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

May combine two claims.

The mean quality of treatment was 5.4/9 (SD 2.3) and was unrelated to year of publication.

“The mean quality of treatment was 5. 4/9 (SD 2.3, range 1 to 9) and was unrelated to year of publication (Spearman's rho = 0.20, nonsignificant).”

May combine two claims.

Of the 24 analyses reported, 10 showed low heterogeneity, six showed modest heterogeneity, and eight showed large heterogeneity.

“Of the 24 analyses reported (CBT or behaviour therapy versus active control or treatment as usual, post-treatment and follow-up, for 'pain', 'disability', 'mood' and 'catastrophic thinking'), 10 showed low heterogeneity (I < 25%), six showed modest heterogeneity (I > 25% to < 50%) and eight, almost all analyses of behaviour therapy, showed large heterogeneity (I > = 50%).”

May combine two claims.

The mean quality of trial design was 15.8/26 (SD 4.3) and increased with year of publication (Spearman's rho = 0.41, P < 0.01).

“As in the 2009 systematic review, we scored the quality of trial design and found a mean 15.8/26 (standard deviation (SD) 4.3, range 9 to 24/26) which increased with year of publication (Spearman's rho = 0.41, P < 0.01); this represented an improvement of about two points per decade.”

May combine two claims.

N at the end of treatment was associated with design quality score and with total quality score.

“N at the end of treatment was associated with design quality score and with total quality score (rho = 0.41 (P < 0.01) and 0.38 respectively (P < 0.05)).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Treatment quality was not associated with year of study.

“Treatment quality was not associated with year of study: see Included studies.”

May combine two claims.

This review includes 22 trials from the previous systematic review and 20 new or re-entered trials; seven trials provided no useable data.

“This review includes 22 trials from the previous systematic review and 20 new or re-entered trials; seven trials provided no useable”

May combine two claims.

Of the eight comparisons of CBT versus active control, three were positive: disability immediately post-treatment and at follow-up, and catastrophic thinking post-treatment.

“Of the eight comparisons of CBT versus active control (four outcomes: pain, disability, mood, catastrophic thinking, at two time points, immediately post-treatment and six to 12 months followup), three were positive: disability immediately post-treatment and at follow-up, and catastrophic thinking post-treatment.”

The quote only partly states this claim.

In the analysis of behaviour therapy versus treatment as usual at follow-up, the overall effect of behaviour therapy on mood was not significant (Z = 0.90, P > 0.05; two studies, 160 participants; Analysis 8.3).

“The overall effect of behaviour therapy was not significant (Z = 0.90, P > 0.05) (Analysis 8.3).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Before applying the new sample size criterion, 65 eligible trials were found.

“Before applying our new sample size criterion, we found 65 eligible trials”

May combine two claims.

CBT and behaviour therapy dominate the evidence base; there were no trials of other psychological treatments such as psychodynamic or interpersonal psychotherapy, or dialectical behaviour therapy.

“Cognitive behavioural therapy (CBT) and behaviour therapy dominate the evidence base; there were no trials of other psychological treatments such as psychodynamic or interpersonal psychotherapy, or dialectical behaviour therapy.”

The quote only partly states this claim.

In the analysis of behaviour therapy versus active control at follow-up, the overall effect of behaviour therapy on pain was not significant (Z = 0.13, P > 0.05; one study, 73 participants; Analysis 6.1).

“The overall effect of behaviour therapy was not significant (Z = 0.13, P > 0.05) (Analysis 6.1).”

May combine two claims.

In Analysis 4.3, removal of Van Koulil 2010 reduced heterogeneity to 9% but produced a non-significant result in place of the just significant one (Z = 1.57, P > 0.05).

“and reduced it to 9% (Analysis 4.3) but also produced a non-significant result in place of the just significant one: Z was 1.57, P > 0.05.”

• cites Van Koulil 2010 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The remainder allowed for reasonable power in the analyses, with the largest analysis being of 1258 participants (CBT versus active control post-treatment) and the smallest of 144 participants (behaviour therapy versus active control at follow-up).

“The remainder allowed for reasonable power in the analyses, with the largest analysis being of 1258 participants (CBT versus active control post-treatment) and the smallest of 144 participants (behaviour therapy versus active control at follow-up).”

May combine two claims.

For behaviour therapy, the evidence is much weaker and, with more stringent criteria, rather sparse.

“For behaviour therapy the evidence is much weaker and, with our more stringent criteria, rather sparse.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The majority of studies were of CBT, reflecting its dominance in chronic pain management and in psychological treatment more widely.

“The majority of studies were of CBT, reflecting its dominance in chronic pain management and in psychological treatment more widely.”

May combine two claims.

In Analysis 3.2, heterogeneity was reduced to 55% by removal of one positive outlier (Williams 1996), without affecting the overall significant result.

“In Analysis 3.2, heterogeneity was reduced to 55% by the removal of one positive outlier (Williams 1996), without affecting the overall significant result.”

• cites Williams 1996 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The quality of treatments, of their reporting, or both, does not appear to have improved over time.

“However, the quality of treatments, of their reporting, or both, does not appear to have improved over time”

The quote only partly states this claim.

CBT has a moderate effect on catastrophising at follow-up compared with doing nothing (sustained).

“which was sustained at follow-up.”

May combine two claims.

In Analysis 7.4, removal of Thieme 2003 reduced heterogeneity to 0% and strengthened the result (Z = 2.41, P < 0.05; SMD -0.34, 95% CI -0.62 to -0.06), now based on two studies.

“In Analysis 7.4, again removal of a single study (Thieme 2003) reduced heterogeneity to 0% and strengthened the result, although this was now only produced by two studies: Z = 2.41 P < 0.05; the effect size was SMD -0.34 (95% CI -0.62 to -0.06).”

• cites Thieme 2003 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Yates 2005 treatment subscale is restricted to five items and may be relatively insensitive.

“but the Yates 2005 treatment subscale is restricted to five items so may be relatively insensitive.”

• cites Yates 2005 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Excluding studies classified as 'high risk' for treatment quality largely increased CBT effect sizes and reduced heterogeneity.

“This largely had the effect of increasing CBT effect sizes and reducing heterogeneity”

The quote only partly states this claim.

In the analysis of behaviour therapy versus active control at follow-up, the overall effect of behaviour therapy on mood was not significant (Z = 1.55, P > 0.05; one study, 71 participants; Analysis 6.3).

“The overall effect of behaviour therapy was not significant (Z = 1.55,P > 0.05) (Analysis 6.3).”

May combine two claims.

In Analysis 4.2, removal of a single study (Van Koulil 2010) reduced heterogeneity to 0% without changing the non-significant result.

“In Analysis 4.2 and Analysis 4.3, removal of a single study (Van Koulil 2010) reduced heterogeneity to 0% but without changing the non-significant result (Analysis 4.2)”

• cites Van Koulil 2010 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Of the four outcome domains, effects on mood (mostly depression) were strongest, followed by catastrophic thinking, disability and, lastly, pain.

“Of our four outcome domains, effects on mood (mostly depression) were strongest, followed by catastrophic thinking, disability and, lastly, pain.”

May combine two claims.

Compared to the 2009 review, the effect sizes for CBT are largely sustained and extended with the addition of catastrophic thinking as an outcome, while those for behaviour therapy are diminished.

“Compared to our 2009 review (Eccleston 2009a), the effect sizes for CBT are largely sustained and extended with the addition of catastrophic thinking as an outcome, while those for behaviour therapy are diminished.”

• cites Eccleston 2009aNot checked yet

  Not checked in the free run.

May combine two claims.

Numbers in trials have steadily increased over time, but in some cases this appears to be at the cost of treatment intensity.

“Numbers in trials have steadily increased over time, but in some cases this appears to be at the cost of treatment intensity”

May combine two claims.

The effect sizes are comparable with effect sizes of CBT for pain problems in children and for major psychological disorders.

“It is also comparable with effect sizes of CBT for pain problems in children (Eccleston 2009b) and for major psychological disorders (Butler 2006).”

• cites Eccleston 2009bNot checked yet

  Not checked in the free run.

• cites Butler 2006 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Treatment gains are of the same order as those of other available treatments, as shown by head-to-head trials of surgery versus psychologically based rehabilitation.

“Treatment gains are of the same order as those of other available treatments (Glombiewski 2010), as shown by head-to-head trials of surgery versus psychologically based rehabilitation (Fairbank 2005;Hellum 2011).”

• cites Glombiewski 2010Not checked yet

  Not checked in the free run.

• cites Fairbank 2005 sourceNot checked yet

  Not checked in the free run.

• cites Hellum 2011 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The average effects are small, as they are for all treatments of chronic pain.

“The average effects are small, as they are for all treatments of chronic pain (Moore 2010).”

• cites Moore 2010 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

No data were available in the trials on adverse events, withdrawal and escape or emergency analgesia.

“No data were available in the trials on adverse events, withdrawal and escape or emergency analgesia.”

May combine two claims.

The evidence for CBT is stronger, particularly when compared with treatment as usual/waiting list, and for mood and catastrophic thinking.

“The evidence for CBT is stronger, particularly when compared with treatment as usual/waiting list, and for mood and catastrophic thinking.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

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.

“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).”

• cites Morley 2006 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

We applied a quality rating scale specifically designed for psychological interventions in pain.

“As in the previous review (Eccleston 2009a), we applied a quality rating scale specifically designed for psychological interventions in pain (Yates 2005).”

• cites Yates 2005 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Behavioural and cognitive treatments designed to ameliorate pain, distress and disability were first introduced over 40 years ago and are now well established.

“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 Rumble 2004).”

• cites Fordyce 1968 sourceNot checked yet

  Not checked in the free run.

• cites Keefe Rumble 2004Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two of the three review authors scored all studies and reached a consensus after initial comparison of ratings.

“Two of the three review authors scored all studies and they reached a consensus a er initial comparison or ratings.”

May combine two claims.

14 studies had adequate allocation concealment, one uncertain, and 27 high risk.

“We judged 14 studies to have adequate allocation concealment, one uncertain and 27 high risk, again mainly because there was no description of any procedure designed to do so.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Eccleston 2009a review found 52 trials, of which 40 had data that could be entered into a meta-analysis.

“The Eccleston 2009a review found 52 trials, of which 40 had data that could be entered into a meta-analysis.”

• cites Eccleston 2009aNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

We excluded the option of 'blinding participants and personnel' because neither therapists nor patients can be blinded to whether they deliver or receive treatment.

“We excluded the option of 'blinding participants and personnel' because neither therapists nor patients can be blinded to whether they deliver or receive treatment.”

May combine two claims.

Fifteen studies described a convincing method of randomisation and were judged low risk of bias; 11 provided an inadequate description and were judged unclear.

“Fi een studies described a convincing method of randomisation so we judged them to have a low risk of bias, and a further 11 provide an inadequate description so we judged them to be unclear.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

This analysis is now out of date and in need of updating.

“This analysis is now out of date and in need of updating (Shojania 2007).”

• cites Shojania 2007 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

13 studies were judged low risk of bias for outcome assessment (blinded assessors); two unclear; 27 high risk.

“Finally, we judged 13 studies at low risk of bias for outcome assessment since they used blinded assessors; two were unclear; and we judged 27 at high risk of bias since they gave no details of outcome assessment procedures.”

Classified as probably not a substantial claim.

We required N > 20 per treatment arm at post-treatment assessment because of the recognised risk of bias of small numbers.

“This last criterion of N > 20 at post-treatment assessment is an improvement from the Eccleston 2009a review in which we used an entry of N > 10.We made this change because of the recognised risk of bias of small numbers (Ioannidis 2005;Nuesch 2009); raising the required N further would be desirable but would exclude too many studies.”

• cites Ioannidis 2005 sourceNot checked yet

  Not checked in the free run.

• cites Nuesch 2009 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

34 studies were judged low risk of bias for selective reporting; one uncertain; seven high risk.

“We judged 34 studies at low risk of bias for selective reporting of outcome since they reported all outcomes, or in one case accounted for those they did not report; we judged one study uncertain because outcomes were combined in factor scores, and seven studies did not report all outcomes which they described in assessment sections of their Methods, and we judged them at high risk of bias.”

May combine two claims.

Compared with doing nothing, behaviour therapy improved pain post-treatment, but showed no other benefits, and there were too few trials of behaviour therapy against active control for analysis.

“Compared with doing nothing, behaviour therapy improved pain post-treatment, but showed no other benefits, and there were too few trials of behaviour therapy against active control for analysis.”

• cites Eccleston 2009aNot checked yet

  Not checked in the free run.

May combine two claims.

Against doing nothing (treatment as usual or waiting list control), there was only significant improvement for pain post-treatment and mood at follow-up.

“Surprisingly, against doing nothing (treatment as usual or waiting list control), there was only significant improvement for pain post-treatment and mood at follow-up.”

• cites Eccleston 2009aNot checked yet

  Not checked in the free run.

May combine two claims.

16 studies were judged high risk of bias for randomisation, mainly because the method of randomisation was not described.

“We judged 16 to have high risk of bias, mainly because the method of randomisation was not described; these were mainly earlier studies.”

May combine two claims.

Against active control, CBT improved disability post-treatment, and pain, disability and mood at follow-up, although effect sizes were small.

“Against active control, CBT improved disability post-treatment, and pain, disability and mood at follow-up, although effect sizes were small.”

• cites Eccleston 2009aNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Mean study completion rate from entry to post-treatment assessment was 87.6% (SD 9.5%).

“Mean study completion rate from entry to posttreatment assessment was 87.6% (SD 9.5%) and ranged from 65% to 100%.”

Classified as probably not a substantial claim.

We assessed risk of bias using the recommended Cochrane guidance.

“We assessed risk of bias using the recommended Cochrane guidance (Higgins 2011).”

• cites Higgins 2011Not checked yet

  Not checked in the free run.

May combine two claims.

Trials of behaviour therapy tended to be small and methodologically weak and have been largely superseded by procedures that claim to be cognitive behavioural.

“As a consequence, trials tended to be small and methodologically weak and have been largely superseded by procedures that claim to be cognitive behavioural.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Behaviour therapy was developed in the 1960s and 1970s and evaluated as part of the first wave of psychological treatment for pain.

“Behaviour therapy was developed in the 1960s and 1970s and evaluated as part of the first wave of psychological treatment for pain (Morley 2011).”

• cites Morley 2011 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Evers 2002 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Ersek 2008 trial, random sequence generation was at low risk of bias.

“Randomisation by (retirement) facility, by statistician using random number generator”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Ehrenborg 2010 trial, blinding of outcome assessment was at high risk of bias.

“Therapists conducted assessments: statement that study not blinded”

May combine two claims.

The evidence of weak to moderate effects across a range of outcomes is clear from our systematic reviews and from the others cited above, and is very unlikely to change as a result of further similar RCTs and systematic reviews.

“The evidence of weak to moderate effects across a range of outcomes is clear from our systematic reviews and from the others cited above, and is very unlikely to change as a result of further similar RCTs and systematic reviews.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Evers 2002 trial, blinding of outcome assessment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S2 (checkable).

It is no longer believed possible to design a 'pure' trial of a single component of intervention (such as relaxation, operant reinforcement or acceptance).

“We no longer believe that it is possible to design a 'pure' trial of a single component of intervention (such as relaxation, operant reinforcement or acceptance)”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Evers 2002 trial, allocation concealment was at low risk of bias.

““previously determined””

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Bliokas 2007 trial, allocation concealment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Altmaier 1992 trial, blinding of outcome assessment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the De Souza 2008 trial, allocation concealment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Evers 2002 trial, incomplete outcome data was at low risk of bias.

“Attrition fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Ersek 2008 trial, allocation concealment was at low risk of bias.

“By independent statistician”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Altmaier 1992 trial, allocation concealment was at high risk of bias.

“Not reported”

May combine two claims.

Although trials do not tend to report adverse effects or deterioration, such effects should be small, so the treatment can be considered to be safe, with the reservation that reasons for discontinuing treatment are rarely given and may be due to hidden adverse effects.

“Although trials do not tend to report adverse effects or deterioration (such as worsening of depression to a level of clinical concern), we know that such effects should be small (Fairbank 2005;Hellum 2011;Morley 2008), so the treatment can be considered to be safe, with the reservation that the reasons for discontinuing treatment are rarely given and may be due to hidden adverse effects.”

• cites Fairbank 2005 sourceNot checked yet

  Not checked in the free run.

• cites Hellum 2011 sourceNot checked yet

  Not checked in the free run.

• cites Morley 2008 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In the Evers 2002 trial, random sequence generation was at unclear risk of bias.

“Random numbers”

May combine two claims.

Psychological interventions can reduce pain, disability, psychological distress and catastrophic ways of thinking about pain.

“Psychological interventions can reduce pain, disability, psychological distress and catastrophic ways of thinking about pain.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In the Ersek 2008 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Falcao 2008 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Altmaier 1992 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Falcao 2008 trial, incomplete outcome data was at unclear risk of bias.

“Attrition partially reported; statement that dropouts were not different”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In the Buckelew 1998 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Bliokas 2007 trial, incomplete outcome data was at low risk of bias.

“Attrition fully reported; no differences”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Buckelew 1998 trial, allocation concealment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Falcao 2008 trial, random sequence generation was at unclear risk of bias.

““Patients were randomized by drawing lots””

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Falcao 2008 trial, allocation concealment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In the Ersek 2008 trial, blinding of outcome assessment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Ehrenborg 2010 trial, incomplete outcome data was at low risk of bias.

“Attrition fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Ehrenborg 2010 trial, allocation concealment was at high risk of bias.

“Not reported”

May combine two claims.

There is no clear benefit of adding further components to multicomponent CBT; it is unlikely that the extra component, such as two sessions on 'mindfulness', will make any measurable difference.

“There is no clear benefit of adding further components to multicomponent CBT: it is unlikely that the extra component, such as two sessions on 'mindfulness', will make any measurable difference.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In the Bliokas 2007 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Basler 1997 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Ehrenborg 2010 trial, random sequence generation was at unclear risk of bias.

““Randomization was performed by casting a die after the participant's acceptance: odd numbers for treatment group ....””

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the De Souza 2008 trial, blinding of outcome assessment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the De Souza 2008 trial, random sequence generation was at high risk of bias.

““randomly assigned””

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Basler 1997 trial, allocation concealment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In the Ehrenborg 2010 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Bliokas 2007 trial, random sequence generation was at low risk of bias.

“Random numbers generation”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In the De Souza 2008 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Ersek 2008 trial, incomplete outcome data was at low risk of bias.

“Fully reported attrition”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In the Basler 1997 trial, blinding of outcome assessment was at high risk of bias.

“Not reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Keefe 1990, incomplete outcome data was judged at low risk of attrition bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Glombiewski 2010b trial, allocation concealment was at unclear risk of bias.

““coordinated by the first author” before study”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Mishra 2000, selective reporting was judged at high risk of reporting bias.

“Partially reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Leeuw 2008, incomplete outcome data was judged at low risk of attrition bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Greco 2004 trial, incomplete outcome data was at unclear risk of bias.

“Attrition fully reported; no test for differences”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Kole-Snijders 1999, random sequence generation was judged at unclear risk of selection bias.

“independent researcher blindly drew [numbers assigned randomly to patients] and assigned to one of three conditions”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Keefe 1996, blinding of outcome assessment was judged at high risk of detection bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Kaapa 2006, incomplete outcome data was judged at unclear risk of attrition bias.

“Fully reported; no test for differences”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Lindell 2008, blinding of outcome assessment was judged at high risk of detection bias.

“Assessors not blind to treatment condition, except for sick listing outcome”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Greco 2004 trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Keefe 1996, allocation concealment was judged at high risk of selection bias.

“Not reported (but equal credibility of treatments rated by participants)”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In the Glombiewski 2010b trial, selective reporting was at low risk of bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Haldorsen 1998 trial, blinding of outcome assessment was at unclear risk of bias.

“Assessment by physiotherapists who tried to remain blind to treatment”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Lindell 2008, selective reporting was judged at low risk of reporting bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Keefe 1996, incomplete outcome data was judged at unclear risk of attrition bias.

“Fully reported; no differential attrition but no test for differences”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Kole-Snijders 1999, allocation concealment was judged at low risk of selection bias.

“independent researcher”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Parker 1988, random sequence generation was judged at high risk of selection bias.

“using a table of random numbers, subjects were assigned”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In McCarberg 1999, blinding of outcome assessment was judged at high risk of detection bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In McCarberg 1999, random sequence generation was judged at unclear risk of selection bias.

“Patients were randomized using a computer-generated random number list”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Litt 2009, blinding of outcome assessment was judged at high risk of detection bias.

“Not reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Lindell 2008, incomplete outcome data was judged at unclear risk of attrition bias.

“Fully reported; no test for differences”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Greco 2004 trial, random sequence generation was at low risk of bias.

““assigned randomly, based on a software-generated randomization plan””

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Litt 2009, selective reporting was judged at low risk of reporting bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Leeuw 2008, allocation concealment was judged at low risk of selection bias.

“Sealed envelope; research assistant only could access randomization schedule”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Litt 2009, incomplete outcome data was judged at high risk of attrition bias.

“Attrition not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Geraets 2005 trial, blinding of outcome assessment was at low risk of bias.

“Researchers not involved in randomisation collect data”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Lindell 2008, allocation concealment was judged at low risk of selection bias.

“Randomisation generated by independent statistician; in opaque envelopes”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In McCarberg 1999, selective reporting was judged at low risk of reporting bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Nicassio 1997, incomplete outcome data was judged at low risk of attrition bias.

“Attrition fully reported; differential attrition across groups; no differences”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Mishra 2000, incomplete outcome data was judged at high risk of attrition bias.

“Attrition not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Litt 2009, random sequence generation was judged at low risk of selection bias.

“Computerised urn randomisation”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Kaapa 2006, blinding of outcome assessment was judged at high risk of detection bias.

“Not reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Keefe 1996, random sequence generation was judged at high risk of selection bias.

“randomly assigned”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Parker 1988, selective reporting was judged at high risk of reporting bias.

“Partially reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Kole-Snijders 1999, selective reporting was judged at unclear risk of reporting bias.

“Reported as factor scores”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Mishra 2000, blinding of outcome assessment was judged at high risk of detection bias.

“Not reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Kraaimaat 1995, allocation concealment was judged at high risk of selection bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Haldorsen 1998, incomplete outcome data was judged at high risk of attrition bias.

“Partially reported; differential attrition; no test of differences”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Nicassio 1997, allocation concealment was judged at high risk of selection bias.

“Not reported, though credibility ratings equal across treatments”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Mishra 2000, allocation concealment was judged at high risk of selection bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Falcao 2008 trial, blinding of outcome assessment was at low risk of bias.

“Evaluation by clinician blind to treatment allocation”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Nicassio 1997, blinding of outcome assessment was judged at high risk of detection bias.

“Not reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Kole-Snijders 1999, incomplete outcome data was judged at low risk of attrition bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Haldorsen 1998, selective reporting was judged at low risk of reporting bias.

“Fully reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Kaapa 2006, selective reporting was judged at low risk of reporting bias.

“Fully reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Keefe 1996, selective reporting was judged at low risk of reporting bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Mishra 2000, random sequence generation was judged at high risk of selection bias.

“patients were assigned to group in a semi-random fashion using the urn method of random assignment”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Parker 1988, incomplete outcome data was judged at high risk of attrition bias.

“Attrition not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Haldorsen 1998, blinding of outcome assessment was judged at unclear risk of detection bias.

“Data gathered by research team”

Probably not a substantial claim: may not pass S3 (load-bearing).

In McCarberg 1999, incomplete outcome data was judged at unclear risk of attrition bias.

“No attrition during treatment, only at follow-up; no test for differences”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Leeuw 2008, blinding of outcome assessment was judged at low risk of detection bias.

“Electronic administration of assessments”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Keefe 1990, blinding of outcome assessment was judged at high risk of detection bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Keefe 1990, random sequence generation was judged at unclear risk of selection bias.

“randomly assigned (using a random number table)”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Keefe 1990, selective reporting was judged at low risk of reporting bias.

“Fully reported”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Litt 2009, allocation concealment was judged at high risk of selection bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Leeuw 2008, selective reporting was judged at low risk of reporting bias.

“Fully reported”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Kaapa 2006, random sequence generation was judged at low risk of selection bias.

“Random numbers”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Geraets 2005 trial, random sequence generation was at low risk of bias.

“Block randomisation according to random number table”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Kraaimaat 1995, random sequence generation was judged at high risk of selection bias.

“randomly assigned”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Leeuw 2008, random sequence generation was judged at low risk of selection bias.

“predetermined and computer-generated randomization schedule”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Glombiewski 2010b trial, random sequence generation was at low risk of bias.

“Randomisation by random number generation”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Haldorsen 1998, random sequence generation was judged at unclear risk of selection bias.

“Shuffled sealed envelopes”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Lindell 2008, random sequence generation was judged at low risk of selection bias.

“Computerised block randomisation procedure”

Probably not a substantial claim: may not pass S3 (load-bearing).

In Haldorsen 1998, allocation concealment was judged at low risk of selection bias.

“Sealed envelopes; procedure by researchers blind to participant screening”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

In Parker 1988, allocation concealment was judged at high risk of selection bias.

“Not reported”

Probably not a substantial claim: may not pass S3 (load-bearing).