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Cited by 1,634Musculoskeletal pain and rehabilitationPain Management and TreatmentMindfulness and Compassion Interventions

The DOI matches its Crossref record; 295 of the 295 references it cites were found in a registry or an index; none of the 38 sources its claims cite is checked for support yet.

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

Open access
Williams, Amanda C de C, Eccleston, Christopher, Morley, Stephen·2012·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd007407.pub3PMC PMC6483325
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Abstract

BACKGROUND: Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012. OBJECTIVES: To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU). SEARCH METHODS: We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials. SELECTION CRITERIA: RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end. DATA COLLECTION AND ANALYSIS: Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment. MAIN RESULTS: We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-q

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This Cochrane review found that cognitive behavioural therapy (CBT) has small-to-moderate benefits for chronic pain in adults, especially compared with treatment as usual or waiting list, while evidence for behaviour therapy is weak and sparse. Effects were strongest for mood and catastrophic thinking, with smaller effects on disability and pain.

Key findings

  • The review included 42 trials; 35 provided usable data, with 4788 treated participants providing post-treatment data from 5424 starting treatment. Mean study quality was 21.2/35 overall, 15.8/26 for design, and 5.4/9 for treatment quality.
  • CBT versus active control: disability improved post-treatment (SMD -0.19, 95% CI -0.33 to -0.05; 12 studies, 1130 participants) and at follow-up (SMD -0.15, 95% CI -0.28 to -0.02; 12 studies, 1295 participants); catastrophising improved post-treatment (SMD -0.18, 95% CI -0.36 to 0.00; 6 studies, 735 participants). Pain and mood were not significant.
  • CBT versus treatment as usual/waiting list: significant post-treatment effects were found for pain (SMD -0.21, 95% CI -0.37 to -0.05; 16 studies, 1148 participants), disability (SMD -0.26, 95% CI -0.47 to -0.04; 15 studies, 1105 participants), mood (SMD -0.38, 95% CI -0.57 to -0.18; 12 studies, 899 participants), and catastrophising (SMD -0.53, 95% CI -0.76 to -0.31; 5 studies, 308 participants). At follow-up, only mood was just significant (SMD -0.26, 95% CI -0.51 to 0.00; 7 studies, 637 participants).
  • Behaviour therapy versus treatment as usual showed no significant post-treatment effects on pain, disability, or mood; catastrophising was just significant (SMD -0.72, 95% CI -1.43 to -0.01; 3 studies, 269 participants) but with high heterogeneity (I² = 84%). There were insufficient studies for meta-analysis of behaviour therapy versus active control.

Methods

  • Systematic review and meta-analysis of RCTs in adults aged 18 years or older with non-malignant chronic pain of at least three months’ duration, excluding headache or migraine. Trials compared a credible psychological treatment with placebo, active treatment, treatment as usual, or waiting list control, and required at least 20 participants per treatment arm at post-treatment assessment.
  • Searches covered CENTRAL, MEDLINE, EMBASE, and Psychlit from inception to September 2011, with no language restrictions. Two treatment classes were analysed: CBT and behavioural therapy; comparators were active control and treatment as usual/waiting list.
  • Outcomes were pain, disability, mood, and catastrophic thinking at post-treatment and follow-up (at least six months and not more than 12 months after treatment). Treatment effects were estimated using standardised mean differences, with heterogeneity assessed by Chi² and I²; risk of bias and the Yates quality scale were applied.

Limitations

  • The paper states that no data were available on adverse events, withdrawal and escape, or emergency analgesia; no dichotomous outcomes were reported, so no numbers needed to treat were calculated; no adjustment for reliability of measures was made; and planned subgroup analyses on doses and different conditions were not undertaken due to lack of data.
  • The review reports high heterogeneity in many analyses, especially for behaviour therapy, and notes that most high risk-of-bias judgements were due to inadequate reporting. Treatment quality did not improve over time, and average effects may mask larger changes in some patients and little or none in others.
  • Evident from the text: behaviour therapy comparisons were often based on only one or two studies, limiting power; control classification of treatment as usual/waiting list was described as not entirely satisfactory; and the review could not resolve whether the psychotherapeutic content of existing trials was adequate.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1002/14651858.cd007407.pub3

Cites

295 of 295 references verified0 citation errors · 0 not checkable

Statistics

Verification

Claims the paper makes

0 of 38 cited sources checked · 0 supported · 0 flagged

Show all 123 claims

  • It may state two separate claims as one. 47
  • Probably not a substantial claim. 168
  • The quote only partly states this claim. 4
208 of 208

  • The paper relies on this without support.

    Chronic pain is a common problem causing significant distress and disability.

    “Chronic pain is a common problem causing significant distress and disability.”

  • The paper relies on this without support.

    The evidence base for psychological therapies is dominated by studies of programmatic and protocolised treatments from a behavioural or cognitive behavioural tradition of clinical psychology.

    “The evidence base for psychological therapies is dominated by studies of programmatic and protocolised treatments from a behavioural or cognitive behavioural tradition of clinical psychology.”

  • The paper relies on this without support.

    Patients in waiting list or treatment as usual conditions receive variable and usually unrecorded treatment.

    “Thus patients in these conditions receive variable and usually unrecorded treatment.”

  • The paper relies on this without support.

    Catastrophic thinking has emerged as a predictor of behavioural and emotional outcomes in the longer term, and is a widely used target of cognitive treatment.

    “This has emerged as a predictor of behavioural and emotional outcomes in the longer term, and is a widely (if not universally) used target of cognitive treatment.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Consistentz = 1.43reported p > .05 · recomputed p = .153

    “(Z = 1.43,p > .05”

  • Consistentz = 2.66reported p < .01 · recomputed p = .008

    “(Z = 2.66, p < .01”

  • Consistentz = 0.72reported p > .05 · recomputed p = .472

    “(Z = 0.72, p > .05”

  • Consistentz = 1.92reported p = .05 · recomputed p = .055

    “Z = 1.92,p = .05”

  • Consistentz = 1.12reported p > .05 · recomputed p = .263

    “(Z = 1.12,p > .05”

  • Consistentz = 2.28reported p < .05 · recomputed p = .023

    “(Z = 2.28, p < .05”

  • Consistentz = 1.15reported p > .05 · recomputed p = .250

    “(Z = 1.15,p > .05”

  • Consistentz = 0.49reported p > .05 · recomputed p = .624

    “Z = 0.49, p > .05”

  • Consistentz = 2.59reported p < .05 · recomputed p = .010

    “(Z = 2.59, p < .05”

  • Consistentz = 2.35reported p < .05 · recomputed p = .019

    “(Z = 2.35, p < .05”

  • Consistentz = 3.84reported p < .01 · recomputed p < .001

    “(Z = 3.84, p < .01”

  • Consistentz = 4.58reported p < .01 · recomputed p < .001

    “Z = 4.58, p < .01”

  • Consistentz = 0.99reported p > .05 · recomputed p = .322

    “(Z = 0.99, p > .05”

  • Consistentz = 0.66reported p > .05 · recomputed p = .509

    “(Z = 0.66, p > .05”

  • Consistentz = 1.99reported p = .05 · recomputed p = .047

    “(Z = 1.99,p = .05”

  • Consistentz = 0.84reported p > .05 · recomputed p = .401

    “Z = 0.84, p > .05”

  • Consistentz = 0.77reported p > .05 · recomputed p = .441

    “(Z = 0.77, p > .05”

  • Consistentz = 1.46reported p > .05 · recomputed p = .144

    “(Z = 1.46,p > .05”

  • Consistentz = 1.94reported p = .05 · recomputed p = .052

    “(Z = 1.94,p = .05”

  • Consistentz = 1.67reported p > .05 · recomputed p = .095

    “Z = 1.67,p > .05”

  • Consistentz = 0.13reported p > .05 · recomputed p = .897

    “(Z = 0.13, p > .05”

  • Consistentz = 1.01reported p > .05 · recomputed p = .312

    “(Z = 1.01,p > .05”

  • Consistentz = 1.55reported p > .05 · recomputed p = .121

    “(Z = 1.55,p > .05”

  • Consistentz = 0.25reported p > .05 · recomputed p = .803

    “Z = 0.25, p > .05”

  • Consistentz = 1.05reported p > .05 · recomputed p = .294

    “(Z = 1.05,p > .05”

  • Consistentz = 1.4reported p > .05 · recomputed p = .162

    “(Z = 1.40,p > .05”

  • Consistentz = 1.18reported p > .05 · recomputed p = .238

    “(Z = 1.18,p > .05”

  • Consistentz = 1.99reported p = .05 · recomputed p = .047

    “Z = 1.99,p = .05”

  • Consistentz = 0.21reported p > .05 · recomputed p = .834

    “(Z = 0.21, p > .05”

  • Consistentz = 1.08reported p > .05 · recomputed p = .280

    “(Z = 1.08,p > .05”

  • Consistentz = 0.9reported p > .05 · recomputed p = .368

    “(Z = 0.90, p > .05”

31 of 31

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Catastrophising benefit at follow-up is claimed despite a nonsignificant result

    Major

    The summary says CBT's benefit for catastrophising versus doing nothing was sustained at follow-up. The follow-up analysis reports only one study and a nonsignificant effect.

  • Nonsignificant Analysis 4.2 is described as showing an effect

    Minor

    The heterogeneity discussion groups Analysis 4.2 among four analyses showing an intervention effect, but the results section explicitly calls its overall effect nonsignificant.

  • Sex counts exceed the stated starting sample in Geraets 2005

    Minor

    The stated numbers of women and men at the start of treatment total 192, exceeding the stated starting sample of 176.

    Reported 176 · recomputed 192

  • Disability analysis has two different Z statistics

    Minor

    The narrative reports Z = 1.46 for behavioural therapy versus active control post-treatment, while the corresponding Analysis 5.2 reports Z = 1.56.

  • Treatment-quality scale has inconsistent denominators

    Minor

    The methods define the Yates treatment-quality subscale as ranging from 0 to 9, but the Lindell 2008 entry reports its treatment-quality score out of 6.

  • The post-treatment arm-size threshold is stated two ways

    Minor

    The inclusion criteria allow 20 participants in each arm, whereas the subsequent description requires more than 20. A study with exactly 20 in an arm would be treated differently under the two rules.

6 of 6

Citations

Cites

2 retracted

Flagged first, then by citations

Show all 293 references

Research works printed but not linked: 6

  1. Jensen, 2005, A 3-year follow-up of a multidisciplinary rehabilitation programme for back and neck pain, Pain, 115, 273, 10.1016/j.pain.2005.03.005 · DOI · Paper page
  2. Corrado, 2003, The effect of biofeedback and relaxation training on anxiety and somatic complaints in chronic pain patients, American Journal of Pain Management, 13, 133
  3. Ferrari, 2006, Individual characteristics and results of biofeedback training and operant treatment in patients with chronic pain, Psicoterapia Cognitiva e Comportmentale, 12, 161
  4. Schulze, 2008, Conception and evaluation of a group therapy intervention for patients with chronic pain disorders and applications for early retirement pensions, Rehabilitation, 47, 211
  5. Bowling, 1997, Measuring Health
  6. Garratt, 2008, Patient reported outcomes in trial, BMJ, 337, a1190

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Metadata

Authors
Williams, A. C. D. C., Eccleston, C., & Morley, S.
Affiliations
  • University College London (GB)
  • University of Bath (GB)
  • University of Leeds (GB)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2012-11-14
Volume
11
Pages
CD007407-CD007407
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd007407.pub3
PMC
PMC6483325
OpenAlex
W1955446149
Semantic Scholar
8018a1d7b6374a784decc549b0fb6bb0de863f57
Cited by
1,634
References
293
Citations by year
2026: 12 · 2025: 94 · 2024: 126 · 2023: 114 · 2022: 144 · 2021: 160 · 2020: 106 · 2019: 133 · 2018: 111 · 2017: 115 · 2016: 117 · 2015: 104 · 2014: 102 · 2013: 82 · 2012: 40
FWCI
11.78
Type
journal article
Language
en
Update notices
new_version (2020-08-14)
Open access
Licence
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
Funders
  • American Heart Association
  • Pfizer
  • Deutsches Krebsforschungszentrum
  • National Institute for Health and Care Research
  • ZonMw
  • National Institutes of Health (5-R01-)
  • National Center for Research Resources (-00056)
Topics
  • Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
Keywords
chronic non-cancer pain, psychotherapy, cognitive behavioral therapy, behavior therapy, acceptance and commitment therapy, fibromyalgia, chronic low back pain, rheumatoid arthritis, pain intensity, disability, psychological distress, adverse events, treatment safety, treatment efficacy, adults, risk of bias, quality of evidence, economic burden, health care costs, treatment expectations, selective reporting
MeSH terms
Adult, Affect, Behavior Therapy, Humans, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Chronic Pain

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

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