatment n = 72
Sex: 72F, 0M
Mean age = 46.0 (s.d. 9.0)
Source = national sick leave register
Diagnosis = mixed chronic pain, 58% neck
Mean years of pain = not given, but half had been on sick leave 3 months, and half for 26
months.

Interventions

Cognitive Behaviour Therapy for return to work

Treatment as usual

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
Days on sick leave
Multidimensional Pain Index
Coping Strategies Questionnaire
Beck Depression Index
Disability Rating Index
Pain and impairment rating scale (PAIRS)

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 20/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 5/9

McCarberg 1999
Methods

RCT. Two arms. Assessed pre-treatment, six months follow-up.

Participants

End of treatment n = 245

Start of treatment n = 353
Sex: 264F, 89M
Mean age = 52.1 (s.d. 9.6)
Source = pain or rehabilitation clinic

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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McCarberg 1999

(Continued)
Diagnosis = mixed chronic pain, many Chronic Low Back Pain
Mean years of pain = 9.6

Interventions

Cognitive Behaviour Therapy

minimal home study

Outcomes

Primary Pain Outcome: MPI pain severity

Primary Disability Outcome: MPI pain interference
Primary Mood Outcome: MPI affective distress
11pt box scale pain severity
pain discomfort scale: pain distress
Multidimensional Pain Inventory: pain severity
Multidimensional Pain Inventory: affective distress
Multidimensional Pain Inventory: self control
Multidimensional Pain Inventory: interference
Multidimensional Pain Inventory: social support and spouse behaviour subscales

Notes

CBT vs Active, follow-up: analyses 2.1, 2.2, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 10/35

Is the Design Quality adequate?

No

Design Quality = 9/26

Is the Treatment Quality adequate?

No

Treatment Quality = 1/9

Mishra 2000
Methods

RCT. Four arms. Assessed at pre-treatment, post-treatment.

Participants

End of treatment n = 94
Start of treatment n = 94
Sex: 77F, 7M
Mean age = 35.8 (s.d. 9.9)
Source = pain or rehabilitation clinic and volunteer
Diagnosis = temporomandibular joint disorder
Mean years of pain = 7.0

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Mishra 2000

(Continued)

Interventions

Biofeedback (BT)
Cognitive behavioural skills training (CBT)
Cognitive behavioural skills training + biofeedback
no treatment control

Outcomes

Primary Pain Outcome: CPI pain index

Primary Disability Outcome: none available
Primary Mood Outcome: none available
Characteristic Pain Index (CPI) pain severity 0-100
Graded Chronic Pain Score
Profile of Mood States total

Notes

CBT vs TAU, post-treatment: analysis 3.1

BT vs TAU, post-treatment: analysis 7.1

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 19/35

Is the Design Quality adequate?

No

Design Quality = 12/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 7/9

Moore 1985
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, three months, seven months.

Participants

End of treatment n = 34
Start of treatment n = 43
Sex: 1F, 42M
Mean age = 49.3 (s.d. 13.2)
Source = pain clinic
Diagnosis = mixed chronic pain
Mean years of pain = 16.5

Interventions

Cognitive Behaviour Therapy in couples group

Cognitive Behaviour Therapy in patient group
waiting list

Outcomes

Primary Pain Outcome: SIP pain

Primary Disability Outcome: none available
Primary Mood Outcome: MMPI depression

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Moore 1985

(Continued)
Visual Analogue Scale pain severity
Visual Analogue Scale spouse rated pain
Sickness Impact Profile: pain
Minnesota Multiphasic Personality Inventory: depression
Minnesota Multiphasic Personality Inventory: somatization
Personal Adjustment and Role Skills: spouse
Marital satisfaction
Medical Visits

Notes

CBT vs TAU, post-treatment: analyses 3.1, 3.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 17/35

Is the Design Quality adequate?

No

Design Quality = 11/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 6/9

Newton-John 1995
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six months.

Participants

End of treatment n = 35
Start of treatment n = 44
Sex: 27F, 17M
Mean age = 45.5 (s.d. 11.6)
Source = pain or rehabilitation clinic, community referral, volunteer
Diagnosis = Chronic Low Back Pain
Mean years of pain = 10.2

Interventions

Cognitive Behaviour Therapy

biofeedback
waiting list

Outcomes

Primary Pain Outcome: pain diary

Primary Disability Outcome: MPI general activity
Primary Mood Outcome: BDI depression
Pain diary
Pain disability
Multidimensional Pain Inventory: general activity
Coping Strategies Questionnaire modified

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Newton-John 1995

(Continued)
Pain Beliefs Questionnaire
Beck Depression Inventory (BDI)
State-Trait Anxiety Index (STAI): state

Notes

CBT vs TAU, post-treatment: analyses 3.1, 3.2, 3.3

BT vs TAU, post-treatment: analyses 7.1, 7.2, 7.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 15/35

Is the Design Quality adequate?

No

Design Quality = 10/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 5/9

Nicassio 1997
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, six months.

Participants

End of treatment n = 71
Start of treatment n = 96
Sex: 63F, 8M (at follow-up)
Mean age = 53.1 (s.d. no given)
Source = pain or rehabilitation clinic, support groups
Diagnosis = fibromyalgia
Mean years of pain = 11.1

Interventions

behavioural treatment
education

Outcomes

Primary Pain Outcome: not available

Primary Disability Outcome: quality of well being
Primary Mood Outcome: CES-D Depression
pain index: composite of Fibromyalgia Impact Questionnaire pain scale, MPQ PRI, number
of body areas, and flare index
Pain Behavior Checklist self-reported pain behaviour
Pain behaviour (Keefe & Block) observation
Center for Epidemiologic Studies Depression Scale (CES-D)
Rheumatology Attitudes Index helplessness subscale
Pain Management Inventory active and passive coping
Quality of Well being Scale QWB: structured interview on functional impairment

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Nicassio 1997

(Continued)
Quality of Social Support Scale
myalgia score, nurse rated on examination

Notes

BT vs Active, post-treatment and follow-up: analyses 5.2, 5.3, 6.2, 6.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 21/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 6/9

OLeary 1988
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment.

Participants

End of treatment n = 30
Start of treatment n = 33
Sex: 30F, 0M
Mean age = 49.3 (s.d. not given)
Source = volunteers, specialist referrals, Arthritis Center
Diagnosis = rheumatoid arthritis
Mean years of pain = 8.0

Interventions

CBT
bibliotherapy

Outcomes

Primary Pain Outcome: Arthritis Self-Efficacy Scale: pain subscale (no data available)
Primary Disability Outcome: Perceived stress (no data available)
Primary Mood Outcome: Perceived stress: coping (no data available)
Average pain 0-100
Highest pain 0-100
Health Assessment Questionnaire disability
Joint impairment
Arthritis Self-Efficacy perceived ability to control pain, depression, and fatigue each 0-100
Arthritis Self-Efficacy to manage pain
Arthritis Self-Efficacy to be active despite pain
Zung Depression
Perceived Stress Scale: coping
University of California Los Angeles loneliness scale
Sleep quantity

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OLeary 1988

(Continued)
Sleep quality

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 10/35

Is the Design Quality adequate?

No

Design Quality = 8/26

Is the Treatment Quality adequate?

No

Treatment Quality = 2/9

Parker 1988
Methods

RCT. Three arms. Assessed at pre-treatment, six months, one year

Participants

End of treatment n = 83
Start of treatment n = not given
Sex: 3F, 80 M
Mean age = 60.6 (s.d. 7.7)
Source = hospital
Diagnosis = rheumatoid arthritis
Mean years of pain = 11.4

Interventions

cognitive behavioural pain management group

attention placebo group
control group (TAU)

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
Visual Analogue Scale pain
McGill Pain Questionnaire pain dimensions
Coping Strategies Questionnaire
Arthritis Impact Measurement Scale (AIMS)
Beck Depression Inventory
Symptom Checklist-90R psychological symptoms
Hassled Scale
Ways of Coping Questionnaire
Arthritis Helplessness Index
Disease status measures including walking speed.

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Parker 1988

(Continued)

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 14/35

Is the Design Quality adequate?

No

Design Quality = 11/26

Is the Treatment Quality adequate?

No

Treatment Quality = 3/9

Puder 1988
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, one month.

Participants

End of treatment n = 69
Start of treatment n = 71
Sex: 49F, 20 M
Mean age = 52.7 (s.d. 14.4)
Source = community
Diagnosis = mixed chronic pain
Mean years of pain = 10.0

Interventions

Cognitive Behaviour Therapy

waiting list

Outcomes

Primary Pain Outcome: pain diary

Primary Disability Outcome: pain interference
Primary Mood Outcome: none available
Pain diary 0-5: highest and lowest ratings
Pain interference 0-5
Coping 0-5
Medication use

Notes

CBT vs TAU, post-treatment: analyses 3.1, 3.2

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 12/35

Is the Design Quality adequate?

No

Design Quality = 9/26

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Puder 1988

(Continued)

Is the Treatment Quality adequate?

No

Treatment Quality = 3/9

Radojevic 1992
Methods

RCT. Four arms. Assessed at pre-treatment, post-treatment, two months.

Participants

End of treatment n = 59
Start of treatment n = 65
Sex: 45F, 14M
Mean age = 54.4 (s.d. not given)
Source = rheumatology clinics
Diagnosis = rheumatoid arthritis
Mean years of pain = 11.8

Interventions

cognitive behavior therapy with family

cognitive behavior therapy (CBT)
education with family support (Active Control)
waiting list

Outcomes

Primary Pain Outcome: AIMS pain

Primary Disability Outcome: AIMS physical disability (Reversed)
Primary Mood Outcome: AIMS psychological disability
Arthritis Impact Measurement Scale (AIMS): pain
Arthritis Impact Measurement Scale (AIMS): physical disability
Arthritis Impact Measurement Scale (AIMS): psychological disability
Center for Epidemiologic Studies Depression Scale (CES-D)
Pain Management Inventory
Joint examination

Notes

CBT vs Active, post-treatment: analyses 1.1, 1.2, 1.3

CBT vs TAU, post-treatment: analyses 3.1, 3.2, 3.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 20/35

Is the Design Quality adequate?

No

Design Quality = 12/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 8/9

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Redondo 2004
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, six months, one year.

Participants

End of treatment n= 31
Start of treatment n = 40
Sex: 40F, 0M
Mean age = not given
Source = pain or rehabilitation clinic
Diagnosis = fibromyalgia
Mean years of pain = not given

Interventions

Cognitive Behavioural Therapy

physical exercise

Outcomes

Primary Pain Outcome: SF36 pain

Primary Disability Outcome: SF36 physical function (reversed)
Primary Mood Outcome: BDI depression
tender point score
Fibromyalgia Impact Questionnaire (FIQ)
Short Form 36: physical role
Short Form 36: pain
Short Form 36: general health
Short Form 36: vitality
Short Form 36: social function
Short Form 36: emotional role
Short Form 36: mental health
Short Form 36: health change
Beck Depression Index
Beck Anxiety Inventory (BAI)
Arthritis Self Efficacy Scale pain management, physical function, symptoms
Chronic Pain Coping Inventory
functional capacity upper limb, lower limb, vertebral column
aerobic exercise capacity

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.2, 1.3, 2.1, 2.2, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 15/35

Is the Design Quality adequate?

No

Design Quality = 12/26

Is the Treatment Quality adequate?

No

Treatment Quality = 3/9

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Smeets 2006
Methods

RCT. Four arms. Assessed at pre-treatment, post-treatment.

Participants

End of treatment n = 212

Start of treatment n = 223
Sex: 106F, 117M
Mean age = 41.6 (s.d. 10.0)
Source = pain or rehabilitation clinic
Diagnosis = CLBP
Mean years of pain = 4/6

Interventions

Cognitive Behavioural Therapy + active physical treatment

Cognitive Behavioural Therapy
active physical treatment
waiting list

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
Roland Morris Disability Questionnaire disability
Difficulty with 3 most limited activities: 0-100
Visual Analogue Scale pain
Beck Depression Inventory
Pain Cognitions List: catastrophizing, pain control subscales.

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 28/35

Is the Design Quality adequate?

Yes

Design Quality = 23/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 5/9

Spence 1989
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six months, two years.

Participants

End of treatment n = 42
Start of treatment n = 45
Sex: 44F, 1M
Mean age = not given
Source = volunteer

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Spence 1989

(Continued)
Diagnosis = chronic pain upper limb
Mean years of pain not given

Interventions

group Cognitive Behavioural Therapy

individual Cognitive Behavioural Therapy
waiting list

Outcomes

Primary Pain Outcome: MPQ PRI

Primary Disability Outcome: SIP self rated
Primary Mood Outcome: BDI depression
Pain Rating: Diary
Multidimensional Pain Questionnaire: Pain Rating Index
Interference: Diary
Distress: Diary
Beck Depression Inventory
State Trait Anxiety Inventory
Sickness Impact Profile: Self
Sickness Impact Profile: Other-rated
Coping Strategies Questionnaire: modified

Notes

CBT vs TAU, post-treatment: analyses 3.1, 3.2, 3.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 17/35

Is the Design Quality adequate?

No

Design Quality = 13/26

Is the Treatment Quality adequate?

No

Treatment Quality = 4/9

Strauss 1986
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six months.

Participants

End of treatment n = 43
Start of treatment n = 57
Sex: 46F, 11M
Mean age = 54.0 (s.d. 13.0)
Source = rheumatology clinic
Diagnosis = rheumatoid arthritis
Mean years of pain not given

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Strauss 1986

(Continued)

Interventions

group psychotherapy
relaxation/assertion
no treatment

Outcomes

Primary Pain Outcome: no data available

Primary Disability Outcome: no data available
Primary Mood Outcome: no data available
4 aggregate outcome measures:
functional status, social adaptation, psychological adaptation, psychological symptoms.
Measures contributing to these:
Arthritis Impact Measurement Scale (AIMS)
Short Form 36
Rathus Assertive Behavior Scale
Rosenberg Self-Esteem Scale
Hostility Inventory
Wrights Human Service Scale & Handicap Problems Inventory

Notes
Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 10/35

Is the Design Quality adequate?

No

Design Quality = 9/26

Is the Treatment Quality adequate?

No

Treatment Quality = 1/9

Strong 1998
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, three months.

Participants

End of treatment n = 30
Start of treatment n = 30
Sex: not given
Mean age = 44.4 (s.d. 13.7)
Source = pain or rehabilitation clinic
Diagnosis = CLBP
Mean years of pain = 8.3

Interventions

CBT psychoeducation + usual management

placebo attention + usual management

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Strong 1998

(Continued)

Outcomes

Primary Pain Outcome: MPI pain severity

Primary Disability Outcome: none available
Primary Mood Outcome: no data available
3 factors derived from measures: illness behaviour, depressive/negative thinking, using pain strategies
Contributing measures:
Box pain scale
Pain Disability Index
Coping Strategies Questionnaire: multiple subscales
Survey of Pain Attitudes Revised: multiple subscales
Illness Behavior Questionnaire: several subscales

Notes

CBT vs Active, post-treatment: analysis 1.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 9/35

Is the Design Quality adequate?

No

Design Quality = 7/26

Is the Treatment Quality adequate?

No

Treatment Quality = 2/9

Thieme 2003
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, six months, 15 months.

Participants

End of treatment n = 61
Start of treatment n = 83
Sex: 61F, 0M
Mean age = 47.3 (s.d. 8.3)
Source = hospital for rheumatic disorders
Diagnosis = fibromyalgia
Mean years of pain = 16.5

Interventions

operant treatment
standard physical treatment

Outcomes

Primary Pain Outcome: MPI pain

Primary Disability Outcome: MPI interference
Primary Mood Outcome: MPI affective distress
Diary pain intensity
Multidimensional Pain Inventory: pain

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Thieme 2003

(Continued)
Multidimensional Pain Inventory: interference
Multidimensional Pain Inventory: life control
Multidimensional Pain Inventory: affective distress
Multidimensional Pain Inventory: social support
Multidimensional Pain Inventory: self-efficacy
Multidimensional Pain Inventory: punishing responses, solicitous responses, distracting responses
Multidimensional Pain Inventory: total activities
doctor visits (from medical records)
hospital days (from medical records)
sleep hours diary
medication diary
Tubingen pain behaviour scale

Notes

BT vs TAU, post-treatment and follow-up: analyses 7.1, 7.2, 7.3, 8.1, 8.2, 8.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

No

Total Quality = 15/35

Is the Design Quality adequate?

No

Design Quality = 11/26

Is the Treatment Quality adequate?

No

Treatment Quality = 4/9

Turner 1988
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, six months, one year.

Participants

End of treatment n = 53
Start of treatment n = 81
Sex: 30F, 51M
Mean age = 46.0 (s.d. not given)
Source = pain or rehabilitation clinic
Diagnosis = CLBP
Mean years of pain = 6.2

Interventions

CBT
operant behavior therapy
waiting list

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Turner 1988

(Continued)

Outcomes

Primary Pain Outcome: MPQ PRI

Primary Disability Outcome: SIP patient-rated
Primary Mood Outcome: none available
Multidimensional Pain Questionnaire: Pain Response Index
Sickness Impact Profile: patient-rated
Sickness Impact Profile: spouse-rated
Pain behaviour (Keefe & Block) observation
Pain Behavior Checklist patient-rated
Pain Behavior Checklist spouse-rated
Cognitive Errors Questionnaire

Notes

CBT vs TAU, post-treatment (waiting list not followed up): analyses 3.1, 3.2
BT vs TAU, post-treatment (waiting list not followed up):
analyses 7.1, 7.2

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 23/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 8/9

Turner 1990
Methods

RCT. Four arms. Assessed at pre-treatment, post-treatment, six months, one year.

Participants

End of treatment n = 76
Start of treatment n = 96
Sex: 46F, 50M
Mean age = 44.0 (s.d. not given)
Source = community
Diagnosis = CLBP
Mean years of pain = 12.9

Interventions

behavior therapy + aerobic exercise

behavior therapy (BT)
aerobic exercise (Active Control)
waiting list

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Turner 1990

(Continued)

Outcomes

Primary Pain Outcome: MPQ PRI

Primary Disability Outcome: SIP patient-rated
Primary Mood Outcome: CES-D depression
Multidimensional Pain Questionnaire: Pain Response Index
Sickness Impact Profile: patient-rated
Sickness Impact Profile: spouse-rated
Pain Behavior CheckList patient-rated
Pain Behavior CheckList spouse-rated
Center for Epidemiologic Studies Depression Scale (CES-D)
Observed Pain Behaviour
Visual Analogue Scale pain spouse-rated
Strength
Flexibility
Pain Ways of Coping -150

Notes

BT vs Active, post-treatment and follow-up: analyses 5.1, 5.2, 5.3, 6.1, 6.2, 6.3
BT vs TAU, post-treatment (waiting list not followed up): analyses 7.1, 7.2, 7.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 20/35

Is the Design Quality adequate?

No

Design Quality = 13/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 7/9

Turner 1993
Methods

RCT. Four arms. Assessed at pre-treatment, post-treatment, 6 months, one year.

Participants

End of treatment n = 54
Start of treatment n = 102
Sex: 55F, 47M
Mean age = 42 (s.d. not given)
Source = pain or rehabilitation clinic, volunteer
Diagnosis = CLBP
Mean years of pain = 5.0

Interventions

cognitive therapy + relaxation (CBT)

cognitive therapy
relaxation (BT)
waiting list

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Turner 1993

(Continued)

Outcomes

Primary Pain Outcome: VAS pain

Primary Disability Outcome: SIP patient-rated
Primary Mood Outcome: BDI depression
Visual Analogue Scale (VAS) Pain
Sickness Impact Profile: patient-rated
Pain behaviour (Keefe & Block) observation
Cognitive Errors Questionnaire
Beck Depression Inventory (BDI)

Notes

CBT vs TAU, post-treatment (waiting list not followed up): analyses 3.1, 3.2, 3.3
BT vs TAU, post-treatment (waiting list not followed up): analyses 7.1, 7.2, 7.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 23/35

Is the Design Quality adequate?

Yes

Design Quality = 15/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 8/9

Turner 2006
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, 6 months, one year.

Participants

End of treatment n = 142

Start of treatment n = 158
Sex: 128F, 30M
Mean age = 37.4 (s.d. 11.3)
Source = pain or rehabilitation clinic
Diagnosis = temporomandibular joint pain
Mean years of pain = not given

Interventions

brief CBT: Pain Management Training

education/attention control: Self care control

Outcomes

Primary Pain Outcome: Graded Chronic Pain Scale: Pain Intensity

Primary Disability Outcome: none available
Primary Mood Outcome: BDI depression
Graded Chronic Pain Scale: Activity Interference
Graded Chronic Pain Scale: Pain Intensity
Beck Depression Inventory (BDI)
Mandibular Function Impairment Questionnaire (MFIQ)

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Turner 2006

(Continued)
Survey of Pain Attitudes (SOPA)
TMD Self efficacy scale
CSQ catastrophizing subscale
Pain Catastrophizing Scale rumination subscale
Chronic Pain Coping Inventory (CPCI) task persistence, coping self-statements, relaxation,
rest

Notes

CBT vs Active, post-treatment and follow-up: analyses 1.1, 1.3, 2.1, 2.3

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 27/35

Is the Design Quality adequate?

Yes

Design Quality = 22/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 5/9

Turner-Stokes 2003
Methods

RCT. Two arms. Assessed at pre-treatment, post-treatment, 6 months, one year.

Participants

End of treatment n = 113

Start of treatment n = 126
Sex: 87F, 39M
Mean age = 47.8 (s.d. not given)
Source = pain or rehabilitation clinic
Diagnosis = mixed chronic pain
Mean years of pain = 8.8

Interventions

group programme
individual programme

Outcomes

Primary Pain Outcome: none available

Primary Disability Outcome: none available
Primary Mood Outcome: none available
McGill Pain Questionnaire
Multidimensional Pain Inventory (MPI)
Beck Depression Inventory (BDI)
State Trait Anxiety Index (STAI)
analgesic consumption

Notes

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Turner-Stokes 2003

(Continued)

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 19/35

Is the Design Quality adequate?

Yes

Design Quality = 17/26

Is the Treatment Quality adequate?

No

Treatment Quality = 2/9

Vlaeyen 1995
Methods

RCT. Four arms. Assessed at pre-treatment, post-treatment, 6 months, one year.

Participants

End of treatment n = 56
Start of treatment n = 71
Sex: 53F, 18M
Mean age = 42.2 (s.d. not given)
Source = pain or rehabilitation clinic
Diagnosis = CLBP
Mean years of pain = 11.4

Interventions

cognitive treatment
operant treatment
respondent treatment
waiting list

Outcomes

Primary Pain Outcome: VAS pain

Primary Disability Outcome: none available
Primary Mood Outcome: BDI (data not available)
Visual Analogue Scale: pain
Behavioural Approach Test (BAT)
Checklist for interpersonal pain behaviour (CHIP)
Pain Cognition List (PCL)
walking distance, walk time
Beck Depression Inventory (BDI)

Notes

CBT vs TAU, post-treatment (waiting list not followed up): analysis 3.1
BT vs TAU, post-treatment (waiting list not followed up): analysis 7.1

Risk of bias
Item

Authors judgement

Description

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Vlaeyen 1995

(Continued)

Is the Study Quality adequate?

No

Total Quality = 16/35

Is the Design Quality adequate?

No

Design Quality = 12/26

Is the Treatment Quality adequate?

No

Treatment Quality = 4/9

Vlaeyen 1996
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, 6 months, one year.

Participants

End of treatment n = 122

Start of treatment n = 131
Sex: 110F, 15M
Mean age = 44.0 (s.d. 9.4)
Source = pain or rehabilitation clinic
Diagnosis = fibromyalgia
Mean years of pain = 10.2

Interventions

cognitive + group discussion

education + group discussion
waiting list

Outcomes

Primary Pain Outcome: pain intensity score

Primary Disability Outcome: none available
Primary Mood Outcome: BDI depression
Composite scores from factor analysis:
Pain intensity, pain coping, pain control, relaxation, catastrophizing, pain behaviour, activity
Measures contributing to factors:
Multidimensional Pain Questionnaire: Pain Response Index
Coping Strategies Questionnaire (CSQ)
Beck Depression Inventory (BDI) (none available)
Fear Survey Schedule
Arthritis knowledge
Maudsley Obsessive Compulsive Inventory
Pain behaviour scale
Multidimensional Pain Locus of Control Scale (MPCL)
Walking distance, walking time, cycling time

Notes

CBT vs Active, post-treatment: analyses 1.1, 1.3

CBT vs TAU, post-treatment: analyses 3.1, 3.3

Risk of bias

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Vlaeyen 1996

(Continued)

Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 20/35

Is the Design Quality adequate?

Yes

Design Quality = 16/26

Is the Treatment Quality adequate?

No

Treatment Quality = 4/9

Williams 1996
Methods

RCT. Three arms. Assessed at pre-treatment, post-treatment, 6 months, one year.

Participants

End of treatment n = 99
Start of treatment n = 121
Sex: 68F, 53M
Mean age = 50.0 (s.d. 11.5)
Source = pain clinic
Diagnosis = mixed chronic pain, low back commonest
Mean years of pain = 7.8

Interventions

inpatient CBT
outpatient CBT
waiting list

Outcomes

Primary Pain Outcome: VAS pain

Primary Disability Outcome: SIP patient-rated
Primary Mood Outcome: BDI depression
Visual Analogue Scale (VAS): pain intensity
Visual Analogue Scale (VAS): pain distress
Sickness Impact Profile (SIP): patient-rated
Beck Depression Inventory (BDI)
State-Trait Anxiety Inventory (STAI)
Coping Strategies Questionnaire (CSQ): catastrophizing
Pain Self-Efficacy Questionnaire (PSEQ)
Pain Cognitions Questionnaire (PCQ)
walk distance
arm endurance
stair climb
standups
medication use
health care use

Notes

CBT vs TAU, post-treatment (waiting list not followed up): analyses 3.1, 3.2, 3.3

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Williams 1996

(Continued)

Risk of bias
Item

Authors judgement

Description

Is the Study Quality adequate?

Yes

Total Quality = 21/35

Is the Design Quality adequate?

Yes

Design Quality = 14/26

Is the Treatment Quality adequate?

Yes

Treatment Quality = 7/9

Characteristics of excluded studies [ordered by study ID]

Alaranta 1994

Insufficient psychotherapeutic content

Appelbaum 1988

Inadequate n: The number of patients in any treatment arm was less than 10

Asenlof 2005

Not chronic pain

Bendix 1997

Insufficient psychotherapeutic content

Broderick 2004

Insufficient psychotherapeutic content

Brox 2003

Insufficient psychotherapeutic content

Corrado 2003

No primary psychological treatment for pain or non psychological comparator

Currie 2000

No primary psychological treatment for pain or non psychological comparator

Dahl 2004

Inadequate n: The number of patients in any treatment arm was less than 10

Dalton 2004

Not chronic pain

Dworkin 2002a

Insufficient psychotherapeutic content

Edinger 2005

No primary psychological treatment for pain or non psychological comparator

Evans 2003

Not chronic pain

Fors 2000

Insufficient psychotherapeutic content

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(Continued)

Haugstad 2006

Insufficient psychotherapeutic content

Keefe 2004

No primary psychological treatment for pain or non psychological comparator

Keller 2004

Insufficient psychotherapeutic content

Kerns 1986

Inadequate n: The number of patients in any treatment arm was less than 10

Linton 1984

Inadequate n: The number of patients in any treatment arm was less than 10

Linton 1985

Inadequate n: The number of patients in any treatment arm was less than 10

Linton 2001

Not chronic pain

Linton 2005

Not chronic pain

Moffett 2005

Insufficient psychotherapeutic content

Moore 2000

Not chronic pain

Nicholas 1991

Inadequate n: The number of patients in any treatment arm was less than 10

Nicholas 1992

Inadequate n: The number of patients in any treatment arm was less than 10

Parker 2003

No primary psychological treatment for pain or non psychological comparator

Peters 1990

Inadequate n: The number of patients in any treatment arm was less than 10

Schweikert 2006

Insufficient psychotherapeutic content

Sharpe 2001

Not chronic pain

Soderlund 2001

Insufficient psychotherapeutic content

Spence 1995

Insufficient psychotherapeutic content

Turner 1982

Inadequate n: The number of patients in any treatment arm was less than 10

Van den Hout 2003

Not chronic pain

Van Lankveld 2004

No primary psychological treatment for pain or non psychological comparator

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Characteristics of studies awaiting classification [ordered by study ID]

Babu 2007
Methods

Not yet assessed

Participants

Diagnosis = Fibromyalgia
Other details of participants not yet assessed

Interventions

EMG Biofeedback
Sham Biofeedback

Outcomes

Not yet assessed

Notes

New study
Change data only

Bliokas 2007
Methods

Not yet assessed

Participants

Diagnosis = Mixed chronic pain

Other details of participants not yet assessed

Interventions

Graded exposure in vivo and outpatient multidisciplinary chronic Pain management group program
outpatient multidisciplinary chronic Pain management group program
Waiting list control

Outcomes

Not yet assessed

Notes

New study

Ersek 2008
Methods

Not yet assessed

Participants

Diagnosis = Mixed sample older adults

Other details of participants not yet assessed

Interventions

pain self-management training group (SMG) intervention

education only control condition

Outcomes

Not yet assessed

Notes

New study

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Leeuw 2008
Methods

Not yet assessed

Participants

Diagnosis = Chronic Low Back Pain (CLBP)

Other details of participants not yet assessed

Interventions

Exposure in vivo
Operant graded activity

Outcomes

Not yet assessed

Notes

New study

Linton 2008
Methods

Not yet assessed

Participants

Diagnosis = spinal pain

Other details of participants not yet assessed

Interventions

exposure plus usual treatment

waiting list control plus usual treatment

Outcomes

Not yet assessed

Notes

New study

Lorig 2008
Methods

Not yet assessed

Participants

Diagnosis = rheumatoid arthritis, osteoarthritis, or fibromyalgia

Other details of participants not yet assessed

Interventions

Internet-based Arthritis Self-Management Program (ASMP)

Usual care

Outcomes

Not yet assessed

Notes

New study

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

81

Morone 2008
Methods

Not yet assessed

Participants

Diagnosis = Chronic Low Back Pain (CLBP)

Other details of participants not yet assessed

Interventions

Mindfulness Meditation
Wait-list control

Outcomes

Not yet assessed

Notes

New study

Smeets 2008
Methods

Not yet assessed

Participants

Diagnosis = Chronic Low Back Pain (CLBP)

Other details of participants not yet assessed

Interventions

active physical treatment; APT

graded activity plus problem solving training; GAP
combination treatment; CT

Outcomes

Not yet assessed

Notes

New study

Woods 2008
Methods

Not yet assessed

Participants

Diagnosis = Chronic Low Back Pain (CLBP)

Other details of participants not yet assessed

Interventions

graded in vivo exposure,

graded activity
Wait-list control

Outcomes

not yet assessed

Notes

New study

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

82

Zautra 2008
Methods

Not yet assessed

Participants

Diagnosis = Rheumatoid Arthritis

Other details of participants not yet assessed

Interventions

cognitive behavioral therapy for pain

mindfulness meditation and emotion regulation therapy
education-only group

Outcomes

not yet assessed

Notes

New study

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

83

DATA AND ANALYSES

Comparison 1. Cognitive behavioural vs active control post-treatment

Outcome or subgroup title

1 Pain
2 Disability
3 Mood

No. of
studies

No. of
participants

Statistical method

Effect size

14
12
15

861
728
890

Std. Mean Difference (IV, Random, 95% CI)

Std. Mean Difference (IV, Random, 95% CI)
Std. Mean Difference (IV, Random, 95% CI)

-0.14 [-0.33, 0.04]

-0.16 [-0.31, -0.02]
-0.11 [-0.29, 0.06]

Comparison 2. Cognitive behavioural vs active control follow-up

Outcome or subgroup title

1 Pain
2 Disability
3 Mood

No. of
studies

No. of
participants

Statistical method

Effect size

12
11
12

935
876
934

Std. Mean Difference (IV, Random, 95% CI)

Std. Mean Difference (IV, Random, 95% CI)
Std. Mean Difference (IV, Random, 95% CI)

-0.15 [-0.28, -0.02]

-0.21 [-0.36, -0.06]
-0.16 [-0.29, -0.03]

Comparison 3. Cognitive behavioural vs treatment as usual

Outcome or subgroup title

1 Pain
2 Disability
3 Mood

No. of
studies

No. of
participants

Statistical method

Effect size

23
18
16

1199
972
839

Std. Mean Difference (IV, Random, 95% CI)

Std. Mean Difference (IV, Random, 95% CI)
Std. Mean Difference (IV, Random, 95% CI)

-0.19 [-0.32, -0.05]

-0.08 [-0.27, 0.12]
-0.14 [-0.32, 0.05]

Comparison 4. Cognitive behavioural vs treatment as usual follow-up

Outcome or subgroup title

1 Pain
2 Disability
3 Mood

No. of
studies

No. of
participants

Statistical method

Effect size

9
8
9

693
496
684

Std. Mean Difference (IV, Random, 95% CI)

Std. Mean Difference (IV, Random, 95% CI)
Std. Mean Difference (IV, Random, 95% CI)

-0.15 [-0.36, 0.05]

-0.06 [-0.25, 0.12]
-0.16 [-0.31, -0.01]

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

84

Comparison 5. Behavioural vs active control post-treatment

Outcome or subgroup title

1 Pain
2 Disability
3 Mood

No. of
studies

No. of
participants

Statistical method

1
2
2

39
110
110

Std. Mean Difference (IV, Random, 95% CI)

Std. Mean Difference (IV, Random, 95% CI)
Std. Mean Difference (IV, Random, 95% CI)

Effect size
-0.25 [-0.88, 0.38]
-0.28 [-0.66, 0.10]
-0.28 [-0.73, 0.16]

Comparison 6. Behavioural vs active control follow-up

Outcome or subgroup title

1 Pain
2 Disability
3 Mood

No. of
studies

No. of
participants

Statistical method

1
2
2

39
110
110

Std. Mean Difference (IV, Random, 95% CI)

Std. Mean Difference (IV, Random, 95% CI)
Std. Mean Difference (IV, Random, 95% CI)

Effect size
0.30 [-0.34, 0.93]
-0.13 [-0.50, 0.25]
-0.19 [-0.63, 0.25]

Comparison 7. Behavioural vs treatment as usual post-treatment

Outcome or subgroup title

1 Pain
2 Disability
3 Mood

No. of
studies

No. of
participants

Statistical method

Effect size

9
7
6

430
374
357

Std. Mean Difference (IV, Random, 95% CI)

Std. Mean Difference (IV, Random, 95% CI)
Std. Mean Difference (IV, Random, 95% CI)

-0.55 [-0.90, -0.19]

-0.46 [-1.00, 0.08]
-0.44 [-1.01, 0.13]

Comparison 8. Behavioural vs treatment as usual follow-up

Outcome or subgroup title

1 Pain
2 Disability
3 Mood

No. of
studies

No. of
participants

Statistical method

3
3
3

232
230
230

Std. Mean Difference (IV, Random, 95% CI)

Std. Mean Difference (IV, Random, 95% CI)
Std. Mean Difference (IV, Random, 95% CI)

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Effect size
-0.25 [-0.71, 0.20]
-0.83 [-2.14, 0.47]
-0.91 [-1.98, 0.16]

85

Analysis 1.1. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 1 Pain.
Review:

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

Comparison: 1 Cognitive behavioural vs active control post-treatment

Outcome: 1 Pain

Study or subgroup

CBT

Active treatment control

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

Mean(SD)

Astin 2003

32

60.2 (17.7)

33

59.2 (18.7)

8.0 %

0.05 [ -0.43, 0.54 ]

Bradley 1987

16

3.05 (1.65)

18

3.79 (1.65)

5.2 %

-0.44 [ -1.12, 0.24 ]

Cook 1998

11

2.9 (1.5)

10

4.8 (2.1)

3.3 %

-1.01 [ -1.93, -0.09 ]

Ersek 2003

19

3.7 (1.6)

20

5.1 (1.9)

5.5 %

-0.78 [ -1.43, -0.13 ]

Greco 2004

32

1.98 (0.87)

33

1.97 (0.91)

8.0 %

0.01 [ -0.48, 0.50 ]

Jensen 1997

29

42.5 (25.5)

25

41 (21.8)

7.1 %

0.06 [ -0.47, 0.60 ]

Kaapa 2006

59

3.3 (2.5)

61

3.4 (2.4)

10.6 %

-0.04 [ -0.40, 0.32 ]

Keefe 1990

31

4.61 (1.73)

35

5.67 (1.65)

7.8 %

-0.62 [ -1.12, -0.13 ]

Keefe 1996

28

4.21 (1.48)

27

5.22 (2.06)

7.1 %

-0.56 [ -1.10, -0.02 ]

Kraaimaat 1995

24

14.8 (4.3)

28

15.4 (4.6)

7.0 %

-0.13 [ -0.68, 0.41 ]

Radojevic 1992

15

5.17 (2.12)

15

5.3 (3.04)

4.9 %

-0.05 [ -0.76, 0.67 ]

Redondo 2004

21

67 (19.5)

19

60.2 (14.8)

5.8 %

0.38 [ -0.24, 1.01 ]

Turner 2006

72

5.2 (1.9)

76

5.2 (2.1)

11.5 %

0.0 [ -0.32, 0.32 ]

Vlaeyen 1996

42

1 (1.8)

30

0.4 (1.8)

8.2 %

0.33 [ -0.14, 0.80 ]

100.0 %

-0.14 [ -0.33, 0.04 ]

Total (95% CI) 431

Std. Mean Difference

IV,Random,95% CI

430

Heterogeneity: Tau2 = 0.05; Chi2 = 22.68, df = 13 (P = 0.05); I2 =43%

Test for overall effect: Z = 1.52 (P = 0.13)

-2

-1

Favours experimental

Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

86

Analysis 1.2. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 2 Disability.
Review:

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

Comparison: 1 Cognitive behavioural vs active control post-treatment

Outcome: 2 Disability

Study or subgroup

CBT

Active treatment control

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

Mean(SD)

Astin 2003

32

48.8 (15.4)

33

50.1 (18.3)

9.0 %

-0.08 [ -0.56, 0.41 ]

Cook 1998

11

5.1 (3.5)

10

7.1 (3.6)

2.8 %

-0.54 [ -1.42, 0.33 ]

Ersek 2003

19

61.3 (27)

20

57.6 (19.8)

5.4 %

0.15 [ -0.48, 0.78 ]

Greco 2004

32

47.82 (22.88)

33

50.87 (26.72)

9.0 %

-0.12 [ -0.61, 0.37 ]

Hammond 2001

63

1.43 (1.8)

58

1.9 (2.18)

16.7 %

-0.23 [ -0.59, 0.12 ]

Jensen 1997

29

37.9 (18.1)

25

42.2 (12.8)

7.4 %

-0.27 [ -0.80, 0.27 ]

Kaapa 2006

59

20.9 (10.1)

61

21.6 (11.4)

16.7 %

-0.06 [ -0.42, 0.29 ]

Keefe 1990

31

2.06 (1.29)

35

2.34 (1.28)

9.1 %

-0.22 [ -0.70, 0.27 ]

Keefe 1996

28

1.72 (0.71)

27

1.53 (0.95)

7.6 %

0.22 [ -0.31, 0.75 ]

Kraaimaat 1995

24

5.8 (5.1)

28

10.1 (5.7)

6.6 %

-0.78 [ -1.35, -0.21 ]

Radojevic 1992

15

12.27 (9.43)

15

14.72 (11.61)

4.1 %

-0.23 [ -0.94, 0.49 ]

Redondo 2004

21

50.7 (20.6)

19

52.9 (19.3)

5.5 %

-0.11 [ -0.73, 0.51 ]

Total (95% CI) 364

Std. Mean Difference

IV,Random,95% CI

100.0 % -0.16 [ -0.31, -0.02 ]

364

Heterogeneity: Tau2 = 0.0; Chi2 = 9.12, df = 11 (P = 0.61); I2 =0.0%

Test for overall effect: Z = 2.20 (P = 0.028)

-2

-1

Favours experimental

Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

87

Analysis 1.3. Comparison 1 Cognitive behavioural vs active control post-treatment, Outcome 3 Mood.
Review:

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

Comparison: 1 Cognitive behavioural vs active control post-treatment

Outcome: 3 Mood

Study or subgroup

CBT

Active treatment control

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

Mean(SD)

Astin 2003

31

13.1 (7.9)

33

14.3 (8.4)

7.5 %

-0.15 [ -0.64, 0.35 ]

Bradley 1987

16

43.48 (31.43)

18

52.05 (31.45)

4.9 %

-0.27 [ -0.94, 0.41 ]

Cook 1998

11

8.1 (4.8)

10

11.6 (6.7)

3.3 %

-0.58 [ -1.46, 0.30 ]

Ersek 2003

19

7.6 (4.7)

20

8.8 (6.8)

5.4 %

-0.20 [ -0.83, 0.43 ]

Greco 2004

32

14.86 (10.07)

33

16.52 (11.53)

7.6 %

-0.15 [ -0.64, 0.34 ]

Jensen 1997

29

9 (6.7)

25

9.9 (6.8)

6.8 %

-0.13 [ -0.67, 0.40 ]

Kaapa 2006

59

5.5 (5.5)

61

5.7 (5.2)

10.5 %

-0.04 [ -0.40, 0.32 ]

Keefe 1990

31

2.59 (1.65)

35

2.09 (0.94)

7.6 %

0.37 [ -0.11, 0.86 ]

Keefe 1996

28

1.7 (0.97)

27

2.48 (1.57)

6.7 %

-0.59 [ -1.13, -0.05 ]

Kraaimaat 1995

24

3.1 (3.5)

28

2.2 (2.9)

6.6 %

0.28 [ -0.27, 0.83 ]

Radojevic 1992

15

6.05 (3.33)

15

4.62 (3.64)

4.4 %

0.40 [ -0.32, 1.12 ]

Redondo 2004

21

15.4 (8.8)

19

16.8 (10.2)

5.5 %

-0.14 [ -0.77, 0.48 ]

Strong 1998

15

-0.36 (0.89)

15

0.66 (0.76)

3.9 %

-1.20 [ -1.99, -0.41 ]

Turner 2006

72

8.8 (9.3)

76

11 (10.6)

11.4 %

-0.22 [ -0.54, 0.10 ]

Vlaeyen 1996

42

13.4 (5.8)

30

11.9 (5.8)

7.9 %

0.26 [ -0.21, 0.73 ]

Total (95% CI) 445

Std. Mean Difference

IV,Random,95% CI

100.0 % -0.11 [ -0.29, 0.06 ]

445

Heterogeneity: Tau2 = 0.04; Chi2 = 22.39, df = 14 (P = 0.07); I2 =37%

Test for overall effect: Z = 1.27 (P = 0.20)

-2

-1

Favours experimental

Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

88

Analysis 2.1. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 1 Pain.
Review:

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

Comparison: 2 Cognitive behavioural vs active control follow-up

Outcome: 1 Pain

Study or subgroup

Experimental
N

Control
Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Astin 2003

32

58.4 (22.2)

33

57.6 (22.5)

7.0 %

0.04 [ -0.45, 0.52 ]

Bradley 1987

16

3.61 (2.23)

18

3.78 (2.24)

3.7 %

-0.07 [ -0.75, 0.60 ]

Cook 1998

11

4.9 (2)

10

5.9 (2.5)

2.2 %

-0.43 [ -1.29, 0.44 ]

Ersek 2003

19

4.2 (2.1)

20

5.1 (2.4)

4.1 %

-0.39 [ -1.02, 0.24 ]

Greco 2004

32

2.05 (0.94)

33

1.87 (0.95)

7.0 %

0.19 [ -0.30, 0.68 ]

Jensen 1997

29

46.1 (19.8)

25

48.7 (28.3)

5.8 %

-0.11 [ -0.64, 0.43 ]

Kaapa 2006

53

3.3 (2.5)

54

3.4 (2.5)

11.6 %

-0.04 [ -0.42, 0.34 ]

Keefe 1990

30

5.22 (2.08)

35

5.91 (1.95)

6.9 %

-0.34 [ -0.83, 0.15 ]

Kraaimaat 1995

24

14.7 (4.7)

28

16.6 (4.6)

5.5 %

-0.40 [ -0.95, 0.15 ]

McCarberg 1999

113

3.63 (1.36)

132

3.79 (1.39)

26.3 %

-0.12 [ -0.37, 0.14 ]

Redondo 2004

21

66.2 (30.7)

19

65.7 (24.2)

4.3 %

0.02 [ -0.60, 0.64 ]

Turner 2006

72

3.9 (2.6)

76

4.7 (2.3)

15.8 %

-0.32 [ -0.65, 0.00 ]

100.0 %

-0.15 [ -0.28, -0.02 ]

Total (95% CI)

452

483

Heterogeneity: Tau2 = 0.0; Chi2 = 6.59, df = 11 (P = 0.83); I2 =0.0%

Test for overall effect: Z = 2.27 (P = 0.023)

-2

-1

Favours experimental

Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

89

Analysis 2.2. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 2 Disability.
Review:

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

Comparison: 2 Cognitive behavioural vs active control follow-up

Outcome: 2 Disability

Study or subgroup

CBT

Active control

Std. Mean Difference

Astin 2003

32

46.4 (29.5)

33

50 (18.2)

8.2 %

-0.15 [ -0.63, 0.34 ]

Cook 1998

11

5.8 (2.9)

10

8.9 (3.6)

2.6 %

-0.92 [ -1.83, -0.01 ]

Ersek 2003

19

61.6 (19)

20

57 (23.7)

5.2 %

0.21 [ -0.42, 0.84 ]

Greco 2004

32

49.52 (25.53)

33

49.78 (23.86)

8.3 %

-0.01 [ -0.50, 0.48 ]

Hammond 2001

63

1.33 (1.82)

60

2.13 (2.46)

13.8 %

-0.37 [ -0.73, -0.01 ]

Jensen 1997

29

45.6 (16.2)

25

46.7 (14.5)

7.0 %

-0.07 [ -0.61, 0.46 ]

Kaapa 2006

53

18.9 (12.8)

54

18.5 (12.4)

12.5 %

0.03 [ -0.35, 0.41 ]

Keefe 1990

30

1.69 (1.16)

35

2.63 (1.5)

7.8 %

-0.69 [ -1.19, -0.18 ]

Kraaimaat 1995

24

8.1 (5.6)

28

10.1 (6.6)

6.7 %

-0.32 [ -0.87, 0.23 ]

McCarberg 1999

113

3.62 (1.36)

132

3.81 (1.36)

22.7 %

-0.14 [ -0.39, 0.11 ]

21

47.8 (18.4)

19

56.1 (18.4)

5.2 %

-0.44 [ -1.07, 0.19 ]

100.0 %

-0.21 [ -0.36, -0.06 ]

Total (95% CI)

427

Mean(SD)

IV,Random,95% CI

Std. Mean Difference

Mean(SD)

Redondo 2004

Weight

IV,Random,95% CI

449

Heterogeneity: Tau2 = 0.01; Chi2 = 11.72, df = 10 (P = 0.30); I2 =15%

Test for overall effect: Z = 2.71 (P = 0.0068)

-2

-1

Favours experimental

Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

90

Analysis 2.3. Comparison 2 Cognitive behavioural vs active control follow-up, Outcome 3 Mood.
Review:

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

Comparison: 2 Cognitive behavioural vs active control follow-up

Outcome: 3 Mood
Study or subgroup

CBT

Active control

IV,Random,95% CI

Std. Mean Difference

Astin 2003

31

12.3 (7.6)

33

14 (9.2)

6.9 %

-0.20 [ -0.69, 0.29 ]

Bradley 1987

16

55.06 (30.93)

18

70.03 (30.95)

3.5 %

-0.47 [ -1.16, 0.21 ]

Cook 1998

11

8.3 (3.5)

10

11 (7)

2.2 %

-0.48 [ -1.35, 0.40 ]

Ersek 2003

19

8 (5.3)

20

9.6 (6.5)

4.2 %

-0.26 [ -0.89, 0.37 ]

Greco 2004

32

15.01 (10.5)

33

14.17 (11.64)

7.0 %

0.07 [ -0.41, 0.56 ]

Jensen 1997

29

10.1 (6.8)

25

10.1 (8.9)

5.8 %

0.0 [ -0.53, 0.53 ]

Kaapa 2006

53

5.7 (4.6)

54

5.8 (5.7)

11.6 %

-0.02 [ -0.40, 0.36 ]

Keefe 1990

30

2.51 (1.33)

35

2.92 (1.94)

6.9 %

-0.24 [ -0.73, 0.25 ]

Kraaimaat 1995

24

3.3 (3.4)

28

4 (4.2)

5.6 %

-0.18 [ -0.73, 0.37 ]

McCarberg 1999

113

3.63 (1.37)

132

3.79 (1.25)

26.3 %

-0.12 [ -0.37, 0.13 ]

Redondo 2004

21

13 (8)

19

13.6 (11.7)

4.3 %

-0.06 [ -0.68, 0.56 ]

Turner 2006

72

8.3 (9.1)

76

11.4 (10.1)

15.8 %

-0.32 [ -0.64, 0.00 ]

100.0 %

-0.16 [ -0.29, -0.03 ]

451

Mean(SD)

Weight

Mean(SD)

Total (95% CI)

Std. Mean Difference

IV,Random,95% CI

483

Heterogeneity: Tau2 = 0.0; Chi2 = 4.44, df = 11 (P = 0.96); I2 =0.0%

Test for overall effect: Z = 2.44 (P = 0.015)

-2

-1

Favours experimental

Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

91

Analysis 3.1. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 1 Pain.

Review:

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

Comparison: 3 Cognitive behavioural vs treatment as usual

Outcome: 1 Pain

Study or subgroup

CBT

usual treatment/waitlist

IV,Random,95% CI

Std. Mean Difference

Altmaier 1992

21

2.05 (0.74)

21

2 (0.89)

3.9 %

0.06 [ -0.55, 0.66 ]

Basler 1997

36

4.08 (2.11)

40

4.18 (1.37)

6.0 %

-0.06 [ -0.51, 0.39 ]

Becker 2000

49

52 (24)

42

65 (24)

6.5 %

-0.54 [ -0.96, -0.12 ]

Buhrman 2004

22

2.4 (1.1)

29

3.2 (0.8)

4.1 %

-0.84 [ -1.42, -0.26 ]

Carson 2005

18

4.86 (1.88)

25

5.14 (2.04)

3.8 %

-0.14 [ -0.75, 0.47 ]

Evers 2002

30

14.93 (5.32)

29

15.35 (4.55)

5.0 %

-0.08 [ -0.59, 0.43 ]

Flor 1993

26

2.32 (1.37)

26

2.52 (1.5)

4.5 %

-0.14 [ -0.68, 0.41 ]

Greco 2004

32

1.98 (0.87)

27

1.65 (0.89)

4.9 %

0.37 [ -0.15, 0.89 ]

Jensen 2001

49

70.2 (11.75)

48

71.48 (15.72)

7.0 %

-0.09 [ -0.49, 0.31 ]

Johansson 1998

18

49.3 (21.9)

19

51.2 (21.9)

3.5 %

-0.08 [ -0.73, 0.56 ]

Keefe 1990

31

4.61 (1.73)

28

5.68 (1.62)

4.8 %

-0.63 [ -1.15, -0.10 ]

Kraaimaat 1995

24

14.8 (4.3)

19

14.6 (4.4)

3.9 %

0.05 [ -0.56, 0.65 ]

Mishra 2000

24

42.5 (15.11)

25

42.53 (23.56)

4.3 %

0.00 [ -0.56, 0.56 ]

Moore 1985

11

4.73 (1.85)

12

6.5 (1.83)

2.1 %

-0.93 [ -1.80, -0.06 ]

Newton-John 1995

16

10.38 (11.37)

12

17.56 (9.05)

2.6 %

-0.67 [ -1.44, 0.10 ]

Puder 1988

31

3.19 (0.89)

38

3.26 (0.66)

5.5 %

-0.09 [ -0.56, 0.38 ]

Radojevic 1992

15

5.17 (2.12)

15

5.5 (2.38)

2.9 %

-0.14 [ -0.86, 0.57 ]

Spence 1989

12

23.17 (13.73)

14

23.29 (11.28)

2.6 %

-0.01 [ -0.78, 0.76 ]

Turner 1988

24

15.91 (11.63)

21

22.14 (12.35)

3.9 %

-0.51 [ -1.11, 0.08 ]

Turner 1993

21

44.33 (28.45)

18

48.06 (20.97)

3.6 %

-0.14 [ -0.77, 0.49 ]

Vlaeyen 1995

18

63.17 (22.14)

13

68.39 (15.98)

2.9 %

-0.26 [ -0.97, 0.46 ]

Vlaeyen 1996

42

1 (1.8)

39

0.4 (1.8)

6.2 %

0.33 [ -0.11, 0.77 ]

Williams 1996

38

60 (21.7)

31

68.1 (20.7)

5.5 %

-0.38 [ -0.86, 0.10 ]

608

Mean(SD)

Weight

Mean(SD)

Total (95% CI)

Std. Mean Difference

IV,Random,95% CI

591

100.0 % -0.19 [ -0.32, -0.05 ]

Heterogeneity: Tau2 = 0.03; Chi2 = 28.96, df = 22 (P = 0.15); I2 =24%

Test for overall effect: Z = 2.72 (P = 0.0065)

-2

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Favours control

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Analysis 3.2. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 2 Disability.

Review:

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

Comparison: 3 Cognitive behavioural vs treatment as usual

Outcome: 2 Disability

Study or subgroup

CBT

usual treatment/waitlist

IV,Random,95% CI

Std. Mean Difference

Altmaier 1992

21

57.43 (15.06)

21

57.67 (16.37)

5.2 %

-0.01 [ -0.62, 0.59 ]

Basler 1997

36

1.63 (0.87)

40

1.84 (0.62)

6.6 %

-0.28 [ -0.73, 0.17 ]

Becker 2000

49

49 (26)

42

51 (24)

7.1 %

-0.08 [ -0.49, 0.33 ]

Buhrman 2004

22

3.2 (1.4)

29

3.5 (1.2)

5.6 %

-0.23 [ -0.79, 0.33 ]

Evers 2002

30

2.46 (0.47)

29

2.4 (0.38)

6.0 %

0.14 [ -0.37, 0.65 ]

Flor 1993

26

1.7 (1.27)

26

2.03 (1.46)

5.7 %

-0.24 [ -0.78, 0.31 ]

Greco 2004

32

47.82 (22.88)

27

39.02 (25.63)

6.0 %

0.36 [ -0.16, 0.88 ]

Jensen 2001

49

44.16 (16.31)

48

41.82 (19.55)

7.2 %

0.13 [ -0.27, 0.53 ]

Johansson 1998

18

3 (0.7)

19

2.6 (0.7)

4.7 %

0.56 [ -0.10, 1.22 ]

Keefe 1990

31

2.06 (1.29)

28

1.96 (1.26)

6.0 %

0.08 [ -0.43, 0.59 ]

Kraaimaat 1995

24

22.2 (5.1)

19

19.5 (6.6)

5.1 %

0.46 [ -0.15, 1.07 ]

Newton-John 1995

16

2.86 (0.89)

12

2.4 (0.86)

4.0 %

0.51 [ -0.25, 1.27 ]

Puder 1988

31

2.62 (0.81)

38

2.97 (0.68)

6.3 %

-0.47 [ -0.95, 0.01 ]

Radojevic 1992

15

12.27 (9.43)

15

16.24 (9.68)

4.2 %

-0.40 [ -1.13, 0.32 ]

Spence 1989

12

15.79 (8.89)

14

18.83 (7.79)

3.9 %

-0.35 [ -1.13, 0.42 ]

Turner 1988

24

5.39 (3.91)

21

5.75 (6.9)

5.3 %

-0.06 [ -0.65, 0.52 ]

Turner 1993

21

9.53 (8.22)

18

9.64 (7.32)

5.0 %

-0.01 [ -0.64, 0.62 ]

Williams 1996

38

15.81 (11.2)

31

29.65 (10.82)

5.9 %

-1.24 [ -1.76, -0.72 ]

495

Mean(SD)

Weight

Mean(SD)

Total (95% CI)

Std. Mean Difference

IV,Random,95% CI

100.0 % -0.08 [ -0.27, 0.12 ]

477

Heterogeneity: Tau2 = 0.10; Chi2 = 38.06, df = 17 (P = 0.002); I2 =55%

Test for overall effect: Z = 0.76 (P = 0.45)

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Favours control

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Analysis 3.3. Comparison 3 Cognitive behavioural vs treatment as usual, Outcome 3 Mood.

Review:

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

Comparison: 3 Cognitive behavioural vs treatment as usual

Outcome: 3 Mood

Study or subgroup

CBT

usual treatment/waitlist

IV,Random,95% CI

Std. Mean Difference

Altmaier 1992

21

14.19 (5.61)

21

14 (5.92)

5.8 %

0.03 [ -0.57, 0.64 ]

Becker 2000

49

6.3 (5.2)

42

5.8 (5.6)

8.6 %

0.09 [ -0.32, 0.50 ]

Buhrman 2004

22

6 (4.7)

29

5.4 (4)

6.5 %

0.14 [ -0.42, 0.69 ]

Evers 2002

30

9.98 (4.62)

29

12.85 (7.87)

7.0 %

-0.44 [ -0.96, 0.08 ]

Flor 1993

26

2.55 (1.2)

26

2.29 (1.02)

6.6 %

0.23 [ -0.32, 0.78 ]

Greco 2004

32

14.86 (10.07)

27

20.33 (14.14)

6.9 %

-0.45 [ -0.97, 0.07 ]

Jensen 2001

49

36.68 (21.79)

48

34.67 (18.71)

8.9 %

0.10 [ -0.30, 0.50 ]

Keefe 1990

31

2.59 (1.65)

28

3.42 (1.8)

6.9 %

-0.48 [ -0.99, 0.04 ]

Kraaimaat 1995

24

3.1 (3.5)

19

2.5 (2.5)

5.8 %

0.19 [ -0.41, 0.79 ]

Moore 1985

11

76.2 (18)

12

82.1 (14.4)

3.8 %

-0.35 [ -1.18, 0.47 ]

Newton-John 1995

16

9.18 (7.67)

12

11.42 (5.21)

4.4 %

-0.32 [ -1.08, 0.43 ]

Radojevic 1992

15

6.05 (3.33)

15

6.18 (3.58)

4.7 %

-0.04 [ -0.75, 0.68 ]

Spence 1989

12

11.75 (9.1)

14

18.57 (9.42)

4.0 %

-0.71 [ -1.51, 0.09 ]

Turner 1993

21

9.81 (6.5)

18

7.22 (4.87)

5.5 %

0.44 [ -0.20, 1.07 ]

Vlaeyen 1996

42

13.4 (5.8)

39

13.2 (5.8)

8.2 %

0.03 [ -0.40, 0.47 ]

Williams 1996

38

9.5 (7.8)

21

17.3 (7)

6.3 %

-1.02 [ -1.59, -0.46 ]

439

Mean(SD)

Weight

Mean(SD)

Total (95% CI)

Std. Mean Difference

IV,Random,95% CI

400

100.0 % -0.14 [ -0.32, 0.05 ]

Heterogeneity: Tau2 = 0.06; Chi2 = 26.54, df = 15 (P = 0.03); I2 =43%

Test for overall effect: Z = 1.43 (P = 0.15)

-2

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Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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Analysis 4.1. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 1 Pain.
Review:

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

Comparison: 4 Cognitive behavioural vs treatment as usual follow-up

Outcome: 1 Pain

Study or subgroup

CBT

usual treatment/waitlist
Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

Mean(SD)

Altmaier 1992

21

2.33 (0.8)

21

2 (0.95)

8.0 %

0.37 [ -0.24, 0.98 ]

Becker 2000

49

52 (24)

43

67 (19)

12.7 %

-0.68 [ -1.10, -0.26 ]

Evers 2002

30

14.99 (5.12)

29

15.79 (4.98)

10.1 %

-0.16 [ -0.67, 0.35 ]

Flor 1993

23

2.3 (1.36)

24

2.94 (1.45)

8.6 %

-0.45 [ -1.03, 0.13 ]

Greco 2004

32

2.05 (0.94)

27

1.69 (1.15)

10.0 %

0.34 [ -0.17, 0.86 ]

Haldorsen 1998

93

48.2 (27.4)

94

52.1 (28.9)

17.9 %

-0.14 [ -0.42, 0.15 ]

Jensen 2001

49

66.91 (16.09)

48

68.09 (19.41)

13.5 %

-0.07 [ -0.46, 0.33 ]

Keefe 1990

30

5.22 (2.08)

28

5.64 (1.79)

10.0 %

-0.21 [ -0.73, 0.30 ]

Kraaimaat 1995

24

14.7 (4.7)

28

15.9 (5.4)

9.3 %

-0.23 [ -0.78, 0.31 ]

100.0 %

-0.15 [ -0.36, 0.05 ]

Total (95% CI) 351

Std. Mean Difference

IV,Random,95% CI

342

Heterogeneity: Tau2 = 0.04; Chi2 = 13.68, df = 8 (P = 0.09); I2 =42%

Test for overall effect: Z = 1.48 (P = 0.14)

-2

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Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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95

Analysis 4.2. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 2 Disability.
Review:

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

Comparison: 4 Cognitive behavioural vs treatment as usual follow-up

Outcome: 2 Disability

Study or subgroup

CBT

usual treatment/waitlist
Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

Mean(SD)

Flor 1993

23

1.6 (1.23)

24

2.47 (1.32)

9.3 %

-0.67 [ -1.26, -0.08 ]

Becker 2000

49

48 (27)

42

54 (24)

17.8 %

-0.23 [ -0.65, 0.18 ]

Keefe 1990

30

1.69 (1.16)

28

1.96 (1.43)

11.9 %

-0.21 [ -0.72, 0.31 ]

Jensen 2001

49

41.88 (18.89)

48

41.57 (23.97)

19.0 %

0.01 [ -0.38, 0.41 ]

Altmaier 1992

21

52.19 (19.58)

21

50.71 (25.95)

8.9 %

0.06 [ -0.54, 0.67 ]

Evers 2002

30

2.42 (0.47)

29

2.37 (0.4)

12.2 %

0.11 [ -0.40, 0.62 ]

Kraaimaat 1995

24

19.9 (5.6)

19

18.8 (7.7)

8.9 %

0.16 [ -0.44, 0.77 ]

Greco 2004

32

49.52 (25.53)

27

43.05 (27.3)

12.0 %

0.24 [ -0.27, 0.76 ]

100.0 %

-0.06 [ -0.25, 0.12 ]

Total (95% CI) 258

Std. Mean Difference

IV,Random,95% CI

238

Heterogeneity: Tau2 = 0.01; Chi2 = 7.67, df = 7 (P = 0.36); I2 =9%

Test for overall effect: Z = 0.66 (P = 0.51)

-2

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Favours control

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96

Analysis 4.3. Comparison 4 Cognitive behavioural vs treatment as usual follow-up, Outcome 3 Mood.
Review:

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

Comparison: 4 Cognitive behavioural vs treatment as usual follow-up

Outcome: 3 Mood

Study or subgroup

CBT

usual treatment/waitlist

Std. Mean Difference

IV,Random,95% CI

Std. Mean Difference

Mean(SD)

Altmaier 1992

21

16.24 (4.22)

21

15 (6.15)

6.2 %

0.23 [ -0.38, 0.84 ]

Becker 2000

49

6.1 (5.4)

43

6.4 (5)

13.5 %

-0.06 [ -0.47, 0.35 ]

Evers 2002

30

9.51 (5.35)

29

13.07 (7.51)

8.4 %

-0.54 [ -1.06, -0.02 ]

Flor 1993

23

2.52 (1.12)

24

2.89 (0.76)

6.8 %

-0.38 [ -0.96, 0.20 ]

Greco 2004

32

15.01 (10.5)

27

16.99 (12.94)

8.6 %

-0.17 [ -0.68, 0.35 ]

Haldorsen 1998

93

35.4 (10.3)

94

36.9 (9.9)

27.6 %

-0.15 [ -0.43, 0.14 ]

Jensen 2001

49

39.19 (22.4)

48

37.71 (26.05)

14.3 %

0.06 [ -0.34, 0.46 ]

Keefe 1990

30

2.51 (1.33)

28

3.06 (1.52)

8.4 %

-0.38 [ -0.90, 0.14 ]

Kraaimaat 1995

24

3.3 (3.4)

19

4.1 (3.8)

6.2 %

-0.22 [ -0.82, 0.38 ]

Total (95% CI) 351

Mean(SD)

Weight

IV,Random,95% CI

333

100.0 % -0.16 [ -0.31, -0.01 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 6.37, df = 8 (P = 0.61); I2 =0.0%

Test for overall effect: Z = 2.04 (P = 0.041)

-2

-1

Favours experimental

Favours control

Analysis 5.1. Comparison 5 Behavioural vs active control post-treatment, Outcome 1 Pain.

Review:

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

Comparison: 5 Behavioural vs active control post-treatment

Outcome: 1 Pain

Study or subgroup

Behavioural treatment
N

Turner 1990

Total (95% CI)

Active control
Mean(SD)

18 14.78 (11.44)

18

Std. Mean Difference

Mean(SD)

21

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

17.52 (10.2)

100.0 %

-0.25 [ -0.88, 0.38 ]

100.0 % -0.25 [ -0.88, 0.38 ]

21

Heterogeneity: not applicable

Test for overall effect: Z = 0.77 (P = 0.44)

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Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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97

Analysis 5.2. Comparison 5 Behavioural vs active control post-treatment, Outcome 2 Disability.

Review:

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

Comparison: 5 Behavioural vs active control post-treatment

Outcome: 2 Disability

Study or subgroup

Behavioural treatment
N

Active control
Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Turner 1990

18

3.63 (2.98)

21

5.49 (6.79)

35.1 %

-0.34 [ -0.97, 0.30 ]

Nicassio 1997

36

0.4 (0.08)

35

0.42 (0.08)

64.9 %

-0.25 [ -0.71, 0.22 ]

Total (95% CI)

54

100.0 % -0.28 [ -0.66, 0.10 ]

56

Heterogeneity: Tau2 = 0.0; Chi2 = 0.05, df = 1 (P = 0.82); I2 =0.0%

Test for overall effect: Z = 1.46 (P = 0.15)

-2

-1

Favours experimental

Favours control

Analysis 5.3. Comparison 5 Behavioural vs active control post-treatment, Outcome 3 Mood.

Review:

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

Comparison: 5 Behavioural vs active control post-treatment

Outcome: 3 Mood

Study or subgroup

Behavioural treatment
N

Active control
Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Nicassio 1997

36 15.47 (12.13)

35

20.69 (9.83)

60.5 %

-0.47 [ -0.94, 0.00 ]

Turner 1990

18

21

7.38 (4.57)

39.5 %

0.00 [ -0.63, 0.63 ]

Total (95% CI)

7.36 (5.89)

54

56

100.0 % -0.28 [ -0.73, 0.16 ]

Heterogeneity: Tau2 = 0.03; Chi2 = 1.33, df = 1 (P = 0.25); I2 =25%

Test for overall effect: Z = 1.26 (P = 0.21)

-2

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Favours control

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)
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98

Analysis 6.1. Comparison 6 Behavioural vs active control follow-up, Outcome 1 Pain.

Review:

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

Comparison: 6 Behavioural vs active control follow-up

Outcome: 1 Pain

Study or subgroup

Behavioural treatment
N

Turner 1990

Active control
Mean(SD)

18 18.21 (13.31)

Total (95% CI)

21

18

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

14.94 (7.96)

21

100.0 %

0.30 [ -0.34, 0.93 ]

100.0 %

0.30 [ -0.34, 0.93 ]

Heterogeneity: not applicable

Test for overall effect: Z = 0.92 (P = 0.36)

-4

-2

Favours experimental

Favours control

Analysis 6.2. Comparison 6 Behavioural vs active control follow-up, Outcome 2 Disability.

Review:

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

Comparison: 6 Behavioural vs active control follow-up

Outcome: 2 Disability

Study or subgroup

Behavioural treatment
N

Active control
Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Nicassio 1997

36

0.4 (0.11)

35

0.42 (0.09)

64.6 %

-0.20 [ -0.66, 0.27 ]

Turner 1990

18

4.75 (3.4)

21

4.73 (7.85)

35.4 %

0.00 [ -0.63, 0.63 ]

Total (95% CI)

54

100.0 % -0.13 [ -0.50, 0.25 ]

56

Heterogeneity: Tau2 = 0.0; Chi2 = 0.25, df = 1 (P = 0.62); I2 =0.0%

Test for overall effect: Z = 0.66 (P = 0.51)

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Favours control

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Analysis 6.3. Comparison 6 Behavioural vs active control follow-up, Outcome 3 Mood.

Review:

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

Comparison: 6 Behavioural vs active control follow-up

Outcome: 3 Mood

Study or subgroup

Behavioural treatment
N

Active control
Mean(SD)

Nicassio 1997

36

13.7 (10.06)

Turner 1990

18

10 (7.57)

Total (95% CI)

54

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

35 17.72 (11.32)

60.9 %

-0.37 [ -0.84, 0.10 ]

21

39.1 %

0.09 [ -0.54, 0.72 ]

9.31 (7.73)

100.0 % -0.19 [ -0.63, 0.25 ]

56

Heterogeneity: Tau2 = 0.03; Chi2 = 1.32, df = 1 (P = 0.25); I2 =24%

Test for overall effect: Z = 0.85 (P = 0.39)

-2

-1

Favours experimental

Favours control

Analysis 7.1. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 1 Pain.

Review:

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

Comparison: 7 Behavioural vs treatment as usual post-treatment

Outcome: 1 Pain

Study or subgroup

Experimental

Control

Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Flor 1993

26

1.85 (1.027)

26

2.524 (1.5)

12.0 %

-0.52 [ -1.07, 0.04 ]

Jensen 2001

54

69.25 (15.22)

48

71.75 (15.72)

14.1 %

-0.16 [ -0.55, 0.23 ]

Mishra 2000

23

40 (22.25)

25

42.53 (23.56)

11.8 %

-0.11 [ -0.68, 0.46 ]

Newton-John 1995

16

8.42 (6.05)

12

17.56 (9.05)

8.9 %

-1.19 [ -2.01, -0.37 ]

Thieme 2003

40

3.82 (0.96)

21

5.47 (1.06)

11.3 %

-1.64 [ -2.24, -1.03 ]

Turner 1988

17

37.88 (20.07)

18

48.06 (12.35)

10.4 %

-0.60 [ -1.28, 0.08 ]

Turner 1990

18

14.78 (11.44)

19

20.95 (10.62)

10.7 %

-0.55 [ -1.21, 0.11 ]

Turner 1993

17

37.88 (20.07)

18

48.06 (20.97)

10.5 %

-0.48 [ -1.16, 0.19 ]

Vlaeyen 1995

19

71.32 (20.9)

13

68.39 (15.98)

10.1 %

0.15 [ -0.56, 0.86 ]

100.0 %

-0.55 [ -0.90, -0.19 ]

Total (95% CI)

230

200

Heterogeneity: Tau2 = 0.19; Chi2 = 24.25, df = 8 (P = 0.002); I2 =67%

Test for overall effect: Z = 3.03 (P = 0.0024)

-2

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Favours control

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Analysis 7.2. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 2 Disability.

Review:

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

Comparison: 7 Behavioural vs treatment as usual post-treatment

Outcome: 2 Disability

Study or subgroup

Experimental

Control

Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Flor 1993

40

1.73 (0.84)

21

2.03 (1.47)

14.9 %

-0.27 [ -0.80, 0.26 ]

Jensen 2001

54

43.71 (20.53)

48

41.82 (19.55)

16.0 %

0.09 [ -0.30, 0.48 ]

Newton-John 1995

16

2.76 (0.91)

12

2.4 (0.86)

13.0 %

0.39 [ -0.36, 1.15 ]

Thieme 2003

40

3.29 (1.02)

21

5.28 (0.86)

14.0 %

-2.03 [ -2.67, -1.38 ]

Turner 1988

29

3.96 (4.7)

21

5.74 (6.9)

14.6 %

-0.31 [ -0.87, 0.26 ]

Turner 1990

18

3.63 (2.98)

19

5.37 (5.93)

13.9 %

-0.36 [ -1.01, 0.29 ]

Turner 1993

17

4.75 (3.97)

18

9.64 (7.32)

13.6 %

-0.80 [ -1.50, -0.11 ]

100.0 %

-0.46 [ -1.00, 0.08 ]

Total (95% CI)

214

160

Heterogeneity: Tau2 = 0.44; Chi2 = 36.36, df = 6 (P<0.00001); I2 =83%

Test for overall effect: Z = 1.67 (P = 0.095)

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Favours control

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Analysis 7.3. Comparison 7 Behavioural vs treatment as usual post-treatment, Outcome 3 Mood.

Review:

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

Comparison: 7 Behavioural vs treatment as usual post-treatment

Outcome: 3 Mood

Study or subgroup

Experimental
N

Control
Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Flor 1993

40

2.11 (1.31)

21

2.29 (1.02)

17.0 %

-0.15 [ -0.67, 0.38 ]

Jensen 2001

54

38.94 (19.67)

48

34.67 (18.71)

18.3 %

0.22 [ -0.17, 0.61 ]

Newton-John 1995

40

6.18 (4.87)

21

11.42 (5.21)

16.7 %

-1.04 [ -1.60, -0.48 ]

Thieme 2003

40

2.54 (1.03)

21

4.46 (1.48)

16.3 %

-1.58 [ -2.18, -0.98 ]

Turner 1990

18

7.36 (5.89)

19

7.03 (5.02)

15.9 %

0.06 [ -0.59, 0.70 ]

Turner 1993

17

6.24 (3.36)

18

7.22 (4.87)

15.7 %

-0.23 [ -0.89, 0.44 ]

100.0 %

-0.44 [ -1.01, 0.13 ]

Total (95% CI)

209

148

Heterogeneity: Tau2 = 0.42; Chi2 = 32.17, df = 5 (P<0.00001); I2 =84%

Test for overall effect: Z = 1.52 (P = 0.13)

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Favours control

Analysis 8.1. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 1 Pain.

Review:

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

Comparison: 8 Behavioural vs treatment as usual follow-up

Outcome: 1 Pain

Study or subgroup

Experimental
N

Control
Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Flor 1993

26

1.8 (1.26)

24

2.94 (1.45)

28.0 %

-0.83 [ -1.41, -0.25 ]

Jensen 2001

54

67.1 (20.48)

48

68.09 (19.41)

37.3 %

-0.05 [ -0.44, 0.34 ]

Thieme 2003

40

3.66 (182)

40

4.85 (0.86)

34.7 %

-0.01 [ -0.45, 0.43 ]

100.0 %

-0.25 [ -0.71, 0.20 ]

Total (95% CI)

120

112

Heterogeneity: Tau2 = 0.11; Chi2 = 5.81, df = 2 (P = 0.05); I2 =66%

Test for overall effect: Z = 1.09 (P = 0.28)

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Favours control

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Analysis 8.2. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 2 Disability.

Review:

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

Comparison: 8 Behavioural vs treatment as usual follow-up

Outcome: 2 Disability

Study or subgroup

Experimental

Control

Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Flor 1993

24

1.42 (1.04)

24

2.47 (1.32)

32.7 %

-0.87 [ -1.46, -0.27 ]

Jensen 2001

54

46.91 (21.77)

48

41.57 (23.97)

34.1 %

0.23 [ -0.16, 0.62 ]

Thieme 2003

40

2.96 (1.18)

40

4.83 (0.72)

33.2 %

-1.89 [ -2.43, -1.36 ]

100.0 %

-0.83 [ -2.14, 0.47 ]

Total (95% CI)

118

112

Heterogeneity: Tau2 = 1.27; Chi2 = 41.03, df = 2 (P<0.00001); I2 =95%

Test for overall effect: Z = 1.25 (P = 0.21)

-2

-1

Favours experimental

Favours control

Analysis 8.3. Comparison 8 Behavioural vs treatment as usual follow-up, Outcome 3 Mood.

Review:

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

Comparison: 8 Behavioural vs treatment as usual follow-up

Outcome: 3 Mood

Study or subgroup

Experimental

Control

Mean(SD)

Std. Mean Difference

Mean(SD)

Weight

IV,Random,95% CI

Std. Mean Difference

IV,Random,95% CI

Flor 1993

24

1.65 (0.91)

24

2.89 (0.76)

32.0 %

-1.45 [ -2.10, -0.81 ]

Jensen 2001

54

39.15 (22.56)

48

37.71 (26.05)

34.5 %

0.06 [ -0.33, 0.45 ]

Thieme 2003

40

2.38 (1.29)

40

4.47 (1.65)

33.6 %

-1.40 [ -1.89, -0.91 ]

100.0 %

-0.91 [ -1.98, 0.16 ]

Total (95% CI)

118

112

Heterogeneity: Tau2 = 0.82; Chi2 = 27.66, df = 2 (P<0.00001); I2 =93%

Test for overall effect: Z = 1.68 (P = 0.094)

-2

-1

Favours experimental

Favours control

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APPENDICES
Appendix 1. MEDLINE search strategy (via OVID)
1. PAIN explode all trees (MeSH)
2. (chronic* near pain*)
3. (#1 and (chronic* near pain*))
4. (chronic* near discomfort)
5. (chronic* near ache*)
6. (chronic* near fibromyalgia:ab)
7. (chronic* near fibromyalgia:ti)
8. (chronic* near neuralgi*:ab)
9. (chronic* near neuralgi*:ti)
10. (chronic* near dysmenorrhea:ti)
11. (chronic* near dysmenorrhea:ab)
12. (chronic* near dysmenorrhoea:ti)
13. (chronic* near dysmenorrhoea:ab)
14. (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13)
15. PSYCHOTHERAPY explode tree 1 (MeSH)
16. COGNITIVE THERAPY single term (MeSH)
17. BEHAVIOR THERAPY explode tree 1 (MeSH)
18. BIOFEEDBACK (PSYCHOLOGY) single term (MeSH)
19. ((behaviour* next therapy) or (behaviour* next therapies))
20. ((cognitive next therapy) or (cognitive next therapies))
21. (relax* near technique*)
22. ((relax* near therapy) or (relax* near therapies))
23. meditat*
24. psychotherap*
25. (psychological next treatment)
26. ((psychological next therapy) or (psychological next therapies))
27. (group next therapy)
28. (self-regulation next training)
29. (coping next skill*)
30. (pain-related next thought*)
31. (behaviour* near rehabilitat*)
32. (psychoeducation* next group)
33. (psychoeducation* next groups)
34. (psycho-education* next groups)
35. (psycho-education* next group)
36. (mind and (body next relaxation next technique*))
37. MIND-BODY AND RELAXATION TECHNIQUES explode tree 1 (MeSH)
38. (#15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32
or #33 or #34 or #35 or #36 or #37)
39. (#14 and #38)

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HISTORY
Protocol first published: Issue 4, 2008
Review first published: Issue 2, 2009

CONTRIBUTIONS OF AUTHORS
CE oversaw the review and authoring of the manuscript, and authored sections of the manuscript. AW authored sections of the
manuscript and extracted data from papers. SM managed the review process, extracted data and advised on statistical strategy. All
authors contributed to conceptualisation of the review, selection of papers, and judging the quality of the studies.

DECLARATIONS OF INTEREST
All authors have received research support from charities, government, and industry sources at various times. This review was supported
by a Department of Health Cochrane Incentive Grant that assisted authors in meeting costs. CE has consulted for various pharmaceutical
and associated companies related to the psychology of analgesic behaviour, and the measurement of patient outcomes in trials. No
direct or indirect industrial funding supported this study or its authors.

SOURCES OF SUPPORT

Internal sources
No sources of support supplied

External sources
Department of Health, UK.
Incentive Scheme Grant

DIFFERENCES BETWEEN PROTOCOL AND REVIEW

1. No data were available in the trials on adverse events, withdrawal, and escape or emergency analgesia.
2. No dichotomous outcomes were reported so no NNTs were calculated.
3. No adjustment for reliability of measures was made.
4. Planned sub-group analyses were not possible to undertake due to lack of data.

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